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Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

> Sincerely,
>
> ![](media/image6.png)
>
> Kay Coles James
>
> Director

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

**Privacy Practices**

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

Unites States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

Table of Contents

[Introduction 3](#_Introduction)

[Plain Language 3](#_Introduction)

[Stop Health Care Fraud! 3](#_Introduction)

[Preventing medical mistakes 4](#_Introduction)

[Section 1. Facts about this HMO plan 6](#_Introduction)

[We also have Point of Service (POS) benefits 6](#_Introduction)

[How we pay providers 6](#_Introduction)

[Your Rights 6](#_Introduction)

[Service Area 7](#service-area)

[Section 2. How we change for 2005 8](#_Introduction)

[Program-wide changes 8](#_Introduction)

[Changes to this Plan 8](#_Introduction)

[Section 3. How you get care 9](#_Introduction)

[Identification cards 9](#identification-cards)

[Where you get covered care 9](#where-you-get-covered-care)

[• Plan providers 9](#plan-providers)

[• Plan facilities 10](#plan-facilities)

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

[• Primary care 10](#primary-care)

[• Specialty care 10](#specialty-care)

[• Hospital care 11](#hospital-care)

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

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

[Section 4. Your costs for covered services 14](#_Introduction)

[Copayments 14](#copayments)

[Deductible 14](#deductible)

[Coinsurance 14](#coinsurance)

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

[Section 5. Benefits -- OVERVIEW *(See page 8 for how our benefits
changed this year and page 75 for a benefits summary.)*
16](#_Introduction)

[Section 5(a) Medical services and supplies provided by physicians and
other health care professionals 18](#_Introduction)

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

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

[Section 5(d) Emergency services/accidents 38](#_Introduction)

[Section 5(e) Mental health and substance abuse benefits
41](#_Introduction)

[Section 5(f) Prescription drug benefits 43](#_Introduction)

[Section 5(g) Special features 46](#_Introduction)

-   
-   
-   

[Flexible benefits option 46](#flexible-benefits-option)[24 hour nurse
line 46](#hour-nurse-line)[Services for deaf and hearing impaired
46](#services-for-deaf-and-hearing-impaired)[Section 5(h) Dental
benefits 47](#_Introduction)

[Section 5(i) Point of Service benefits
48](#section-5i-point-of-service-benefits)

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

[Section 6. General exclusions -- things we don't cover
56](#_Introduction)

[Section 7. Filing a claim for covered services 57](#_Introduction)

[Section 8. The disputed claims process 58](#_Introduction)

[Section 9. Coordinating benefits with other coverage
60](#_Introduction)

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

[What is Medicare? 60](#_What_is_Medicare?)

• [Should I enroll in Medicare? 60](#should-i-enroll-in-medicare)

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

• [Medicare Advantage 63](#medicare-advantage)

[TRICARE and CHAMPVA 63](#tricare-and-champva)

[Workers' Compensation 64](#_Workersí_Compensation)

[Medicaid 64](#medicaid)

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

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

[Section 10. Definitions of terms we use in this brochure
65](#_Introduction)

[Section 11. FEHB Facts 67](#_Introduction)

[Coverage information 67](#_Introduction)

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

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

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

• [Children's Equity Act 68](#childrens-equity-act)

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

• [When you retire 68](#when-you-retire)

[When you lose benefits 68](#_Introduction)

• [When FEHB coverage ends 68](#when-fehb-coverage-ends)

• [Spouse equity coverage 69](#spouse-equity-coverage)

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

• [Converting to individual coverage
69](#converting-to-individual-coverage)

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

[Section 12. Two Federal Programs complement FEHB benefits
70](#_Introduction)

[The Federal Flexible Spending Account Program -- *FSAFEDS*
70](#_Introduction)

[The Federal Long Term Care Insurance Program 73](#_Introduction)

[Index 74](#_Introduction)

[Summary of benefits for the Mercy Health Plans/Premier Health Plans *-*
2005 75](#_Introduction)

[2005 Rate Information for Mercy Health Plans/Premier Health Plans
77](#_Introduction)

# Introduction

This brochure describes the benefits of Mercy Health Plans/Premier
Health Plans under our contract (CS 2834) with the United States Office
of Personnel Management, as authorized by the Federal Employees Health
Benefits law. The address for Mercy Health Plans/Premier Health Plans
administrative offices is:

Mercy Health Plans Premier Health Plans Mercy Health Plans

14528 South Outer 40 One Corporate Centre, Suite 200 5901 McPherson

Suite 300 1949 East Sunshine Suites 1 & 2B

Chesterfield, MO 63017 Springfield, MO 65804 Laredo, TX 78041

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

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

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2005, and changes are summarized on
page 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
    Mercy Health Plans/Premier Health Plans*.*

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

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

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

# Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

    If the provider does not resolve the matter, call Mercy Health Plans
    (Eastern and Central Missouri Regions) at 314-214-8196 or
    1-800-327-0763; (Texas Region) at 956-723-7667 or 1-800-617-3433; or
    Premier Health Plans (Southwest Missouri Region) at 417-836-0402 or
    1-800-836-0402 and explain the situation.

    If we do not resolve the issue:

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

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

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

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

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

# Preventing medical mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

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

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

Want more information on patient safety?

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

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

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

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

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

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

# Section 1. Facts about this HMO plan

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

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

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

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

### We also have Point of Service (POS) benefits

Our HMO offers POS benefits. This means you can receive covered services
from a participating provider without a required referral, or from a
non-participating provider. These out-of-network benefits have higher
out-of-pocket costs than our in-network benefits.

### How we pay providers

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

### 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 Web site
([www.opm.gov/insure](http://www.opm.gov/insure)) lists the specific
types of information that we must make available to you. Some of the
required information is listed below.

If you want more information about us, call our Member Services
department at:

Mercy Health Plans: (Eastern and Central Missouri Regions) at
314-214-8196 or 1-800-327-0763

Mercy Health Plans: (Texas Region) at 956-723-7667 or 1-800-617-3433

Premier Health Plans: (Southwest Missouri Region) at 417-836-0402 or
1-800-836-0402

or write to:

Mercy Health Plans: 14528 South Outer 40, Suite 300, Chesterfield, MO
63017 (Eastern and Central Missouri Region)

Mercy Health Plans: 5901 McPherson, Suite 1 & 2B, Laredo, TX 78041
(Texas Region)

Premier Health Plans: One Corporate Center, Suite 200, 1949 East
Sunshine, Springfield, MO 65804 (Southwest Missouri Region)

You may also contact us by fax at:

(Eastern and Central Missouri Region): 314-214-8102;

(Southwest Missouri Region): 417-836-0457; or

(Texas Region): 956-723-8246.

Visit our Web site at
[www.mercyhealthplans.com](http://www.mercyhealthplans.com/).

### Service Area

To enroll in this Plan, you must live in or work in our Service Area.
This is where our providers practice. Our service area is: MERCY HEALTH
PLANS (Eastern and Central Missouri Regions) include these Missouri
counties: Audrain, Boone, Callaway, Chariton, Cole, Cooper, Franklin,
Gasconade, Howard, Iron, Jefferson, Lincoln, Linn, Macon, Madison,
Maries, Miller, Moniteau, Monroe, Montgomery, Morgan, Osage, Pettis,
Pike, Ralls, Randolph, Reynolds, Saline, St. Charles, St. Francois, St.
Louis, St. Louis City, Warren and Washington. The Illinois counties are:
Clinton, Jersey, Macoupin, Madison, Monroe, Randolph and St. Clair.

MERCY HEALTH PLANS (Texas Region) include these Texas counties: Duval,
Jim Hogg, Webb and Zapata.

PREMIER HEALTH PLANS (Southwest Missouri Region) include these Missouri
counties: Barry, Barton, Benton, Cedar, Christian, Crawford, Dade,
Dallas, Dent, Douglas, Greene, Henry, Hickory, Howell, Jasper, Laclede,
Lawrence, McDonald, Newton, Oregon, Ozark, Phelps, Polk, Pulaski,
Shannon, St. Clair, Stone, Taney, Texas, Vernon, Webster and Wright.

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

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

# Section 2. How we change for 2005

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

### Program-wide changes

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

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

### Changes to this Plan

-   Your share of the non-Postal premium will increase by 18.8% for Self
    Only or by 20.6% for Self and Family for the (7M) Missouri Regions.

-   Your share of the non-Postal premium will decrease by 17.4% for Self
    Only or 13.4% for Self and Family for the (HM) Texas Regions.

-   The address of our Central and Eastern Missouri regions has changed
    as follows: Mercy Health Plans, 14528 South Outer 40, Suite 300,
    Chesterfield, MO 63017.

    The following services will require prior authorization:

-   MRIs

-   CT scans

-   Home Infusion Intravenous (IV) Services

Please see Sections 3 and 5(i) for details.

# Section 3. How you get care

+--------------------+-------------------------------------------------+
| ### Id             | We will send you an identification (ID) card    |
| entification cards | when you enroll. You should carry your ID card  |
|                    | with you at all times. You must show it         |
|                    | whenever you receive services from a Plan       |
|                    | provider, or fill a prescription at a Plan      |
|                    | pharmacy. Until you receive your ID card, use   |
|                    | your copy of the Health Benefits Election Form, |
|                    | SF-2809, your health benefits enrollment        |
|                    | confirmation (for annuitants), or your Employee |
|                    | Express confirmation letter.                    |
+--------------------+-------------------------------------------------+
|                    | If you do not receive your ID card within 30    |
|                    | days after the effective date of your           |
|                    | enrollment, or if you need replacement cards,   |
|                    | call us :                                       |
|                    |                                                 |
|                    | Eastern and Central Missouri Regions:           |
|                    | 314-214-8196 or 1-800-327-0763                  |
|                    |                                                 |
|                    | Southwest Missouri Region: 417-836-0402 or      |
|                    | 1-800-836-0402                                  |
|                    |                                                 |
|                    | Texas Region: 956-723-7667 or 1-800-617-3433    |
|                    |                                                 |
|                    | Or write to us at:                              |
|                    |                                                 |
|                    | Eastern and Central Missouri Regions: Mercy     |
|                    | Health Plans                                    |
|                    |                                                 |
|                    | 14528 South Outer 40, Suite 300                 |
|                    |                                                 |
|                    | Chesterfield, MO 63017                          |
|                    |                                                 |
|                    | Southwest Missouri Region: Premier Health Plans |
|                    |                                                 |
|                    | One Corporate Centre, Suite 200                 |
|                    |                                                 |
|                    | 1949 East Sunshine                              |
|                    |                                                 |
|                    | Springfield, MO 65804                           |
|                    |                                                 |
|                    | Texas Region: Mercy Health Plans                |
|                    |                                                 |
|                    | 5901 McPherson                                  |
|                    |                                                 |
|                    | Suites 1 & 2B                                   |
|                    |                                                 |
|                    | Laredo, TX 78041                                |
+--------------------+-------------------------------------------------+
| ### Where yo       | You get care from "Plan providers" and "Plan    |
| u get covered care | facilities." You will only pay copayments       |
|                    | and/or coinsurance, and you will not have to    |
|                    | file claims. You can access health care from    |
|                    | the point-of-service plan. These services are   |
|                    | subject to a calendar year deductible,          |
|                    | coinsurance copayments and balance billing.     |
|                    | (Balance billing refers to the amount billed by |
|                    | a provider that exceeds the usual, customary    |
|                    | and reasonable (UCR) charges allowed for        |
|                    | payment by the Plan). Balanced-billed charges   |
|                    | are your responsibility along with the annual   |
|                    | deductible and coinsurance and do not apply to  |
|                    | out-of-pocket maximums. You are responsible for |
|                    | verifying that the required prior approval is   |
|                    | given by the Plan for certain procedures.       |
|                    | Please contact Member Services for further      |
|                    | details. If you use our point-of-service        |
|                    | program, you can also get care from non-Plan    |
|                    | providers, or from participating providers      |
|                    | without a required referral, but it will cost   |
|                    | you more.                                       |
+--------------------+-------------------------------------------------+
| #                  | We list Plan providers in the provider          |
| ### Plan providers | directory, which we update periodically. The    |
|                    | list is also on our Web site. Plan providers    |
|                    | are physicians and other health care            |
|                    | professionals in our service area that we       |
|                    | contract with to provide covered services to    |
|                    | our members. We credential Plan providers       |
|                    | according to national standards. Log on to      |
|                    | [http://www.mercyhea                            |
|                    | lthplans.com](http://www.mercyhealthplans.com/) |
|                    | and learn more about our physicians. The site   |
|                    | features our Physician Directory, so you will   |
|                    | be able to find the information you need on our |
|                    | large selection of doctors.                     |
+--------------------+-------------------------------------------------+

+--------------------+-------------------------------------------------+
| ##                 | Plan facilities are hospitals and other         |
| ## Plan facilities | facilities in our service area that we contract |
|                    | with to provide covered services to our         |
|                    | members. We list these in the provider          |
|                    | directory, which we update periodically. The    |
|                    | list is also on our Web site.                   |
+--------------------+-------------------------------------------------+
| ###                | It depends on the type of care you need. First, |
| What you must do t | you and each family member must choose a        |
| o get covered care | primary care physician. If you are enrolled in  |
|                    | the Option product, you should select a PCP.    |
|                    | This decision is important since your primary   |
|                    | care physician provides or arranges for most of |
|                    | your health care. You should ask yourself some  |
|                    | questions before you choose your PCP. What is   |
|                    | the doctor's specialty? Does the PCP have a     |
|                    | subspecialty, such as gastroenterology or       |
|                    | pulmonology? Is the doctor's office close to    |
|                    | your home, office or school? Are the doctor's   |
|                    | office hours convenient for you? We suggest     |
|                    | that you call the doctors you are considering   |
|                    | so you can conduct your own interview. You will |
|                    | be one step ahead in ensuring your health and   |
|                    | the health of your family.                      |
+--------------------+-------------------------------------------------+
| #### Primary care  | Your primary care physician can be a family     |
|                    | practitioner, general practitioner, internist,  |
|                    | or pediatrician. Your primary care physician    |
|                    | will provide most of your health care, or give  |
|                    | you a referral to see a specialist (if needed). |
|                    | Female Members have direct access to an         |
|                    | Obstetrician or Gynecologist (OB/GYN).          |
|                    |                                                 |
|                    | Members in the Texas Region must select an      |
|                    | OB/GYN, on or before open enrollment, to        |
|                    | provide health care services within their scope |
|                    | of practice.                                    |
|                    |                                                 |
|                    | If you want to change primary care physicians   |
|                    | or if your primary care physician leaves the    |
|                    | Plan, call us. We will help you select a new    |
|                    | one.                                            |
+--------------------+-------------------------------------------------+
| #                  | **Members covered by Mercy Health Plans' Option |
| ### Specialty care | product in the Eastern Missouri Region should   |
|                    | choose a participating PCP.** Once your PCP     |
|                    | determines you have a medical condition, which  |
|                    | requires specialty consultation, your PCP will  |
|                    | provide you with the information needed to see  |
|                    | a participating provider. No additional Mercy   |
|                    | Health Plans' generated referral number is      |
|                    | required. However, the Alton MultiSpecialist    |
|                    | Group is an exception to the Option Product. If |
|                    | you receive care within the Alton               |
|                    | MultiSpecialist Group, you are still required   |
|                    | to select a PCP and obtain Plan approval and    |
|                    | the required Plan generated referral number for |
|                    | PCP referrals to a specialist.                  |
|                    |                                                 |
|                    | **Members with Mercy/Premier Health Plans in    |
|                    | our Central and Southwest Missouri Regions and  |
|                    | Texas Regions are required to select a PCP.**   |
|                    | Once the PCP determines that the individual     |
|                    | requires specialty care, a referral number is   |
|                    | obtained from our (or Mercy/Premier Health      |
|                    | Plans' designee's/delegate's) utilization       |
|                    | management department. This referral number     |
|                    | must be obtained in advance of services in      |
|                    | order for benefits to be considered.            |
|                    |                                                 |
|                    | When you receive a referral from your primary   |
|                    | care physician, you must return to the primary  |
|                    | care physician after the consultation, unless   |
|                    | your primary care physician authorized a        |
|                    | certain number of visits without additional     |
|                    | referrals. The primary care physician must      |
|                    | provide or authorize all follow-up care. Do not |
|                    | go to the specialist for return visits unless   |
|                    | your primary care physician gives you a         |
|                    | referral. However, you may see an OB/GYN        |
|                    | without a referral. You can access a            |
|                    | non-participating OB/GYN under your POS         |
|                    | benefit, except for well-woman visits.          |
|                    |                                                 |
|                    | When medically necessary, your PCP will arrange |
|                    | for referrals to a specialist. Your primary     |
|                    | care physician and specialist will work         |
|                    | together to coordinate your total care. If you  |
|                    | access specialty care without an understanding  |
|                    | of the number of visits and the amount of time  |
|                    | approved for treatment, you may be responsible  |
|                    | for the entire bill. Your PCP will arrange a    |
|                    | standing referral to a specialist or            |
|                    | specialists center (if necessary). Your PCP,    |
|                    | the Chief Medical Officer and participating     |
|                    | specialist will determine the need and          |
|                    | parameters of a standing referral. A standing   |
|                    | referral is based on a diagnosis of a           |
|                    | life-threatening condition or disease; a        |
|                    | degenerative and disabling condition or         |
|                    | disease; ongoing care from a specialist or      |
|                    | required specialized medical care over a        |
|                    | prolonged period of time. Your PCP may request  |
|                    | standing referrals.                             |
|                    |                                                 |
|                    | **Here are other things you should know about   |
|                    | specialty care for all Regions:**               |
|                    |                                                 |
|                    | -   If you need to see a specialist frequently  |
|                    |     because of a chronic, complex, or serious   |
|                    |     medical condition, your PCP will develop a  |
|                    |     treatment plan that allows you to see your  |
|                    |     specialist for a certain number of visits   |
|                    |     without additional referrals. Your primary  |
|                    |     care physician will use our criteria when   |
|                    |     creating your treatment plan (the physician |
|                    |     may have to get an authorization or         |
|                    |     approval beforehand).                       |
|                    |                                                 |
|                    | -   If you are seeing a specialist when you     |
|                    |     enroll in our Plan, talk to your primary    |
|                    |     care physician. Your primary care physician |
|                    |     will decide what treatment you need. If he  |
|                    |     or she decides to refer you to a            |
|                    |     specialist, ask if you can see your current |
|                    |     specialist. If your current specialist does |
|                    |     not participate with us, you must receive   |
|                    |     treatment from a specialist who does.       |
|                    |     Generally, we will not pay for you to see a |
|                    |     specialist who does not participate with    |
|                    |     our Plan.                                   |
|                    |                                                 |
|                    | -   If you are seeing a specialist and your     |
|                    |     specialist leaves the Plan, call your       |
|                    |     primary care physician, who will arrange    |
|                    |     for you to see another specialist. You may  |
|                    |     receive services from your current          |
|                    |     specialist until we can make arrangements   |
|                    |     for you to see someone else.                |
|                    |                                                 |
|                    | -   If you have a chronic and disabling         |
|                    |     condition and lose access to your           |
|                    |     specialist because we:                      |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   terminate our contract with your specialist |
|                    |     for other than cause; or                    |
|                    |                                                 |
|                    | -   drop out of the Federal Employees Health    |
|                    |     Benefits (FEHB) Program and you enroll in   |
|                    |     another FEHB Plan; or                       |
|                    |                                                 |
|                    | -   reduce our service area and you enroll in   |
|                    |     another FEHB Plan,                          |
|                    |                                                 |
|                    | You may be able to continue seeing your         |
|                    | specialist for up to 90 days after you receive  |
|                    | notice of the change. Contact us or, if we drop |
|                    | out of the Program, contact your new plan.      |
|                    |                                                 |
|                    | If you are in the second or third trimester of  |
|                    | pregnancy and you lose access to your           |
|                    | specialist based on the above circumstances,    |
|                    | you can continue to see your specialist until   |
|                    | the end of your postpartum care, even if it is  |
|                    | beyond the 90 days.                             |
+--------------------+-------------------------------------------------+
| #### Hospital care | Your Plan primary care physician or specialist  |
|                    | will make necessary hospital arrangements and   |
|                    | supervise your care. This includes admission to |
|                    | a skilled nursing or other type of facility.    |
|                    |                                                 |
|                    | If you are in the hospital when your enrollment |
|                    | in our Plan begins, call our customer service   |
|                    | department immediately at                       |
|                    |                                                 |
|                    | Eastern and Central Missouri Regions:           |
|                    | 314-214-8196 or 1-800-327-0763                  |
|                    |                                                 |
|                    | Southwest Missouri Region: 417-836-0402 or      |
|                    | 1-800-836-0402                                  |
|                    |                                                 |
|                    | Texas Region: 956-723-7667 or 1-800-617-3433    |
|                    |                                                 |
|                    | If you are new to the FEHB Program, we will     |
|                    | arrange for you to receive care.                |
|                    |                                                 |
|                    | If you changed from another FEHB plan to us,    |
|                    | your former plan will pay for the hospital stay |
|                    | until:                                          |
|                    |                                                 |
|                    | -   You are discharged, not merely moved to an  |
|                    |     alternative care center; or                 |
|                    |                                                 |
|                    | -   The day your benefits from your former plan |
|                    |     run out; or                                 |
|                    |                                                 |
|                    | -   The 92^nd^ day after you become a member of |
|                    |     this Plan, whichever happens first.         |
|                    |                                                 |
|                    | These provisions apply only to the benefits of  |
|                    | the hospitalized person. If your plan           |
|                    | terminates participation in the FEHB Program in |
|                    | whole or in part, or if OPM orders an           |
|                    | enrollment change, this continuation of         |
|                    | coverage provision does not apply. In such      |
|                    | case, the hospitalized family member's benefits |
|                    | under the new plan begin on the effective date  |
|                    | of enrollment..                                 |
+--------------------+-------------------------------------------------+
| ### Circumstances  | Under certain extraordinary circumstances, such |
| beyond our control | as natural disasters, we may have to delay your |
|                    | services or we may be unable to provide them.   |
|                    | In that case, we will make all reasonable       |
|                    | efforts to provide you with the necessary care. |
+--------------------+-------------------------------------------------+
| ### S              | Your primary care physician has authority to    |
| ervices requiring  | refer you for most services. For certain        |
| our prior approval | services, however, your physician must obtain   |
|                    | approval from us. Before giving approval, we    |
|                    | consider if the service is covered, medically   |
|                    | necessary, and follows generally accepted       |
|                    | medical practice.                               |
|                    |                                                 |
|                    | We call this review and approval process prior  |
|                    | approval. Your physician must obtain prior      |
|                    | approval for services such as:                  |
|                    |                                                 |
|                    | -   Certain medications                         |
|                    |                                                 |
|                    | -   All inpatient hospitalizations              |
|                    |                                                 |
|                    | -   All skilled nursing facility services       |
|                    |                                                 |
|                    | -   All rehabilitation facility services        |
|                    |                                                 |
|                    | -   All infertility services                    |
|                    |                                                 |
|                    | -   Home Health Care                            |
|                    |                                                 |
|                    | -   Home Infusion Intravenous (IV) Services     |
|                    |                                                 |
|                    | -   Durable Medical Equipment                   |
|                    |                                                 |
|                    | -   PET scans                                   |
|                    |                                                 |
|                    | -   MRIs                                        |
|                    |                                                 |
|                    | -   CT scans                                    |
|                    |                                                 |
|                    | -   TMJ Arthrography                            |
|                    |                                                 |
|                    | -   Computerized axial tomography bone density  |
|                    |     study                                       |
|                    |                                                 |
|                    | -   Radiographic absorptiometry (e.g.           |
|                    |     photodensitometry)                          |
|                    |                                                 |
|                    | -   Greater than two ultrasounds per pregnancy  |
|                    |                                                 |
|                    | -   Ultrasound bone density measurement         |
|                    |                                                 |
|                    | -   Surgical procedures                         |
|                    |                                                 |
|                    | -   Hospice care, inpatient or outpatient       |
|                    |                                                 |
|                    | -   Routine patient care associated with phase  |
|                    |     III or IV cancer clinical trials            |
|                    |                                                 |
|                    | It is the shared responsibility of both you and |
|                    | your PCP or specialist to assure that referrals |
|                    | are obtained, accurate and current. If a        |
|                    | referral is required, you are responsible for   |
|                    | verifying the approved date range of the        |
|                    | referral, number of visits and types of         |
|                    | services that have been authorized. When you    |
|                    | choose to receive                               |
|                    |                                                 |
|                    | services from a participating provider without  |
|                    | a prior referral from your chosen primary care  |
|                    | physician, the specialists will request that    |
|                    | you be responsible for payment of the services. |
|                    | When this occurs, you may be responsible for    |
|                    | the charges. If required, a referral must be    |
|                    | obtained prior to receiving certain services.   |
|                    |                                                 |
|                    | It is your responsibility to verify that the    |
|                    | required prior approval has been given by the   |
|                    | Plan for out-of-network services. If prior      |
|                    | approval is not given, eligible charges will be |
|                    | subject to the non-compliance reduction and the |
|                    | amount of the reduction will not apply toward   |
|                    | your out-of-pocket maximum or deductible. See   |
|                    | Section 5(i).                                   |
+--------------------+-------------------------------------------------+

# Section 4. Your costs for covered services

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

+------------------+---------------------------------------------------+
| ### Copayments   | A copayment is a fixed amount of money you pay to |
|                  | the provider, facility, pharmacy, etc., when you  |
|                  | receive services.                                 |
|                  |                                                   |
|                  | Example: When you see your primary care physician |
|                  | you pay a copayment of \$10 per office visit and  |
|                  | when you go in the hospital, you pay \$0 per      |
|                  | admission.                                        |
+------------------+---------------------------------------------------+
| ### Deductible   | A deductible is a fixed expense you must incur    |
|                  | for certain covered services and supplies before  |
|                  | we start paying benefits for them. Copayments do  |
|                  | not count toward any deductible.                  |
|                  |                                                   |
|                  | In **[Missouri Regions]{.underline}**, you are    |
|                  | required to pay a \$500 deductible per member per |
|                  | calendar year and \$1,000 deductible per family   |
|                  | per calendar year for out-of-network benefits.    |
|                  | Your cost is 30% coinsurance after the            |
|                  | deductible. This deductible applies to Point of   |
|                  | Service (POS) benefits only. The catastrophic     |
|                  | protection out-of-pocket maximum per member is    |
|                  | \$3,500 (including the deductible) and \$7,000    |
|                  | per family (including deductible). Please refer   |
|                  | to Section 5(i) for additional information.       |
|                  |                                                   |
|                  | In the **[Texas Region]{.underline}**, you are    |
|                  | required to pay a \$1,000 deductible per member   |
|                  | per calendar year and a \$2,000 deductible per    |
|                  | family per calendar year for out-of-network       |
|                  | benefits. This deductible applies to POS benefits |
|                  | only. Your cost is 40% coinsurance after the      |
|                  | deductible. There is an unlimited out-of-pocket   |
|                  | maximum for members and their families in the     |
|                  | Texas Region. Please refer to Section 5(i) for    |
|                  | additional information.                           |
|                  |                                                   |
|                  | 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  | Coinsurance is the percentage of our negotiated   |
|                  | fee that you must pay for your care. Coinsurance  |
|                  | doesn't begin until you meet your deductible.     |
|                  |                                                   |
|                  | Example: You pay 50% of our allowance for         |
|                  | in-network Infertility services.                  |
+------------------+---------------------------------------------------+
| ### You          | In **[Missouri Regions]{.underline}**, after your |
| r catastrophic p | copayments and/or coinsurance for in-network      |
| rotection out-of | services total \$2,200 per person or \$6,600 per  |
| -pocket maximum  | family enrollment in any calendar year, you do    |
|                  | not have to pay any more for covered services.    |
|                  | However, copayments or coinsurance for the        |
|                  | following services do not count toward your       |
|                  | catastrophic protection out-of-pocket maximum,    |
|                  | and you must continue to pay copayments or        |
|                  | coinsurance for these services:                   |
|                  |                                                   |
|                  | -   *Chiropractic Care*                           |
|                  |                                                   |
|                  | -   *Infertility Services*                        |
|                  |                                                   |
|                  | -   *Outpatient Prescription Drugs*               |
|                  |                                                   |
|                  | In the **[Texas Region]{.underline}**, after your |
|                  | copayments and/or coinsurance for in-network      |
|                  | services total \$1,000 per person or \$2,000 per  |
|                  | family enrollment in any calendar year, you do    |
|                  | not have to pay any more for covered services.    |
+------------------+---------------------------------------------------+
|                  | *Out of Network*                                  |
|                  |                                                   |
|                  | In **[Missouri Regions]{.underline}**, after your |
|                  | deductible, coinsurance and/or copayments for     |
|                  | out-of-network services total \$3,500 (including  |
|                  | deductible) per person or \$7,000 (including      |
|                  | deductible) per family, you do not have to pay    |
|                  | any more for covered services.                    |
|                  |                                                   |
|                  | In the **[Texas Region]{.underline}**, members    |
|                  | and their families have unlimited out-of-pocket   |
|                  | maximums.                                         |
|                  |                                                   |
|                  | Be sure to keep accurate records of your          |
|                  | copayments or coinsurance since you are           |
|                  | responsible for informing us when you reach the   |
|                  | maximum.                                          |
+------------------+---------------------------------------------------+

# Section 5. Benefits -- OVERVIEW *(See page 8 for how our benefits changed this year and page 75 for a benefits summary.)*

**NOTE**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at

Mercy Health Plans (Eastern and Central Missouri Regions): (314)
214-8196 or 1-800-327-0763

Premier Health Plans (Southwest Missouri Regions): (417) 836-0402 or
1-800-836-0402

Mercy Health Plans (Texas Region): (956) 723-7667 or 1-800-617-3433

or at our Web site at
[www.mercyhealthplans.com](http://www.mercyhealthplans.com/) *.*

[Section 5(a) Medical services and supplies provided by physicians and
other health care professionals 18](#_Introduction)

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

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

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

[Preventive care, children 20](#preventive-care-children)

[Maternity care 21](#maternity-care)

[Family planning 21](#family-planning)

[Infertility services 22](#infertility-services)

[Allergy care 22](#allergy-care)

[Treatment therapies 23](#treatment-therapies)

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

[Speech therapy 24](#speech-therapy)

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

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

[Foot care 25](#foot-care)

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

[Durable medical equipment (DME) 27](#durable-medical-equipment-dme)

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

[Chiropractic 29](#chiropractic)

[Alternative treatments 29](#alternative-treatments)

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

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

[Surgical procedures 30](#surgical-procedures)

[Reconstructive surgery 31](#reconstructive-surgery)

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

[Organ/tissue transplants 33](#_Organ/tissue_transplants)

[Anesthesia 34](#anesthesia)

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

[Inpatient hospital 35](#inpatient-hospital)

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

[Extended care benefits/Skilled nursing care facility benefits
36](#_Extended_care_benefits/Skilled)

[Hospice care 37](#hospice-care)

[Ambulance 37](#ambulance)

[Section 5(d) Emergency services/accidents 38](#_Introduction)

[Emergency within our service area 39](#EWS)

[Emergency outside our service area 39](#EOS)

[Ambulance 40](#AMB)

[Section 5(e) Mental health and substance abuse benefits
41](#_Introduction)

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

[Section 5(f) Prescription drug benefits 43](#_Introduction)

[Covered medications and supplies 44](#covered-medications-and-supplies)

[Section 5(g) Special features 46](#_Introduction)

[Flexible benefits option 46](#flexible-benefits-option)

[24 hour nurse line 46](#hour-nurse-line)

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

[Section 5(h) Dental benefits 47](#_Introduction)

[Accidental injury benefit 47](#accidental-injury-benefit)

[Dental benefits 47](#dental-benefits)

[Section 5(i) Point of Service benefits 48](#_Hlt514733838)

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

[Summary of benefits for the Mercy Health Plans/Premier Health Plans *-*
2005 75](#_Introduction)

[2005 Rate Information for Mercy Health Plans/Premier Health Plans
77](#_Introduction)

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

+---+---+-------------------------------------+---------------------+---+---+
|   | * | **Here are some important things    |                     | * |   |
|   | * | you should keep in mind about these |                     | * |   |
|   | I | benefits:**                         |                     | I |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Plan physicians must provide or |                     | * |   |
|   | * |     arrange your care.              |                     | * |   |
|   | P |                                     |                     | P |   |
|   | * | -   We have no in-network calendar  |                     | * |   |
|   | * |     year deductible.                |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Be sure to read Section 4,      |                     | * |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | O |     services*, for valuable         |                     | O |   |
|   | * |     information about how cost      |                     | * |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   |   |     Section 9 about coordinating    |                     |   |   |
|   | * |     benefits with other coverage,   |                     | * |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | R |                                     |                     | R |   |
|   | * | -   **Your physician must get       |                     | * |   |
|   | * |     pre-authorization for some      |                     | * |   |
|   |   |     in-network services and         |                     |   |   |
|   | * |     supplies. Please see Section    |                     | * |   |
|   | * |     3.**                            |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * | -   **POS out-of-network services   |                     | * |   |
|   | * |     are subject to a calendar year  |                     | * |   |
|   |   |     deductible. You must get        |                     |   |   |
|   | * |     preauthorization before any     |                     | * |   |
|   | * |     service is rendered             |                     | * |   |
|   | A |     out-of-network. POS benefits    |                     | A |   |
|   | * |     and services are limited.       |                     | * |   |
|   | * |     Please see Section 3 & 5(i) for |                     | * |   |
|   |   |     details.**                      |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | N |                                     |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | **[Missouri         |   |   |
| r |   |                                     | Re                  |   |   |
| o |   |                                     | gion]{.underline}** |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     | \$10 per visit to   |   |   |
| s |   |                                     | your primary care   |   |   |
| s |   |                                     | physician           |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     | \$20 per visit to a |   |   |
| n |   |                                     | specialist          |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     | **[Texas            |   |   |
| s |   |                                     | Re                  |   |   |
| e |   |                                     | gion]{.underline}** |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     | \$10 per visit to   |   |   |
| i |   |                                     | your primary care   |   |   |
| c |   |                                     | physician           |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     | \$10 per visit to a |   |   |
| o |   |                                     | specialist          |   |   |
| f |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| I |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| ' |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$25 per visit      |   |   |
| r |   |                                     |                     |   |   |
| o |   |                                     | Nothing             |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     | Nothing             |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     | For office medical  |   |   |
| i |   |                                     | consultations and   |   |   |
| o |   |                                     | second surgical     |   |   |
| n |   |                                     | opinion, copays are |   |   |
| a |   |                                     | the following:      |   |   |
| l |   |                                     |                     |   |   |
| s |   |                                     | **[Missouri         |   |   |
| e |   |                                     | Re                  |   |   |
| r |   |                                     | gion]{.underline}** |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     | \$10 per visit to   |   |   |
| c |   |                                     | your primary care   |   |   |
| e |   |                                     | physician           |   |   |
| s |   |                                     |                     |   |   |
| o |   |                                     | \$20 per visit to a |   |   |
| f |   |                                     | specialist          |   |   |
| p |   |                                     |                     |   |   |
| h |   |                                     | **[Texas            |   |   |
| y |   |                                     | Re                  |   |   |
| s |   |                                     | gion]{.underline}** |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     | \$10 per visit to   |   |   |
| i |   |                                     | your primary care   |   |   |
| a |   |                                     | physician           |   |   |
| n |   |                                     |                     |   |   |
| s |   |                                     | \$10 per visit to a |   |   |
|   |   |                                     | specialist          |   |   |
| - |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

*Diagnostic and treatment services -- continued on next page*

+------------------------------------------+---------------------------+
| Diagnostic and treatment services        | You pay                   |
| *(continued)*                            |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| *Physical examinations that are not      |                           |
| necessary for medical reasons, such as   |                           |
| those required for obtaining or          |                           |
| continuing employment or insurance,      |                           |
| attending camp or travel*                |                           |
+------------------------------------------+---------------------------+
| ####                                     |                           |
| ## Lab, X-ray and other diagnostic tests |                           |
+------------------------------------------+---------------------------+
| Tests, such as:                          | Nothing                   |
|                                          |                           |
| -   Blood tests                          |                           |
|                                          |                           |
| -   Urinalysis                           |                           |
|                                          |                           |
| -   Non-routine pap tests                |                           |
|                                          |                           |
| -   Pathology                            |                           |
|                                          |                           |
| -   X-rays                               |                           |
|                                          |                           |
| -   Non-routine Mammograms               |                           |
|                                          |                           |
| -   CAT Scans/MRI                        |                           |
|                                          |                           |
| -   Ultrasound                           |                           |
|                                          |                           |
| -   Electrocardiogram and EEG            |                           |
+------------------------------------------+---------------------------+
| ###### Preventive care, adult            |                           |
+------------------------------------------+---------------------------+
| Routine screenings, such as:             | **[Missouri               |
|                                          | Region]{.underline}**     |
| -   Total Blood Cholesterol -- once      |                           |
|     every three years                    | \$10 per visit to your    |
|                                          | primary care physician    |
| -   Colorectal Cancer Screening,         |                           |
|     including                            | \$20 per visit to a       |
|                                          | specialist                |
| ```{=html}                               |                           |
| <!-- -->                                 | **[Texas                  |
| ```                                      | Region]{.underline}**     |
| -   Fecal occult blood test              |                           |
|                                          | \$10 per visit to your    |
| -   Sigmoidoscopy, screening -- every    | primary care physician    |
|     five years starting at age 50        |                           |
|                                          | \$10 per visit to a       |
| -   Double contrast barium enema --      | specialist                |
|     every five years starting at age 50  |                           |
|                                          |                           |
| -   Colonoscopy screening -- every ten   |                           |
|     years starting at age 50             |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Hearing and vision screening         |                           |
|                                          |                           |
| -   Blood pressure testing               |                           |
|                                          |                           |
| -   Complete Blood Count (CBC)           |                           |
+------------------------------------------+---------------------------+
| Routine Prostate Specific Antigen (PSA)  | **[Missouri               |
| test -- one annually for men age 40 and  | Region]{.underline}**     |
| older                                    |                           |
|                                          | \$10 per visit to your    |
|                                          | primary care physician    |
|                                          |                           |
|                                          | \$20 per visit to a       |
|                                          | specialist                |
|                                          |                           |
|                                          | **[Texas                  |
|                                          | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per visit to your    |
|                                          | primary care physician    |
|                                          |                           |
|                                          | \$10 per visit to a       |
|                                          | specialist                |
+------------------------------------------+---------------------------+
|                                          | *Preventive care, adult − |
|                                          | continued on next page*   |
+------------------------------------------+---------------------------+
| Preventive care, adult *(continued)*     | You pay                   |
+------------------------------------------+---------------------------+
| Routine pap test                         | **[Missouri               |
|                                          | Region]{.underline}**     |
| Note: The office visit is covered if pap |                           |
| test is received on the same day; see    | \$10 per visit to your    |
| *Diagnosis and Treatment*, above.        | primary care physician    |
|                                          |                           |
|                                          | \$20 per visit to a       |
|                                          | specialist                |
|                                          |                           |
|                                          | **[Texas                  |
|                                          | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per visit to your    |
|                                          | primary care physician    |
|                                          |                           |
|                                          | \$10 per visit to a       |
|                                          | specialist                |
+------------------------------------------+---------------------------+
| Routine mammogram -- covered for women   | Nothing                   |
| age 35 and older, as follows:            |                           |
|                                          |                           |
| -   From age 35 through 39, one during   |                           |
|     this five year period                |                           |
|                                          |                           |
| -   From age 40 and older, one every     |                           |
|     calendar year                        |                           |
+------------------------------------------+---------------------------+
| Routine immunizations, limited to:       | Nothing                   |
|                                          |                           |
| -   Tetanus-diphtheria (Td) booster --   |                           |
|     once every 10 years, ages19 and over |                           |
|     (except as provided for under        |                           |
|     Childhood immunizations)             |                           |
|                                          |                           |
| -   Influenza vaccine, annually          |                           |
|                                          |                           |
| -   Pneumococcal vaccine, age 65 and     |                           |
|     older                                |                           |
+------------------------------------------+---------------------------+
| *Not covered: Physical exams required    | *All charges.*            |
| for obtaining or continuing employment   |                           |
| or insurance, attending schools or camp, |                           |
| or travel.*                              |                           |
+------------------------------------------+---------------------------+
| ###### Preventive care, children         |                           |
+------------------------------------------+---------------------------+
| -   Childhood immunizations recommended  | Nothing                   |
|     by the American Academy of           |                           |
|     Pediatrics                           |                           |
+------------------------------------------+---------------------------+
| -   Well-child care charges for routine  | **[Missouri               |
|     examinations, immunizations and care | Region]{.underline}**     |
|     (up to age 22)                       |                           |
|                                          | \$10 per visit to your    |
| -   Examinations, such as:               | primary care physician    |
|                                          |                           |
| ```{=html}                               | \$20 per visit to a       |
| <!-- -->                                 | specialist                |
| ```                                      |                           |
| -   Eye exams through age 17 to          | **[Texas                  |
|     determine the need for vision        | Region]{.underline}**     |
|     correction                           |                           |
|                                          | \$10 per visit to your    |
| -   Ear exams through age 17 to          | primary care physician    |
|     determine the need for hearing       |                           |
|     correction                           | \$10 per visit to a       |
|                                          | specialist                |
| -   Examinations done on the day of      |                           |
|     immunizations (up to age 22)         |                           |
+------------------------------------------+---------------------------+
| ###### Maternity care                    | You pay                   |
+------------------------------------------+---------------------------+
| Complete maternity (obstetrical) care,   | **[Missouri               |
| such as:                                 | Region]{.underline}**     |
|                                          |                           |
| -   Prenatal care                        | One time \$20 Copayment   |
|                                          | for all office visits     |
| -   Delivery                             | associated with prenatal  |
|                                          | care during a single      |
| -   Postnatal care                       | pregnancy.                |
|                                          |                           |
| Note: Here are some things to keep in    | **[Texas                  |
| mind:                                    | Region]{.underline}**     |
|                                          |                           |
| -   You do not need to precertify your   | One time \$10 Copayment   |
|     normal delivery; see page 12 for     | for all office visits     |
|     other circumstances, such as         | associated with prenatal  |
|     extended stays for you or your baby. | care during a single      |
|                                          | pregnancy.                |
| -   You may remain in the hospital up to |                           |
|     48 hours after a regular delivery    |                           |
|     and 96 hours after a cesarean        |                           |
|     delivery. We will extend your        |                           |
|     inpatient stay if medically          |                           |
|     necessary.                           |                           |
|                                          |                           |
| -   We cover routine nursery care of the |                           |
|     newborn child during the covered     |                           |
|     portion of the mother's maternity    |                           |
|     stay. We will cover other care of an |                           |
|     infant who requires non-routine      |                           |
|     treatment only if we cover the       |                           |
|     infant under a Self and Family       |                           |
|     enrollment. Circumcision is covered  |                           |
|     under surgical benefits.             |                           |
|                                          |                           |
| -   We pay hospitalization and surgeon   |                           |
|     services (delivery) the same as for  |                           |
|     illness and injury. See Hospital     |                           |
|     benefits (Section 5c) and Surgery    |                           |
|     benefits (Section 5b).               |                           |
+------------------------------------------+---------------------------+
| *Not covered: Routine sonograms to       | *All charges.*            |
| determine fetal age, size or sex.*       |                           |
+------------------------------------------+---------------------------+
| ###### Family planning                   |                           |
+------------------------------------------+---------------------------+
| A range of voluntary family planning     | **[Missouri               |
| services, limited to:                    | Region]{.underline}**     |
|                                          |                           |
| -   Voluntary sterilization (See         | \$10 per visit to your    |
|     Surgical procedures Section 5 (b))   | primary care physician    |
|                                          |                           |
| -   Surgically implanted contraceptives  | \$20 per visit to a       |
|     (such as Norplant)                   | specialist                |
|                                          |                           |
| -   Injectable contraceptive drugs (such | **[Texas                  |
|     as Depo provera)                     | Region]{.underline}**     |
|                                          |                           |
| -   Intrauterine devices (IUDs)          | \$10 per visit to your    |
|                                          | primary care physician    |
| -   Diaphragms                           |                           |
|                                          | \$10 per visit to a       |
| Note: We cover oral contraceptives under | specialist                |
| the prescription drug benefit.           |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   Reversal of voluntary surgical       |                           |
|     sterilization                        |                           |
|                                          |                           |
| -   Genetic counseling.                  |                           |
+------------------------------------------+---------------------------+
| ###### Infertility services              | You pay                   |
+------------------------------------------+---------------------------+
| Diagnosis and treatment of infertility   | **[Missouri               |
| such as:                                 | Region]{.underline}**     |
|                                          |                           |
| -   Artificial insemination:             | \$10 per visit to your    |
|                                          | primary care physician    |
| ```{=html}                               | for the diagnosis of      |
| <!-- -->                                 | infertility               |
| ```                                      |                           |
| -   *intravaginal insemination (IVI)*    | \$20 per visit to a       |
|                                          | specialist for the        |
| -   *intracervical insemination (ICI)*   | diagnosis of infertility  |
|                                          |                           |
| -   *intrauterine insemination (IUI)*    | 50% Coinsurance of the    |
|                                          | Plan allowance for the    |
| Note: Prior Authorization is required    | treatment of infertility. |
| for these services. Please see Section   |                           |
| 3.                                       | **[Texas                  |
|                                          | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per visit to your    |
|                                          | primary care physician    |
|                                          | for the diagnosis of      |
|                                          | infertility               |
|                                          |                           |
|                                          | \$10 per visit to a       |
|                                          | specialist for the        |
|                                          | diagnosis of infertility  |
|                                          |                           |
|                                          | 50% Coinsurance of the    |
|                                          | Plan allowance for the    |
|                                          | treatment of infertility. |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Assisted reproductive technology    |                           |
|     (ART) procedures, such as:*          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *- in vitro fertilization*           |                           |
|                                          |                           |
| -   *- embryo transfer, gamete           |                           |
|     intra-fallopian transfer (GIFT) and  |                           |
|     zygote intra-fallopian transfer      |                           |
|     (ZIFT)*                              |                           |
|                                          |                           |
| -   *- Zygote transfer*                  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Services and supplies related to    |                           |
|     excluded ART procedures*             |                           |
|                                          |                           |
| -   *Cost of donor sperm*                |                           |
|                                          |                           |
| -   *Cost of donor egg*                  |                           |
|                                          |                           |
| -   *Fees for preparation and storage of |                           |
|     sperm and embryos*                   |                           |
|                                          |                           |
| -   *Fertility drugs*                    |                           |
|                                          |                           |
| -   *Infertility services after          |                           |
|     voluntary sterilization*             |                           |
+------------------------------------------+---------------------------+
| ###### Allergy care                      |                           |
+------------------------------------------+---------------------------+
| Testing and treatment                    | **[Missouri               |
|                                          | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per visit to your    |
|                                          | primary care physician    |
|                                          |                           |
|                                          | \$20 per visit to a       |
|                                          | specialist                |
|                                          |                           |
|                                          | **[Texas                  |
|                                          | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per visit to your    |
|                                          | primary care physician    |
|                                          |                           |
|                                          | \$10 per visit to a       |
|                                          | specialist                |
+------------------------------------------+---------------------------+
| Allergy injection                        | Nothing                   |
+------------------------------------------+---------------------------+
| Allergy serum                            | Nothing                   |
+------------------------------------------+---------------------------+
| *Not covered: Provocative food testing   | *All charges.*            |
| and sublingual allergy desensitization*  |                           |
+------------------------------------------+---------------------------+
| ###### Treatment therapies               | You pay                   |
+------------------------------------------+---------------------------+
| -   Chemotherapy and radiation therapy   | **[Missouri               |
|                                          | Region]{.underline}**     |
| Note: High dose chemotherapy in          |                           |
| association with autologous bone marrow  | \$20 per office visit     |
| transplants is limited to those          |                           |
| transplants listed under Organ/Tissue    | \$20 per outpatient visit |
| Transplants on page 33.                  |                           |
|                                          | **[Texas                  |
| -   Respiratory and inhalation therapy   | Region]{.underline}**     |
|                                          |                           |
| -   Dialysis -- hemodialysis and         | \$10 per office visit     |
|     peritoneal dialysis                  |                           |
|                                          | \$10 per outpatient visit |
| -   Intravenous (IV)/Infusion Therapy -- |                           |
|     Home IV and antibiotic therapy       | All other services        |
|                                          | covered at no additional  |
| -   Coverage is provided for routine     | charge.                   |
|     patient care costs incurred as a     |                           |
|     result of phase III or IV of         |                           |
|     clinical trials undertaken for the   |                           |
|     purposes of the prevention, early    |                           |
|     detection, or treatment of cancer.   |                           |
|     This coverage includes coverage for  |                           |
|     drugs and devices approved by the    |                           |
|     United States Food and Drug          |                           |
|     Administration (FDA) regardless of   |                           |
|     whether the FDA has approved the     |                           |
|     drug or device for the patient\'s    |                           |
|     particular condition. The clinical   |                           |
|     trials must be approved or funded by |                           |
|     certain entities such as the         |                           |
|     National Institutes of Health        |                           |
|     Cooperative or an equivalent entity. |                           |
|     The clinical trial treatment is not  |                           |
|     covered. Routine patient care        |                           |
|     associated with phase III or IV      |                           |
|     cancer clinical trials require prior |                           |
|     authorization.                       |                           |
|                                          |                           |
| -   Growth hormone therapy (GHT)         |                           |
|                                          |                           |
| Note: Growth hormone is covered under    |                           |
| the prescription drug benefit.           |                           |
|                                          |                           |
| Note: Before we cover GHT, there are     |                           |
| certain guidelines to be performed and   |                           |
| documented. There are separate           |                           |
| guidelines for children and adults. We   |                           |
| will ask you to submit information that  |                           |
| establishes that the GHT is medically    |                           |
| necessary for that child or adult. Ask   |                           |
| us to authorize GHT before you begin     |                           |
| treatment; otherwise, we will only cover |                           |
| GHT services from the date you submit    |                           |
| the information. If you do not ask or if |                           |
| we determine GHT is not medically        |                           |
| necessary, we will not cover the GHT or  |                           |
| related services and supplies. See       |                           |
| *Services requiring our prior approval*  |                           |
| in Section 3.                            |                           |
+------------------------------------------+---------------------------+
| *Not covered: Treatments that have no    | *All charges.*            |
| proven clinical benefit for your         |                           |
| condition.*                              |                           |
+------------------------------------------+---------------------------+
| ###                                      |                           |
| ### Physical and occupational therapies  |                           |
+------------------------------------------+---------------------------+
| 60 visits per calendar year for the      | **[Missouri               |
| services of each of the following:       | Region]{.underline}**     |
|                                          |                           |
| -   qualified physical therapists and    | \$20 per office visit     |
|                                          |                           |
| -   occupational therapists              | \$20 per outpatient visit |
|                                          |                           |
| Note: We only cover therapy to restore   | **[Texas                  |
| bodily function when there has been a    | Region]{.underline}**     |
| total or partial loss of bodily function |                           |
| due to illness or injury.                | \$10 per office visit     |
|                                          |                           |
| -   Cardiac rehabilitation following a   | \$10 per outpatient visit |
|     heart transplant, bypass surgery or  |                           |
|     a myocardial infarction, is provided | Nothing per visit during  |
|     for up to 36 sessions per condition. | covered inpatient         |
|                                          | admission                 |
+------------------------------------------+---------------------------+

*Physical and occupational therapies -- continued on next page*

+------------------------------------------+---------------------------+
| Physical and occupational therapies      | You pay                   |
| *(continued)*                            |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Long-term rehabilitative therapy*   |                           |
|                                          |                           |
| -   *Exercise programs*                  |                           |
|                                          |                           |
| -   *Neuro-rehabilitation*               |                           |
|                                          |                           |
| -   *Work hardening programs or          |                           |
|     developmental educational therapy*   |                           |
+------------------------------------------+---------------------------+
| ###### Speech therapy                    |                           |
+------------------------------------------+---------------------------+
| 60 visits per calendar year.             | **[Missouri               |
|                                          | Region]{.underline}**     |
|                                          |                           |
|                                          | \$20 per office visit     |
|                                          |                           |
|                                          | \$20 per outpatient visit |
|                                          |                           |
|                                          | **[Texas                  |
|                                          | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per office visit     |
|                                          |                           |
|                                          | \$10 per outpatient visit |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Therapies that are not considered   |                           |
|     medically necessary by the Plan*     |                           |
+------------------------------------------+---------------------------+
| ###### Hearing ser                       |                           |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| -   First hearing aid and testing only   | **[Missouri               |
|     when necessitated by accidental      | Region]{.underline}**     |
|     injury                               |                           |
|                                          | \$10 per visit to your    |
| -   Hearing testing for children through | primary care physician    |
|     age 17 (see *Preventive care,        |                           |
|     children)*                           | \$20 per visit to a       |
|                                          | specialist                |
|                                          |                           |
|                                          | **[Texas                  |
|                                          | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per visit to your    |
|                                          | primary care physician    |
|                                          |                           |
|                                          | \$10 per visit to a       |
|                                          | specialist                |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *All other hearing testing*          |                           |
|                                          |                           |
| -   *Hearing aids, testing and           |                           |
|     examinations for them*               |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Vision ser                        | You pay                   |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| Diagnosis and treatment of diseases of   | **[Missouri               |
| eye, annual eye refractions (to provide  | Region]{.underline}**     |
| a written lens prescription for          |                           |
| eyeglasses or contact lenses) may be     | \$10 per visit to your    |
| obtained from Plan providers.            | primary care physician    |
|                                          |                           |
| One pair of eyeglasses or contact lenses | \$20 per visit to a       |
| to correct an impairment directly caused | specialist                |
| by accidental ocular injury or           |                           |
| intraocular surgery (such as for         | **[Texas                  |
| cataracts)                               | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per visit to your    |
|                                          | primary care physician    |
|                                          |                           |
|                                          | \$10 per visit to a       |
|                                          | specialist                |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Eyeglasses or contact lenses,       |                           |
|     except as described above*           |                           |
|                                          |                           |
| -   *Eye exercises and orthoptics*       |                           |
|                                          |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
+------------------------------------------+---------------------------+
| ###### Foot care                         |                           |
+------------------------------------------+---------------------------+
| -   Routine foot care when you are under | **[Missouri               |
|     active treatment for a metabolic or  | Region]{.underline}**     |
|     peripheral vascular disease, such as |                           |
|     diabetes.                            | \$10 per visit to your    |
|                                          | primary care physician    |
| -   See Orthopedic and prosthetic        |                           |
|     devices for information on podiatric | \$20 per visit to a       |
|     shoe inserts.                        | specialist                |
|                                          |                           |
|                                          | **[Texas                  |
|                                          | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per visit to your    |
|                                          | primary care physician    |
|                                          |                           |
|                                          | \$10 per visit to a       |
|                                          | specialist                |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Cutting trimming or removal of      |                           |
|     corns, calluses, or the free edge of |                           |
|     toenails, and similar routine        |                           |
|     treatment of conditions of the foot, |                           |
|     except as stated above*              |                           |
|                                          |                           |
| -   *Treatment of weak, strained or flat |                           |
|     feet or bunions or spurs; and of any |                           |
|     instability, imbalance or            |                           |
|     subluxation of the foot (unless the  |                           |
|     treatment is by open cutting         |                           |
|     surgery*                             |                           |
+------------------------------------------+---------------------------+
| #                                        | You pay                   |
| ##### Orthopedic and prosthetic devices  |                           |
+------------------------------------------+---------------------------+
| -   Artificial limbs and eyes; stump     | 20% Coinsurance           |
|     hose                                 |                           |
|                                          |                           |
| -   Externally worn breast prostheses    |                           |
|     and surgical bras, including         |                           |
|     necessary replacements following a   |                           |
|     mastectomy                           |                           |
|                                          |                           |
| -   Internal prosthetic devices, such as |                           |
|     artificial joints, pacemakers,       |                           |
|     cochlear implants, and surgically    |                           |
|     implanted breast implant following   |                           |
|     mastectomy. Note: See 5(b) for       |                           |
|     coverage of the surgery to insert    |                           |
|     the device.                          |                           |
|                                          |                           |
| -   Corrective orthopedic appliances for |                           |
|     non-dental treatment of              |                           |
|     temporomandibular joint (TMJ) pain   |                           |
|     dysfunction syndrome.                |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *orthopedic and corrective shoes*    |                           |
|                                          |                           |
| -   *arch supports*                      |                           |
|                                          |                           |
| -   *foot orthotics (except those        |                           |
|     authorized by the Plan)*             |                           |
|                                          |                           |
| -   *heel pads and heel cups*            |                           |
|                                          |                           |
| -   *lumbosacral supports*               |                           |
|                                          |                           |
| -   *corsets, trusses, elastic           |                           |
|     stockings, support hose, and other   |                           |
|     supportive devices*                  |                           |
|                                          |                           |
| -   *prosthetic replacements provided    |                           |
|     less than 3 years after the last one |                           |
|     we covered*                          |                           |
|                                          |                           |
| -   *electrical continence aids, anal or |                           |
|     urethral*                            |                           |
|                                          |                           |
| -   *implants for cosmetic or            |                           |
|     psychologic reasons*                 |                           |
|                                          |                           |
| -   *other dental appliances*            |                           |
|                                          |                           |
| -   *replacement of cataract lenses      |                           |
|     necessary after cataract surgery*    |                           |
|                                          |                           |
| -   *remote control devices*             |                           |
|                                          |                           |
| -   *devices employing robotics*         |                           |
|                                          |                           |
| -   *all mechanical organs*              |                           |
|                                          |                           |
| -   *investigational or obsolete devices |                           |
|     and supplies*                        |                           |
|                                          |                           |
| -   *computer assisted devices*          |                           |
|                                          |                           |
| -   *prosthetic devices to restore       |                           |
|     sexual function (i.e. penile         |                           |
|     implants)*                           |                           |
+------------------------------------------+---------------------------+
| ###### Durable medical equipment (DME)   | You pay                   |
+------------------------------------------+---------------------------+
| Rental or purchase, at our option,       | Nothing                   |
| including repair and adjustment, of      |                           |
| durable medical equipment prescribed by  |                           |
| your Plan physician, such as oxygen and  |                           |
| dialysis equipment. Under this benefit,  |                           |
| we also cover:                           |                           |
|                                          |                           |
| -   casts, splints, surgical supplies    |                           |
|     and appliances, catheters and        |                           |
|     ileostomy supplies;                  |                           |
|                                          |                           |
| -   purchase of a truss, brace or        |                           |
|     support;                             |                           |
|                                          |                           |
| -   oxygen and the equipment necessary   |                           |
|     for its administration;              |                           |
|                                          |                           |
| -   mechanical equipment required for    |                           |
|     the treatment of a chronic or acute  |                           |
|     respiratory illness or failure, such |                           |
|     as asthmatic equipment;              |                           |
|                                          |                           |
| -   ambulatory dialysis;                 |                           |
|                                          |                           |
| -   wheelchairs;                         |                           |
|                                          |                           |
| -   hospital-type bed;                   |                           |
|                                          |                           |
| -   crutches;                            |                           |
|                                          |                           |
| -   walkers;                             |                           |
|                                          |                           |
| -   blood glucose monitors; and          |                           |
|                                          |                           |
| -   insulin pumps.                       |                           |
|                                          |                           |
| Note: Call us at:                        |                           |
|                                          |                           |
| (Eastern and Central Missouri Regions):  |                           |
| 314-214-8196 or 1-800-327-0763           |                           |
|                                          |                           |
| (Southwest Missouri Regions):            |                           |
| 417-836-0402 or 1-800-836-0402           |                           |
|                                          |                           |
| (Texas Region): 956-723-7667 or          |                           |
| 1-800-617-3433                           |                           |
|                                          |                           |
| as soon as your Plan physician           |                           |
| prescribes this equipment. We will       |                           |
| arrange with a health care provider to   |                           |
| rent or sell you durable medical         |                           |
| equipment at discounted rates and will   |                           |
| tell you more about this service when    |                           |
| you call.                                |                           |
+------------------------------------------+---------------------------+

*Durable medical equipment − continued on next page*

+------------------------------------------+---------------------------+
| Durable medical equipment *(continued)*  | You pay                   |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Motorized wheel chairs*             |                           |
|                                          |                           |
| -   *augmentative communication devices  |                           |
|     (i.e., computer assisted speech      |                           |
|     devices, speech teaching machines,   |                           |
|     telephones, TDD equipment, etc.)*    |                           |
|                                          |                           |
| -   *automated travel devices (i.e.,     |                           |
|     motor scooters, etc.)*               |                           |
|                                          |                           |
| -   *chair lifts and other transfer      |                           |
|     devices*                             |                           |
|                                          |                           |
| -   *devices that are primarily          |                           |
|     non-medical in nature or used        |                           |
|     primarily for comfort (i.e., foam    |                           |
|     pads, maternity belts, heating pads, |                           |
|     etc.)*                               |                           |
|                                          |                           |
| -   *elevators*                          |                           |
|                                          |                           |
| -   *equipment designed to alter the     |                           |
|     environment (i.e., air filters,      |                           |
|     humidifiers, dehumidifiers, air      |                           |
|     conditioners, lighting, etc.)*       |                           |
|                                          |                           |
| -   *exercise equipment*                 |                           |
|                                          |                           |
| -   *hygienic items (i.e., shower        |                           |
|     chairs, raised toilet seats, sauna   |                           |
|     baths, incontinence supplies, etc.)* |                           |
|                                          |                           |
| -   *massage devices*                    |                           |
|                                          |                           |
| -   *overhead tables*                    |                           |
|                                          |                           |
| -   *whirlpools, whirlpool pumps, hot    |                           |
|     tubs, and related items*             |                           |
|                                          |                           |
| -   *telephone alert systems*            |                           |
+------------------------------------------+---------------------------+
| ###### Home health services              |                           |
+------------------------------------------+---------------------------+
| -   Home health care ordered by a Plan   | Nothing                   |
|     physician and provided by a          |                           |
|     registered nurse (R.N.), licensed    |                           |
|     practical nurse (L.P.N.), licensed   |                           |
|     vocational nurse (L.V.N.), or home   |                           |
|     health aide.                         |                           |
|                                          |                           |
| -   Services include oxygen therapy,     |                           |
|     intravenous therapy and medications. |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Services primarily for hygiene,     |                           |
|     feeding, exercising, moving the      |                           |
|     patient, homemaking, companionship   |                           |
|     or giving oral medication*           |                           |
|                                          |                           |
| -   *Nursing care requested by, or for   |                           |
|     the convenience of, the patient or   |                           |
|     the patient's family*                |                           |
|                                          |                           |
| -   *Home care primarily for personal    |                           |
|     assistance that does not include a   |                           |
|     medical component and is not         |                           |
|     diagnostic, therapeutic, or          |                           |
|     rehabilitative*                      |                           |
|                                          |                           |
| -   *Private duty nursing or nursing     |                           |
|     assistants*                          |                           |
+------------------------------------------+---------------------------+
| ###### Chiropractic                      | You pay                   |
+------------------------------------------+---------------------------+
| -   Manipulation of the spine and        | **[Missouri               |
|     extremities                          | Region]{.underline}**     |
|                                          |                           |
| -   Adjunctive procedures such as        | \$20 per office visit     |
|     ultrasound, electrical muscle        |                           |
|     stimulation, vibratory therapy, and  | **[Texas                  |
|     cold pack application                | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per office visit     |
|                                          |                           |
|                                          | Referrals are required    |
|                                          | for Central Missouri      |
|                                          | Region and Texas Region.  |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| *Services for examination and/or         |                           |
| treatment of strictly                    |                           |
| non-neuromusculoskeletal disorders.*     |                           |
+------------------------------------------+---------------------------+
| ###### Alternative treatments            |                           |
+------------------------------------------+---------------------------+
| Acupuncture -- by a doctor of medicine   | **[Missouri               |
| or osteopathy for: anesthesia, pain      | Region]{.underline}**     |
| relief                                   |                           |
|                                          | \$10 per visit to your    |
|                                          | primary care physician    |
|                                          |                           |
|                                          | \$20 per visit to a       |
|                                          | specialist                |
|                                          |                           |
|                                          | **[Texas                  |
|                                          | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per visit to your    |
|                                          | primary care physician    |
|                                          |                           |
|                                          | \$10 per visit to a       |
|                                          | specialist                |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Biofeedback*                        |                           |
|                                          |                           |
| -   *Birth Coaches (other                |                           |
|     prenatal/parenting education         |                           |
|     classes)*                            |                           |
|                                          |                           |
| -   *Homeopathy*                         |                           |
|                                          |                           |
| -   *Hypnotherapy*                       |                           |
|                                          |                           |
| -   *Massage Therapy*                    |                           |
|                                          |                           |
| -   *Naturopathic services (i.e., herbal |                           |
|     therapy, etc.)*                      |                           |
+------------------------------------------+---------------------------+
| ###### Educational classes and programs  |                           |
+------------------------------------------+---------------------------+
| Coverage is limited to:                  | \$25 copayment per        |
|                                          | program per year.         |
| -   Smoking Cessation -- Up to \$100 for |                           |
|     one smoking cessation program per    | Will vary with the type   |
|     member per year, including all       | of services required      |
|     related expenses such as drugs.      |                           |
|     Smoking Cessation drugs are covered  |                           |
|     through the Prescription drug        |                           |
|     benefit. See Section 5(f).           |                           |
|     **(Smoking Cessation programs not    |                           |
|     available in the Texas Region.)**    |                           |
|                                          |                           |
| -   Diabetes self management             |                           |
+------------------------------------------+---------------------------+

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

+---+---+------------------------------------+--------------------+---+---+
|   | * | **Here are some important things   |                    | * |   |
|   | * | you should keep in mind about      |                    | * |   |
|   | I | these benefits:**                  |                    | I |   |
|   | * |                                    |                    | * |   |
|   | * | -   Please remember that all       |                    | * |   |
|   |   |     benefits are subject to the    |                    |   |   |
|   | * |     definitions, limitations, and  |                    | * |   |
|   | * |     exclusions in this brochure    |                    | * |   |
|   | M |     and are payable only when we   |                    | M |   |
|   | * |     determine they are medically   |                    | * |   |
|   | * |     necessary.                     |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   Plan physicians must provide   |                    | * |   |
|   | * |     or arrange your care.          |                    | * |   |
|   | P |                                    |                    | P |   |
|   | * | -   We have no calendar year       |                    | * |   |
|   | * |     deductible                     |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   Be sure to read Section 4,     |                    | * |   |
|   | * |     *Your costs for covered        |                    | * |   |
|   | O |     services*, for valuable        |                    | O |   |
|   | * |     information about how cost     |                    | * |   |
|   | * |     sharing works. Also read       |                    | * |   |
|   |   |     Section 9 about coordinating   |                    |   |   |
|   | * |     benefits with other coverage,  |                    | * |   |
|   | * |     including with Medicare.       |                    | * |   |
|   | R |                                    |                    | R |   |
|   | * | -   The amounts listed below are   |                    | * |   |
|   | * |     for the charges billed by a    |                    | * |   |
|   |   |     physician or other health care |                    |   |   |
|   | * |     professional for your surgical |                    | * |   |
|   | * |     care. Look in Section 5(c) for |                    | * |   |
|   | T |     charges associated with the    |                    | T |   |
|   | * |     facility (i.e. hospital,       |                    | * |   |
|   | * |     surgical center, etc.).        |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   **Your physician must get      |                    | * |   |
|   | * |     pre-authorization for some     |                    | * |   |
|   | A |     in-network services. Please    |                    | A |   |
|   | * |     see Section 3.**               |                    | * |   |
|   | * |                                    |                    | * |   |
|   |   | -   **POS out-of-network services  |                    |   |   |
|   | * |     are subject to a calendar year |                    | * |   |
|   | * |     deductible. You must get       |                    | * |   |
|   | N |     preauthorization before any    |                    | N |   |
|   | * |     service is rendered            |                    | * |   |
|   | * |     out-of-network. POS benefits   |                    | * |   |
|   |   |     and services are limited.      |                    |   |   |
|   | * |     Please see Sections 3 & 5(i)   |                    | * |   |
|   | * |     for details.**                 |                    | * |   |
|   | T |                                    |                    | T |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
+---+---+------------------------------------+--------------------+---+---+
| B |   |                                    | You pay            |   |   |
| e |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| f |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| D |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| s |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| p |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| o |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| S |   |                                    |                    |   |   |
| u |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| g |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| a |   |                                    |                    |   |   |
| l |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| p |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| o |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| d |   |                                    |                    |   |   |
| u |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| s |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| A |   |                                    | **[Missouri        |   |   |
| c |   |                                    | Reg                |   |   |
| o |   |                                    | ion]{.underline}** |   |   |
| m |   |                                    |                    |   |   |
| p |   |                                    | \$10 per visit if  |   |   |
| r |   |                                    | performed in a     |   |   |
| e |   |                                    | primary care       |   |   |
| h |   |                                    | physician's office |   |   |
| e |   |                                    |                    |   |   |
| n |   |                                    | \$20 per visit if  |   |   |
| s |   |                                    | performed in a     |   |   |
| i |   |                                    | specialist's       |   |   |
| v |   |                                    | office             |   |   |
| e |   |                                    |                    |   |   |
| r |   |                                    | Nothing for        |   |   |
| a |   |                                    | inpatient or       |   |   |
| n |   |                                    | outpatient surgery |   |   |
| g |   |                                    |                    |   |   |
| e |   |                                    | **[Texas           |   |   |
| o |   |                                    | Reg                |   |   |
| f |   |                                    | ion]{.underline}** |   |   |
| s |   |                                    |                    |   |   |
| e |   |                                    | \$10 per visit if  |   |   |
| r |   |                                    | performed in a     |   |   |
| v |   |                                    | primary care       |   |   |
| i |   |                                    | physician's office |   |   |
| c |   |                                    |                    |   |   |
| e |   |                                    | \$10 per visit if  |   |   |
| s |   |                                    | performed in a     |   |   |
| , |   |                                    | specialist's       |   |   |
| s |   |                                    | office             |   |   |
| u |   |                                    |                    |   |   |
| c |   |                                    | Nothing for        |   |   |
| h |   |                                    | inpatient or       |   |   |
| a |   |                                    | outpatient surgery |   |   |
| s |   |                                    |                    |   |   |
| : |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| - |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
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+---+---+------------------------------------+--------------------+---+---+

*Surgical procedures −* continued on next page

+------------------------------------------+---------------------------+
| Surgical procedures *(continued)*        | You pay                   |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Reversal of voluntary               |                           |
|     sterilization*                       |                           |
|                                          |                           |
| -   *Routine treatment of conditions of  |                           |
|     the foot; see Foot care*             |                           |
+------------------------------------------+---------------------------+
| ###### Reconstructive surgery            |                           |
+------------------------------------------+---------------------------+
| -   Surgery to correct a functional      | **[Missouri               |
|     defect                               | Region]{.underline}**     |
|                                          |                           |
| -   Surgery to correct a condition       | \$10 per visit if         |
|     caused by injury or illness if:      | performed in a primary    |
|                                          | care physician's office   |
| ```{=html}                               |                           |
| <!-- -->                                 | \$20 per visit if         |
| ```                                      | performed in a            |
| -   the condition produced a major       | specialist's office       |
|     effect on the member's appearance    |                           |
|     and                                  | Nothing for inpatient or  |
|                                          | outpatient surgery        |
| -   the condition can reasonably be      |                           |
|     expected to be corrected by such     | **[Texas                  |
|     surgery                              | Region]{.underline}**     |
|                                          |                           |
| ```{=html}                               | \$10 per visit if         |
| <!-- -->                                 | performed in a primary    |
| ```                                      | care physician's office   |
| -   Surgery to correct a condition that  |                           |
|     existed at or from birth and is a    | \$10 per visit if         |
|     significant deviation from the       | performed in a            |
|     common form or norm. Examples of     | specialist's office       |
|     congenital anomalies are: protruding |                           |
|     ear deformities; cleft lip; cleft    | Nothing for inpatient or  |
|     palate; birth marks; webbed fingers; | outpatient surgery        |
|     and webbed toes.                     |                           |
|                                          |                           |
| -   All stages of breast reconstruction  |                           |
|     surgery following a mastectomy, such |                           |
|     as:                                  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   surgery to produce a symmetrical     |                           |
|     appearance on the other breast;      |                           |
|                                          |                           |
| -   treatment of any physical            |                           |
|     complications, such as lymphedemas;  |                           |
|                                          |                           |
| -   breast prostheses and surgical bras  |                           |
|     and replacements (see Prosthetic     |                           |
|     devices)                             |                           |
|                                          |                           |
| Note: If you need a mastectomy, you may  |                           |
| choose to have the procedure performed   |                           |
| on an inpatient basis and remain in the  |                           |
| hospital up to 48 hours after the        |                           |
| procedure.                               |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Cosmetic surgery -- any surgical    |                           |
|     procedure (or any portion of a       |                           |
|     procedure) performed primarily to    |                           |
|     improve physical appearance through  |                           |
|     change in bodily form, except repair |                           |
|     of accidental injury*                |                           |
|                                          |                           |
| -   *Surgeries related to sex            |                           |
|     transformation*                      |                           |
|                                          |                           |
| -   *Removal of tattoo*                  |                           |
|                                          |                           |
| -   *Hair transplant for baldness,       |                           |
|     lipectomy (operation for removal of  |                           |
|     adipose tissue (fat) from the        |                           |
|     abdomen or other part of the body)   |                           |
|     -- unless required by a sickness     |                           |
|     condition.*                          |                           |
|                                          |                           |
| -   *Augmentation of mammoplasty         |                           |
|     (operation for augmentation of the   |                           |
|     breasts) for cosmetic reasons.*      |                           |
+------------------------------------------+---------------------------+
| ###### Oral and maxillofacial surgery    | You pay                   |
+------------------------------------------+---------------------------+
| Oral surgical procedures, limited to:    | **[Missouri               |
|                                          | Region]{.underline}**     |
| -   Reduction of fractures of the jaws   |                           |
|     or facial bones;                     | \$10 per visit if         |
|                                          | performed in a primary    |
| -   Surgical correction of cleft lip,    | care physician's office   |
|     cleft palate or severe functional    |                           |
|     malocclusion;                        | \$20 per visit if         |
|                                          | performed in a            |
| -   Removal of stones from salivary      | specialist's office       |
|     ducts;                               |                           |
|                                          | Nothing for inpatient or  |
| -   Excision of leukoplakia or           | outpatient surgery        |
|     malignancies;                        |                           |
|                                          | **[Texas                  |
| -   Excision of cysts and incision of    | Region]{.underline}**     |
|     abscesses when done as independent   |                           |
|     procedures; and                      | \$10 per visit if         |
|                                          | performed in a primary    |
| -   Other surgical procedures that do    | care physician's office   |
|     not involve the teeth or their       |                           |
|     supporting structures.               | \$10 per visit if         |
|                                          | performed in a            |
| **NOTICE OF NETWORK ACCESS AND           | specialist's office       |
| AVAILABILITY**                           |                           |
|                                          | Nothing for inpatient or  |
| We require that your Primary Care        | outpatient surgery        |
| Physician (PCP) obtain referrals for     |                           |
| covered oral surgery services from us.   |                           |
| If your PCP determines that you require  |                           |
| a referral to an oral surgeon and there  |                           |
| is not a participating provider within a |                           |
| reasonable distance from your home or    |                           |
| workplace, we will arrange for a         |                           |
| referral to an appropriate provider.     |                           |
| Your copayment will be the same as if    |                           |
| you obtained services from a provider    |                           |
| within the Mercy network.                |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Enabling procedures for implants,   |                           |
|     as well as placement, maintenance,   |                           |
|     restoration, and removal of dental   |                           |
|     implants*                            |                           |
|                                          |                           |
| -   *Oral implants and transplants*      |                           |
|                                          |                           |
| -   *Any prosthetic superstructure       |                           |
|     fabricated upon a dental implant*    |                           |
|                                          |                           |
| -   *Procedures that involve the teeth   |                           |
|     or their supporting structures (such |                           |
|     as the periodontal membrane,         |                           |
|     gingiva, and alveolar bone)*         |                           |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
| ###### Organ/tissue transplants          | You pay                   |
+------------------------------------------+---------------------------+
| Limited to:                              | Nothing                   |
|                                          |                           |
| -   Cornea                               |                           |
|                                          |                           |
| -   Heart                                |                           |
|                                          |                           |
| -   Heart/lung                           |                           |
|                                          |                           |
| -   Kidney                               |                           |
|                                          |                           |
| -   Kidney/Pancreas                      |                           |
|                                          |                           |
| -   Liver                                |                           |
|                                          |                           |
| -   Lung: Single -- Double               |                           |
|                                          |                           |
| -   Pancreas                             |                           |
|                                          |                           |
| -   Allogeneic (donor) bone marrow       |                           |
|     transplants                          |                           |
|                                          |                           |
| -   Autologous bone marrow transplants   |                           |
|     (autologous stem cell and peripheral |                           |
|     stem cell support) for the following |                           |
|     conditions: acute lymphocytic or     |                           |
|     non-lymphocytic leukemia; advanced   |                           |
|     Hodgkin's lymphoma; advanced         |                           |
|     non-Hodgkin's lymphoma; advanced     |                           |
|     neuroblastoma; breast cancer;        |                           |
|     multiple myeloma; epithelial ovarian |                           |
|     cancer; and testicular, mediastinal, |                           |
|     retroperitoneal and ovarian germ     |                           |
|     cell tumors                          |                           |
|                                          |                           |
| -   Intestinal transplants (small        |                           |
|     intestine) and the small intestine   |                           |
|     with the liver or small intestine    |                           |
|     with multiple organs such as the     |                           |
|     liver, stomach, and pancreas         |                           |
|                                          |                           |
| Limited Benefits -- Treatment for breast |                           |
| cancer, multiple myeloma, and epithelial |                           |
| ovarian cancer may be provided in a      |                           |
| National Cancer Institute -- or National |                           |
| Institutes of Health-approved clinical   |                           |
| trial at a Plan-designated center of     |                           |
| excellence and if approved by the Plan's |                           |
| medical director in accordance with the  |                           |
| Plan's protocols. Payments are limited   |                           |
| to the allowed amount at a participating |                           |
| transplant facility.                     |                           |
|                                          |                           |
| Note: We cover related medical and       |                           |
| hospital expenses of the donor when we   |                           |
| cover the recipient.                     |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Donor screening tests and donor     |                           |
|     search expenses, except those        |                           |
|     performed for the actual donor*      |                           |
|                                          |                           |
| -   *Implants of artificial organs*      |                           |
|                                          |                           |
| -   *Transplants not listed as covered*  |                           |
+------------------------------------------+---------------------------+
| ###### Anesthesia                        | You pay                   |
+------------------------------------------+---------------------------+
| Professional services provided in --     | **[Missouri               |
|                                          | Region]{.underline}**     |
| -   Office                               |                           |
|                                          | \$20 per office visit     |
|                                          |                           |
|                                          | **[Texas                  |
|                                          | Region]{.underline}**     |
|                                          |                           |
|                                          | \$10 per office visit     |
+------------------------------------------+---------------------------+
| -   Hospital (inpatient)                 | Nothing                   |
|                                          |                           |
| -   Hospital outpatient department       | Nothing                   |
|                                          |                           |
| -   Skilled nursing facility             | Nothing                   |
|                                          |                           |
| -   Ambulatory surgery center            | Nothing                   |
+------------------------------------------+---------------------------+

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

+---+---+-------------------------------------+---------------------+---+---+
|   | * | **Here are some important things    |                     | * |   |
|   | * | you should keep in mind about these |                     | * |   |
|   | I | benefits:**                         |                     | I |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Plan physicians must provide or |                     | * |   |
|   | * |     arrange your care and you must  |                     | * |   |
|   | P |     be hospitalized in a Plan       |                     | P |   |
|   | * |     facility.                       |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | -   We have no in-network calendar  |                     |   |   |
|   | * |     year deductible.                |                     | * |   |
|   | * |                                     |                     | * |   |
|   | O | -   Be sure to read Section 4,      |                     | O |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | * |     services* for valuable          |                     | * |   |
|   |   |     information about how cost      |                     |   |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   | * |     Section 9 about coordinating    |                     | * |   |
|   | R |     benefits with other coverage,   |                     | R |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | -   The amounts listed below are    |                     |   |   |
|   | * |     for the charges billed by the   |                     | * |   |
|   | * |     facility (i.e., hospital or     |                     | * |   |
|   | T |     surgical center) or ambulance   |                     | T |   |
|   | * |     service for your surgery or     |                     | * |   |
|   | * |     care. Any costs associated with |                     | * |   |
|   |   |     the professional charge (i.e.,  |                     |   |   |
|   | * |     physicians, etc.) are covered   |                     | * |   |
|   | * |     in Sections 5(a) or (b).        |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * | -   **Your Physician must get       |                     | * |   |
|   | * |     preauthorization for all        |                     | * |   |
|   |   |     hospital stays and some         |                     |   |   |
|   | * |     in-network services. Please     |                     | * |   |
|   | * |     refer to Section 3 to be sure   |                     | * |   |
|   | N |     which services require          |                     | N |   |
|   | * |     preauthorization.**             |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | -   **POS out-of-network services   |                     |   |   |
|   | * |     are subject to a calendar year  |                     | * |   |
|   | * |     deductible. You must get        |                     | * |   |
|   | T |     preauthorization before any     |                     | T |   |
|   | * |     service is rendered             |                     | * |   |
|   | * |     out-of-network. POS benefits    |                     | * |   |
|   |   |     and services are limited.       |                     |   |   |
|   |   |     Please see Sections 3 & 5(i)    |                     |   |   |
|   |   |     for details.**                  |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
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| p |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| R |   |                                     | Nothing             |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| O |   |                                     | Nothing             |   |   |
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| u |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| . |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

Inpatient hospital - continued on next page.

+------------------------------------------+---------------------------+
| Inpatient hospital *(continued)*         | You pay                   |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Custodial care*                     |                           |
|                                          |                           |
| -   *Non-covered facilities, such as     |                           |
|     nursing homes, schools*              |                           |
|                                          |                           |
| -   *Personal comfort items, such as     |                           |
|     telephone, television, barber        |                           |
|     services, guest meals and beds*      |                           |
|                                          |                           |
| -   *Private nursing care*               |                           |
+------------------------------------------+---------------------------+
| ###### Outpatien                         |                           |
| t hospital or ambulatory surgical center |                           |
+------------------------------------------+---------------------------+
| -   Operating, recovery, and other       | Nothing                   |
|     treatment rooms                      |                           |
|                                          |                           |
| -   Prescribed drugs and medicines       |                           |
|                                          |                           |
| -   Diagnostic laboratory tests, X-rays, |                           |
|     and pathology services               |                           |
|                                          |                           |
| -   Administration of blood, blood       |                           |
|     plasma, and other biologicals        |                           |
|                                          |                           |
| -   Blood and blood plasma, if not       |                           |
|     donated or replaced                  |                           |
|                                          |                           |
| -   Pre-surgical testing                 |                           |
|                                          |                           |
| -   Dressings, casts, and sterile tray   |                           |
|     services                             |                           |
|                                          |                           |
| -   Medical supplies, including oxygen   |                           |
|                                          |                           |
| -   Anesthetics and anesthesia service   |                           |
|                                          |                           |
| Note**:** We cover hospital services and |                           |
| supplies related to dental procedures    |                           |
| when necessitated by a non-dental        |                           |
| physical impairment. We do not cover the |                           |
| dental procedures.                       |                           |
+------------------------------------------+---------------------------+
| *Not covered: Blood and blood            | *All charges.*            |
| derivatives not replaced by the member*  |                           |
+------------------------------------------+---------------------------+
| ###### Extended care benefit             |                           |
| s/Skilled nursing care facility benefits |                           |
+------------------------------------------+---------------------------+
| Skilled nursing facility (SNF):          | Nothing                   |
|                                          |                           |
| Medically Necessary room and board,      |                           |
| services and supplies, including         |                           |
| medications provided under the direction |                           |
| of a Participating Physician in a        |                           |
| Participating Skilled Nursing Facility   |                           |
| for the care and treatment of an Injury  |                           |
| or Illness which would otherwise require |                           |
| inpatient confinement in a Hospital.     |                           |
| Coverage for up to a maximum of          |                           |
| one-hundred twenty (120) days per        |                           |
| calendar year.                           |                           |
+------------------------------------------+---------------------------+
| *Not covered: Custodial care, which is   | *All charges.*            |
| care designed to assist with activities  |                           |
| of daily living such as bathing,         |                           |
| exercising, moving a patient, cooking,   |                           |
| cleaning, etc. and involves non-medical  |                           |
| personnel. For an institutionalized      |                           |
| individual, custodial care includes room |                           |
| and board, non-skilled care, or such     |                           |
| other care that is provided to an        |                           |
| individual who cannot reasonably be      |                           |
| expected to live outside an institution. |                           |
| Rest care, respite care, and home care   |                           |
| provided by a family member (including a |                           |
| spouse, sibling, child, or parent of the |                           |
| member) is also considered custodial     |                           |
| care.*                                   |                           |
+------------------------------------------+---------------------------+
| ###### Hospice care                      | You pay                   |
+------------------------------------------+---------------------------+
| Services provided either on an inpatient | Nothing                   |
| or an outpatient basis, based on         |                           |
| approved acceptable medical practices,   |                           |
| when approved in advance by the Plan\'s  |                           |
| Chief Medical Officer or designee.       |                           |
|                                          |                           |
| This benefit is available once per       |                           |
| lifetime for terminally ill person with  |                           |
| a life expectancy of less than six       |                           |
| months.                                  |                           |
+------------------------------------------+---------------------------+
| *Not covered: Independent nursing,       | *All charges.*            |
| homemaker services, services received    |                           |
| out-of-network*                          |                           |
+------------------------------------------+---------------------------+
| ###### Ambulance                         |                           |
+------------------------------------------+---------------------------+
| -   Local professional ambulance service | Nothing                   |
|     when medically appropriate           |                           |
+------------------------------------------+---------------------------+

## Section 5(d) Emergency services/accidents

+---+---+-------------------------------------+---------------------+---+---+
| # | * | **Here are some important things to |                     | * |   |
| # | * | keep in mind about these            |                     | * |   |
| # | I | benefits:**                         |                     | I |   |
| # | * |                                     |                     | * |   |
| # | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   We have no calendar year        |                     | * |   |
|   | * |     deductible.                     |                     | * |   |
|   | P |                                     |                     | P |   |
|   | * | -   Be sure to read Section 4,      |                     | * |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   |   |     services,* for valuable         |                     |   |   |
|   | * |     information about how cost      |                     | * |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   | O |     Section 9 about coordinating    |                     | O |   |
|   | * |     benefits with other coverage,   |                     | * |   |
|   | * |     including with Medicare.        |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | #####                               |                     | * |   |
|   | * |                                     |                     | * |   |
|   | R |                                     |                     | R |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | N |                                     |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| W |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| ? |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
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| f |   |                                     |                     |   |   |
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| o |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
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| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| [ |   |                                     |                     |   |   |
| ] |   |                                     |                     |   |   |
| { |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| W |   |                                     |                     |   |   |
| S |   |                                     |                     |   |   |
| . |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| } |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| w |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | **[Missouri         |   |   |
|   |   |                                     | Re                  |   |   |
|   |   |                                     | gion]{.underline}** |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     | \$10 per visit to   |   |   |
| m |   |                                     | your primary care   |   |   |
| e |   |                                     | physician           |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     | \$20 per visit to a |   |   |
| e |   |                                     | specialist          |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     | **[Texas            |   |   |
| y |   |                                     | Re                  |   |   |
|   |   |                                     | gion]{.underline}** |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     | \$10 per visit to   |   |   |
|   |   |                                     | your primary care   |   |   |
| c |   |                                     | physician           |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     | \$10 per visit to a |   |   |
| e |   |                                     | specialist          |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| ' |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$25 per office     |   |   |
|   |   |                                     | visit               |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | **[Missouri         |   |   |
|   |   |                                     | Re                  |   |   |
|   |   |                                     | gion]{.underline}** |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     | \$75 per visit,     |   |   |
| m |   |                                     | except Copayment    |   |   |
| e |   |                                     | charge will be      |   |   |
| r |   |                                     | waived if you are   |   |   |
| g |   |                                     | admitted to an      |   |   |
| e |   |                                     | observation,        |   |   |
| n |   |                                     | outpatient surgery, |   |   |
| c |   |                                     | outpatient          |   |   |
| y |   |                                     | procedure or        |   |   |
|   |   |                                     | inpatient care      |   |   |
|   |   |                                     | setting             |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     | **[Texas            |   |   |
| c |   |                                     | Re                  |   |   |
| a |   |                                     | gion]{.underline}** |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     | \$50 per visit,     |   |   |
|   |   |                                     | except Copayment    |   |   |
|   |   |                                     | charge will be      |   |   |
|   |   |                                     | waived if you are   |   |   |
|   |   |                                     | admitted to an      |   |   |
| a |   |                                     | observation,        |   |   |
| s |   |                                     | outpatient surgery, |   |   |
|   |   |                                     | outpatient          |   |   |
|   |   |                                     | procedure or        |   |   |
|   |   |                                     | inpatient care      |   |   |
|   |   |                                     | setting             |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| u |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
| N |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| [ |   |                                     |                     |   |   |
| ] |   |                                     |                     |   |   |
| { |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| O |   |                                     |                     |   |   |
| S |   |                                     |                     |   |   |
| . |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| } |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | **[Missouri         |   |   |
|   |   |                                     | Re                  |   |   |
|   |   |                                     | gion]{.underline}** |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     | \$10 per visit to   |   |   |
| m |   |                                     | your primary care   |   |   |
| e |   |                                     | physician           |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     | \$20 per visit to a |   |   |
| e |   |                                     | specialist          |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     | **[Texas            |   |   |
| y |   |                                     | Re                  |   |   |
|   |   |                                     | gion]{.underline}** |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     | \$10 per visit to   |   |   |
|   |   |                                     | your primary care   |   |   |
| c |   |                                     | physician           |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     | \$10 per visit to a |   |   |
| e |   |                                     | specialist          |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| ' |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$25 per office     |   |   |
|   |   |                                     | visit               |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

*Emergency outside our service area - continued on next page.*

+-------------------------------------------+--------------------------+
| Emergency outside our service area        | You pay                  |
| *(continued)*                             |                          |
+-------------------------------------------+--------------------------+
| -   Emergency care as an outpatient or    | **[Missouri              |
|     inpatient at a hospital, including    | Region]{.underline}**    |
|     doctors' services                     |                          |
|                                           | \$75 per visit, except   |
|                                           | Copayment charge will be |
|                                           | waived if you are        |
|                                           | admitted to an           |
|                                           | observation, outpatient  |
|                                           | surgery, outpatient      |
|                                           | procedure or inpatient   |
|                                           | care setting             |
|                                           |                          |
|                                           | **[Texas                 |
|                                           | Region]{.underline}**    |
|                                           |                          |
|                                           | \$50 per visit, except   |
|                                           | Copayment charge will be |
|                                           | waived if you are        |
|                                           | admitted to an           |
|                                           | observation, outpatient  |
|                                           | surgery, outpatient      |
|                                           | procedure or inpatient   |
|                                           | care setting             |
+-------------------------------------------+--------------------------+
| *Not covered:*                            | *All charges.*           |
|                                           |                          |
| -   *Elective care or non-emergency care* |                          |
|                                           |                          |
| -   *Emergency care provided outside the  |                          |
|     service area if the need for care     |                          |
|     could have been foreseen before       |                          |
|     leaving the service area*             |                          |
+-------------------------------------------+--------------------------+
| []{#AMB .anchor}Ambulance                 |                          |
+-------------------------------------------+--------------------------+
| Professional ambulance service when       | Nothing                  |
| medically appropriate.                    |                          |
|                                           |                          |
| Note: See 5(c) for non-emergency service. |                          |
+-------------------------------------------+--------------------------+
| *Not covered:*                            | *All charges.*           |
|                                           |                          |
| -   *Air ambulance (unless Medically      |                          |
|     necessary)*                           |                          |
|                                           |                          |
| -   *Air ambulance transportation out of  |                          |
|     a foreign country is not covered      |                          |
|     under any circumstances*              |                          |
+-------------------------------------------+--------------------------+

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

+---+---+-----------------------------------+----------------------+---+---+
|   | * | When you get our approval for     |                      | * |   |
|   | * | services and follow a treatment   |                      | * |   |
|   | I | plan we approve, cost-sharing and |                      | I |   |
|   | * | limitations for Plan mental       |                      | * |   |
|   | * | health and substance abuse        |                      | * |   |
|   |   | benefits will be no greater than  |                      |   |   |
|   | * | for similar benefits for other    |                      | * |   |
|   | * | illnesses and conditions.         |                      | * |   |
|   | M |                                   |                      | M |   |
|   | * | **Here are some important things  |                      | * |   |
|   | * | to keep in mind about these       |                      | * |   |
|   |   | benefits:**                       |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * | -   Please remember that all      |                      | * |   |
|   | P |     benefits are subject to the   |                      | P |   |
|   | * |     definitions, limitations, and |                      | * |   |
|   | * |     exclusions in this brochure   |                      | * |   |
|   |   |     and are payable only when we  |                      |   |   |
|   | * |     determine they are medically  |                      | * |   |
|   | * |     necessary.                    |                      | * |   |
|   | O |                                   |                      | O |   |
|   | * | -   We have no in-network         |                      | * |   |
|   | * |     calendar year deductible.     |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * | -   Be sure to read Section 4,    |                      | * |   |
|   | * |     *Your costs for covered       |                      | * |   |
|   | R |     services*, for valuable       |                      | R |   |
|   | * |     information about how cost    |                      | * |   |
|   | * |     sharing works. Also read      |                      | * |   |
|   |   |     Section 9 about coordinating  |                      |   |   |
|   | * |     benefits with other coverage, |                      | * |   |
|   | * |     including with Medicare.      |                      | * |   |
|   | T |                                   |                      | T |   |
|   | * | -   A deductible applies to       |                      | * |   |
|   | * |     out-of-network Mental Health  |                      | * |   |
|   |   |     and Substance Abuse benefits  |                      |   |   |
|   | * |     only in the Texas Region      |                      | * |   |
|   | * |     Point of Service (POS) plan.  |                      | * |   |
|   | A |     There are no POS benefits in  |                      | A |   |
|   | * |     the Missouri Regions. Please  |                      | * |   |
|   | * |     refer to Section 5(i) for     |                      | * |   |
|   |   |     details.                      |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * | -   **YOU MUST GET                |                      | * |   |
|   | N |     PREAUTHORIZATION OF THESE     |                      | N |   |
|   | * |     SERVICES.** See the           |                      | * |   |
|   | * |     instructions after the        |                      | * |   |
|   |   |     benefits description below.   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | T |                                   |                      | T |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
+---+---+-----------------------------------+----------------------+---+---+
| B |   |                                   | You pay              |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| f |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| D |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| c |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| M |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| h |   |                                   |                      |   |   |
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| d |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| u |   |                                   |                      |   |   |
| b |   |                                   |                      |   |   |
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| t |   |                                   |                      |   |   |
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|   |   |                                   |                      |   |   |
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| b |   |                                   |                      |   |   |
| u |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
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|   |   |                                   |                      |   |   |
| b |   |                                   |                      |   |   |
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| n |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| f |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| A |   |                                   | Your cost sharing    |   |   |
| l |   |                                   | responsibilities are |   |   |
| l |   |                                   | no greater than for  |   |   |
| d |   |                                   | other illnesses or   |   |   |
| i |   |                                   | conditions.          |   |   |
| a |   |                                   |                      |   |   |
| g |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | **[Missouri          |   |   |
|   |   |                                   | R                    |   |   |
|   |   |                                   | egion]{.underline}** |   |   |
|   |   |                                   |                      |   |   |
| P |   |                                   | \$10 per visit to    |   |   |
| r |   |                                   | your primary care    |   |   |
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| i |   |                                   | **[Texas             |   |   |
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|   |   |                                   |                      |   |   |
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|   |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | Nothing              |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| D |   |                                   |                      |   |   |
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| a |   |                                   |                      |   |   |
| g |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| c |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+

*Mental health and substance abuse benefits −* continued on next page.

+------------------------------------------+---------------------------+
| Mental health and substance abuse        | You pay                   |
| benefits *(continued)*                   |                           |
+------------------------------------------+---------------------------+
| -   Services provided by a hospital or   | Nothing                   |
|     other facility                       |                           |
|                                          |                           |
| -   Services in approved alternative     |                           |
|     care settings such as partial        |                           |
|     hospitalization, half-way house,     |                           |
|     residential treatment, full-day      |                           |
|     hospitalization, facility based      |                           |
|     intensive outpatient treatment       |                           |
+------------------------------------------+---------------------------+
| *Not covered: Services we have not       | *All charges.*            |
| 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.*                       |                           |
+------------------------------------------+---------------------------+
| **Preauthorization** To be eligible to   |                           |
| receive these benefits you must obtain a |                           |
| treatment plan and follow all of the     |                           |
| following authorization processes:       |                           |
|                                          |                           |
| You must obtain services from            |                           |
| Participating Providers. These services  |                           |
| must be authorized in advance by the     |                           |
| Plan by calling the Mental Health and    |                           |
| Substance Abuse Member Assistance        |                           |
| Hotline (MH/SA Hotline) for assistance.  |                           |
|                                          |                           |
| (Eastern and Central Missouri): (314)    |                           |
| 729-4600 or 1-800-413-8008               |                           |
|                                          |                           |
| (Southwest Missouri): (417) 836-0402 or  |                           |
| 1-800-836-0402                           |                           |
|                                          |                           |
| (Texas): 1-800-413-8008                  |                           |
+------------------------------------------+---------------------------+
| **Limitation** We may limit your         |                           |
| benefits if you do not obtain a          |                           |
| treatment plan.                          |                           |
+------------------------------------------+---------------------------+

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

+---+---+--------------------------------------------------------+---+---+
|   | * | **Here are some important things to keep in mind about | * |   |
|   | * | these benefits:**                                      | * |   |
|   | I |                                                        | I |   |
|   | * | -   We cover prescribed drugs and medications, as      | * |   |
|   | * |     described in the chart beginning on the next page. | * |   |
|   |   |                                                        |   |   |
|   | * | -   All benefits are subject to the definitions,       | * |   |
|   | * |     limitations and exclusions in this brochure and    | * |   |
|   | M |     are payable only when we determine they are        | M |   |
|   | * |     medically necessary.                               | * |   |
|   | * |                                                        | * |   |
|   |   | -   There are a handful of medications that require    |   |   |
|   | * |     prior authorizations. Your Plan physician has a    | * |   |
|   | * |     listing of the specific drugs.                     | * |   |
|   | P |                                                        | P |   |
|   | * | -   Be sure to read Section 4, *Your costs for covered | * |   |
|   | * |     services,* for valuable information about how cost | * |   |
|   |   |     sharing works. Also read Section 9 about           |   |   |
|   | * |     coordinating benefits with other coverage,         | * |   |
|   | * |     including with Medicare.                           | * |   |
|   | O |                                                        | O |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   |   |                                                        |   |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   | R |                                                        | R |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   |   |                                                        |   |   |
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|   | * |                                                        | * |   |
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|   | A |                                                        | A |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   |   |                                                        |   |   |
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|   | * |                                                        | * |   |
|   | N |                                                        | N |   |
|   | * |                                                        | * |   |
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|   | * |                                                        | * |   |
|   | T |                                                        | T |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
+---+---+--------------------------------------------------------+---+---+
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| t |   |                                                        |   |   |
| . |   |                                                        |   |   |
+---+---+--------------------------------------------------------+---+---+

+------------------------------------------+---------------------------+
| **Benefit Description**                  | **You pay**               |
+------------------------------------------+---------------------------+
| ###### Covered medications and supplies  |                           |
+------------------------------------------+---------------------------+
| We cover the following medications and   | **[Missouri               |
| supplies prescribed by a Plan physician  | Region]{.underline}**     |
| and obtained from a Plan pharmacy or     |                           |
| through our mail order program:          | \$10 Copayment for        |
|                                          | generic drugs on          |
| -   Drugs and medicines that by Federal  | Formulary                 |
|     law of the United States require a   |                           |
|     physician's prescription for their   | \$20 Copayment for        |
|     purchase, except those listed as     | Formulary brand name      |
|     *Not covered.*                       | drugs                     |
|                                          |                           |
| -   Disposable needles and syringes      | \$35 Copayment for        |
|     needed to inject covered prescribed  | Non-formulary approved    |
|     medication                           | drugs                     |
|                                          |                           |
| -   Diabetic supplies, including insulin | 2 Copayments for a 90-day |
|     syringes needles, glucose test       | supply for mail-order     |
|     tablets and test tape, Benedict's    |                           |
|     solution or equivalent, glucose      | **[Texas                  |
|     monitors and acetone test tablets    | Region]{.underline}**     |
|                                          |                           |
| -   Drugs for sexual dysfunction (see    | \$7 Copayment for generic |
|     Section 3 -- Services requiring our  | drugs on Formulary        |
|     prior approval)                      |                           |
|                                          | \$12 Copayment for        |
| -   Insulin; a copay charge applies to   | Formulary brand name      |
|     each vial                            | drugs                     |
|                                          |                           |
| -   Contraceptive drugs and devices      | \$25 Copayment for        |
|                                          | Non-formulary approved    |
| **[Missouri Region]{.underline}**        | drugs                     |
|                                          |                           |
| You are entitled to receive prescription | 2 Copayments for a 90-day |
| drugs included on the formulary at the   | supply for mail-order     |
| time a written prescription is actually  |                           |
| filled by a participating pharmacy. You  |                           |
| will pay a \$10 Copayment for Formulary  |                           |
| generic drugs, \$20 Copayment for        |                           |
| Formulary brand name drugs and \$35      |                           |
| Copayment for non-formulary approved     |                           |
| drugs. If a brand name drug is dispensed |                           |
| when a generic alternative is available  |                           |
| and your physician has not specified     |                           |
| Dispense as Written (DAW) for the brand  |                           |
| name drug, you pay the appropriate       |                           |
| Copayment plus the difference in cost of |                           |
| the brand name drug and the generic      |                           |
| drug.                                    |                           |
|                                          |                           |
| **[Texas Region]{.underline}**           |                           |
|                                          |                           |
| You are entitled to receive prescription |                           |
| drugs included on the formulary at the   |                           |
| time a written prescription is actually  |                           |
| filled by a participating pharmacy. You  |                           |
| will pay a Copayment of \$7 for          |                           |
| Formulary generic drugs, \$12 Copayment  |                           |
| for Formulary brand name drugs and \$25  |                           |
| Copayment for non-formulary approved     |                           |
| drugs. If a brand name drug is dispensed |                           |
| when a generic alternative is available  |                           |
| and your physician has not specified     |                           |
| Dispense as Written (DAW) for the brand  |                           |
| name drug, you pay the appropriate       |                           |
| Copayment plus the difference in cost of |                           |
| the brand name drug and the generic      |                           |
| drug.                                    |                           |
+------------------------------------------+---------------------------+

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

+------------------------------------------+---------------------------+
| Covered medications and supplies         | You pay                   |
| *(continued)*                            |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Drugs available without a           |                           |
|     prescription or for which there is a |                           |
|     nonprescription equivalent           |                           |
|     available*                           |                           |
|                                          |                           |
| -   *Prescriptions dispensed by other    |                           |
|     than a Plan pharmacy, except in the  |                           |
|     case of a medical emergency*         |                           |
|                                          |                           |
| -   *Vitamins and nutritional substances |                           |
|     that can be purchased without a      |                           |
|     prescription*                        |                           |
|                                          |                           |
| -   *Medical supplies such as dressing   |                           |
|     and antiseptics*                     |                           |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes*                            |                           |
|                                          |                           |
| -   *Drugs to enhance athletic           |                           |
|     performance*                         |                           |
|                                          |                           |
| -   *Appetite suppressants and other     |                           |
|     drugs taken for the purpose of       |                           |
|     weight loss*                         |                           |
|                                          |                           |
| -   *Drugs which have not been approved  |                           |
|     by the FDA*                          |                           |
|                                          |                           |
| -   *Fertility drugs*                    |                           |
+------------------------------------------+---------------------------+

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

+----------------------+-----------------------------------------------+
| Feature              | Description                                   |
+----------------------+-----------------------------------------------+
| ##### Flex           | Under the flexible benefits option, we        |
| ible benefits option | determine the most effective way to provide   |
|                      | services.                                     |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| ####                 | For any of your health concerns, 24 hours a   |
| # 24 hour nurse line | day, 7 days a week, you may call:             |
|                      |                                               |
| (not available in    | (Eastern and Central Missouri): 800-811-1187; |
| Texas)               | or                                            |
|                      |                                               |
|                      | (Southwest Missouri): 417-888-8888 or         |
|                      | 800-909-TEAM (8326)                           |
|                      |                                               |
|                      | and talk with a registered nurse who will     |
|                      | discuss treatment options and answer your     |
|                      | health questions.                             |
+----------------------+-----------------------------------------------+
| ####                 | Mercy Health Plans/Premier Health Plans       |
| # Services for deaf  | offers a TDD Line:                            |
| and hearing impaired |                                               |
|                      | -   Mercy Health Plans (Eastern and Central   |
|                      |     Missouri Region) at 314-214-8299 or       |
|                      |     800-698-4807                              |
|                      |                                               |
|                      | -   Mercy Health Plans (Texas Region) at      |
|                      |     877-206-7903                              |
|                      |                                               |
|                      | -   Premier Health Plans (Southwest Missouri  |
|                      |     Regions) at 417-837-0249 or 800-446-1468  |
+----------------------+-----------------------------------------------+

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

+---+---+------------------------------------+---------------------+---+---+
|   | * | **Here are some important things   |                     | * |   |
|   | * | to keep in mind about these        |                     | * |   |
|   | I | benefits:**                        |                     | I |   |
|   | * |                                    |                     | * |   |
|   | * | -   Please remember that all       |                     | * |   |
|   |   |     benefits are subject to the    |                     |   |   |
|   | * |     definitions, limitations, and  |                     | * |   |
|   | * |     exclusions in this brochure    |                     | * |   |
|   | M |     and are payable only when we   |                     | M |   |
|   | * |     determine they are medically   |                     | * |   |
|   | * |     necessary                      |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   Plan dentists must provide or  |                     | * |   |
|   | * |     arrange your care.             |                     | * |   |
|   | P |                                    |                     | P |   |
|   | * | -   We have no in-network calendar |                     | * |   |
|   | * |     year deductible.               |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   We cover hospitalization for   |                     | * |   |
|   | * |     dental procedures only when a  |                     | * |   |
|   | O |     nondental physical impairment  |                     | O |   |
|   | * |     exists which makes             |                     | * |   |
|   | * |     hospitalization necessary to   |                     | * |   |
|   |   |     safeguard the health of the    |                     |   |   |
|   | * |     patient. See Section 5 (c) for |                     | * |   |
|   | * |     inpatient hospital benefits.   |                     | * |   |
|   | R |     We do not cover the dental     |                     | R |   |
|   | * |     procedure unless it is         |                     | * |   |
|   | * |     described below.               |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   Be sure to read Section 4,     |                     | * |   |
|   | * |     *Your costs for covered        |                     | * |   |
|   | T |     services,* for valuable        |                     | T |   |
|   | * |     information about how cost     |                     | * |   |
|   | * |     sharing works. Also read       |                     | * |   |
|   |   |     Section 9 about coordinating   |                     |   |   |
|   | * |     benefits with other coverage,  |                     | * |   |
|   | * |     including with Medicare.       |                     | * |   |
|   | A |                                    |                     | A |   |
|   | * | -   **POS out-of-network services  |                     | * |   |
|   | * |     are subject to a calendar year |                     | * |   |
|   |   |     deductible. You must get       |                     |   |   |
|   | * |     preauthorization before any    |                     | * |   |
|   | * |     service is rendered            |                     | * |   |
|   | N |     out-of-network. POS benefits   |                     | N |   |
|   | * |     and services are limited.      |                     | * |   |
|   | * |     Please see Sections 3 & 5(i)   |                     | * |   |
|   |   |     for details.**                 |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | T |                                    |                     | T |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
+===+===+====================================+=====================+===+===+
| # |   |                                    | You pay             |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
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| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| W |   |                                    | 20% Coinsurance     |   |   |
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| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| x |   |                                    |                     |   |   |
| ( |   |                                    |                     |   |   |
| 6 |   |                                    |                     |   |   |
| ) |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| A |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| I |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| j |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| . |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| E |   |                                    | See section 5(d),   |   |   |
| m |   |                                    | Emergency           |   |   |
| e |   |                                    | Services/Accidents, |   |   |
| r |   |                                    | for your cost       |   |   |
| g |   |                                    | sharing             |   |   |
| e |   |                                    | responsibilities.   |   |   |
| n |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
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| s |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
| , |   |                                    |                     |   |   |
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| s |   |                                    |                     |   |   |
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| b |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
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| s |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
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| t |   |                                    |                     |   |   |
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| m |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| g |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
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| f |   |                                    |                     |   |   |
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| o |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
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| u |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
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| t |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| g |   |                                    |                     |   |   |
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| t |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| g |   |                                    |                     |   |   |
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| a |   |                                    |                     |   |   |
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| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| , |   |                                    |                     |   |   |
| w |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
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| l |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
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| v |   |                                    |                     |   |   |
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| r |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| - |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| g |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| . |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
| T |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| g |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
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| c |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
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| r |   |                                    |                     |   |   |
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| c |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| w |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| - |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| g |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| ( |   |                                    |                     |   |   |
| 4 |   |                                    |                     |   |   |
| 8 |   |                                    |                     |   |   |
| ) |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| . |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| * |   |                                    | *All charges.*      |   |   |
| N |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
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| m |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
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| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| - |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
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| r |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
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| a |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| D |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| W |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
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| p |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
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| r |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
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| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
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| r |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
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| p |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
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| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| g |   |                                    |                     |   |   |
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| b |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
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| p |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
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| . |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+

+---+---+-------------------------------------------------------+---+----+
| # |   |                                                       |   |    |
| # |   |                                                       |   |    |
|   |   |                                                       |   |    |
| * |   |                                                       |   |    |
| * |   |                                                       |   |    |
| S |   |                                                       |   |    |
| e |   |                                                       |   |    |
| c |   |                                                       |   |    |
| t |   |                                                       |   |    |
| i |   |                                                       |   |    |
| o |   |                                                       |   |    |
| n |   |                                                       |   |    |
| * |   |                                                       |   |    |
| * |   |                                                       |   |    |
|   |   |                                                       |   |    |
| 5 |   |                                                       |   |    |
| ( |   |                                                       |   |    |
| i |   |                                                       |   |    |
| ) |   |                                                       |   |    |
|   |   |                                                       |   |    |
| P |   |                                                       |   |    |
| o |   |                                                       |   |    |
| i |   |                                                       |   |    |
| n |   |                                                       |   |    |
| t |   |                                                       |   |    |
|   |   |                                                       |   |    |
| o |   |                                                       |   |    |
| f |   |                                                       |   |    |
|   |   |                                                       |   |    |
| S |   |                                                       |   |    |
| e |   |                                                       |   |    |
| r |   |                                                       |   |    |
| v |   |                                                       |   |    |
| i |   |                                                       |   |    |
| c |   |                                                       |   |    |
| e |   |                                                       |   |    |
|   |   |                                                       |   |    |
| b |   |                                                       |   |    |
| e |   |                                                       |   |    |
| n |   |                                                       |   |    |
| e |   |                                                       |   |    |
| f |   |                                                       |   |    |
| i |   |                                                       |   |    |
| t |   |                                                       |   |    |
| s |   |                                                       |   |    |
+---+---+-------------------------------------------------------+---+----+
|   | * | **Here are some important things to keep in mind      | * |    |
|   | * | about these benefits:**                               | * |    |
|   | I |                                                       | I |    |
|   | * | -   All benefits are subject to the definitions,      | * |    |
|   | * |     limitations and exclusions in this brochure and   | * |    |
|   |   |     are payable only when we determine they are       |   |    |
|   | * |     medically necessary.                              | * |    |
|   | * |                                                       | * |    |
|   | M | -   Be sure to read Section 4, *Your costs for        | M |    |
|   | * |     covered services,* for valuable information about | * |    |
|   | * |     how cost sharing works.                           | * |    |
|   |   |                                                       |   |    |
|   | * | -   POS out-of-network services are subject to a      | * |    |
|   | * |     calendar year deductible. You must get            | * |    |
|   | P |     preauthorization before any service is rendered   | P |    |
|   | * |     out-of-network. POS benefits and services are     | * |    |
|   | * |     limited. Please see Sections 3 & 5(i) for         | * |    |
|   |   |     details.                                          |   |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
|   | O |                                                       | O |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
|   |   |                                                       |   |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
|   | R |                                                       | R |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
|   |   |                                                       |   |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
|   | T |                                                       | T |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
|   |   |                                                       |   |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
|   | A |                                                       | A |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
|   |   |                                                       |   |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
|   | N |                                                       | N |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
|   |   |                                                       |   |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
|   | T |                                                       | T |    |
|   | * |                                                       | * |    |
|   | * |                                                       | * |    |
+---+---+-------------------------------------------------------+---+----+

[Facts about this Plan\'s POS option]{.underline}

At your option, you may choose to obtain benefits covered by this Plan
from non-Plan doctors and hospitals whenever you need care,
[except]{.underline} for the benefits listed below under "What is not
covered." Benefits not covered under Point of Service must either be
received from or arranged by Plan doctors to be covered. When you obtain
covered non-emergency medical treatment from a non-Plan doctor without a
referral from a Plan doctor, you are subject to the deductibles,
coinsurance and maximum benefit stated below.

**[What is covered]{.underline}**

+-----------------------+-----------------------+-----------------------+
| **Benefits Subject to |                       |                       |
| the Plan allowance,   |                       |                       |
| precertification      |                       |                       |
| required for all      |                       |                       |
| services and          |                       |                       |
| supplies.**           |                       |                       |
+=======================+=======================+=======================+
|                       | **Missouri Regions**  | **Texas Region**      |
+-----------------------+-----------------------+-----------------------+
| **[PLAN               | \$2,500,000           | Unlimited             |
| MA                    |                       |                       |
| XIMUMS]{.underline}** | \$500                 | \$1,000               |
|                       |                       |                       |
| Medical Benefit       | \$1,000               | \$2,000               |
| Maximum Per Person    |                       |                       |
|                       | \$3,500 per Person    | Unlimited             |
| (While Covered)       | \--Includes           |                       |
|                       | Deductible            |                       |
| Calendar Year         |                       |                       |
| Deductible-Person     | \$7,000               |                       |
|                       |                       |                       |
| (Family)              |                       |                       |
|                       |                       |                       |
| Calendar Year         |                       |                       |
| Out-of-Pocket         |                       |                       |
| Maximum- Family       |                       |                       |
+-----------------------+-----------------------+-----------------------+
| **[MEDICAL            | 30% Coinsurance After | 40% Coinsurance After |
| SE                    | Deductible            | Deductible            |
| RVICES]{.underline}** |                       |                       |
|                       |                       |                       |
| Services and Supplies |                       |                       |
+-----------------------+-----------------------+-----------------------+
| Surgery performed in  | 30% Coinsurance After | 40% Coinsurance After |
| a Physician\'s Office | Deductible            | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Allergy Services      | 30% Coinsurance After | 40% Coinsurance After |
|                       | Deductible            | Deductible            |
| -   Office Visits     |                       |                       |
|                       | 30% Coinsurance After | 40% Coinsurance After |
| -                     | Deductible            | Deductible            |
|  Injections/Treatment |                       |                       |
|                       | 30% Coinsurance After | 40% Coinsurance After |
| -   Allergy serum     | Deductible            | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Lab and X-ray         | 30% Coinsurance After | 40% Coinsurance After |
|                       | Deductible            | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Maternity (includes   | 30% Coinsurance After | 40% Coinsurance After |
| prenatal, delivery,   | Deductible            | Deductible            |
| and postnatal care)   |                       |                       |
+-----------------------+-----------------------+-----------------------+
| **[INPATIENT HOSPITAL | 30% Coinsurance After | 40% Coinsurance After |
| SE                    | Deductible            | Deductible            |
| RVICES]{.underline}** |                       |                       |
+-----------------------+-----------------------+-----------------------+
| **[OUTPATIENT         | \$75 per visit,       | \$50 per visit,       |
| SE                    | except Copayment      | except Copayment      |
| RVICES]{.underline}** | charge will be waived | charge will be waived |
|                       | if you are admitted   | if you are admitted   |
| Emergency Care        | to an observation,    | to an observation,    |
|                       | outpatient surgery,   | outpatient surgery,   |
|                       | outpatient procedure  | outpatient procedure  |
|                       | or inpatient care     | or inpatient care     |
|                       | setting               |                       |
+-----------------------+-----------------------+-----------------------+
| Non-Emergency         | 30% Coinsurance After | 40% Coinsurance After |
| Services              | Deductible            | Deductible            |
|                       |                       |                       |
| -   Outpatient        | 30% Coinsurance After | 40% Coinsurance After |
|     Surgery           | Deductible            | Deductible            |
|                       |                       |                       |
| -   Outpatient        |                       |                       |
|     Hospital          |                       |                       |
|     Procedures        |                       |                       |
+-----------------------+-----------------------+-----------------------+
| Urgent Care           | \$25 Copayment per    | \$25 Copayment per    |
|                       | visit                 | visit                 |
+-----------------------+-----------------------+-----------------------+
| Outpatient            | 30% Coinsurance After | 40% Coinsurance After |
| Rehabilitative        | Deductible            | Deductible            |
| Therapy Services:     |                       |                       |
| Physical and          | (Max. of up to 60     | (Max. of up to 60     |
| Occupational          | visits per calendar   | visits per calendar   |
|                       | year)                 | year)                 |
| Speech                |                       |                       |
+-----------------------+-----------------------+-----------------------+
| **[MISCELLANEOUS      | 30% Coinsurance After | 40% Coinsurance After |
| COVERED               | Deductible            | Deductible            |
| SE                    |                       |                       |
| RVICES]{.underline}** |                       |                       |
|                       |                       |                       |
| Home Health Agency    |                       |                       |
| Services              |                       |                       |
|                       |                       |                       |
| (includes intravenous |                       |                       |
| fluids and            |                       |                       |
| medications)          |                       |                       |
+-----------------------+-----------------------+-----------------------+
| Skilled Nursing       | 30% Coinsurance After | 40% Coinsurance After |
| Facility Services     | Deductible            | Deductible            |
|                       |                       |                       |
|                       | (Max. of up to 120    | (Max. of up to 120    |
|                       | days per calendar     | days per calendar     |
|                       | year)                 | year)                 |
+-----------------------+-----------------------+-----------------------+
| Ambulance             | 30% Coinsurance After | 40% Coinsurance After |
|                       | Deductible            | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Prosthetic Equipment  | 30% Coinsurance After | 40% Coinsurance After |
|                       | Deductible            | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Chemotherapy,         | Covered In-Mercy      | 40% Coinsurance After |
| radiation therapy and | Network Only          | Deductible            |
| inhalation therapy    |                       |                       |
+-----------------------+-----------------------+-----------------------+
| Hemodialysis and      | Covered In-Mercy      | 40% Coinsurance After |
| Dialysis services     | Network Only          | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Durable Medical       | 30% Coinsurance After | 40% Coinsurance After |
| Equipment and         | Deductible            | Deductible            |
| Supplies              |                       |                       |
+-----------------------+-----------------------+-----------------------+
| Diabetes Services     | 30% Coinsurance After | 40% Coinsurance After |
|                       | Deductible            | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Transplant Services   | Covered In-Mercy      | 40% Coinsurance After |
|                       | Network Only          | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Family Planning       | Covered In-Mercy      | 40% Coinsurance After |
| Services              | Network Only          | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Infertility Services  | Covered In-Mercy      | 40% Coinsurance After |
|                       | Network Only          | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Accidental Dental     | 30% Coinsurance After | 40% Coinsurance After |
|                       | Deductible            | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Hospice Services      | Covered In-Mercy      | Covered In-Mercy      |
|                       | Network Only          | Network Only          |
+-----------------------+-----------------------+-----------------------+
| Alcoholism/Chemical   | Covered In-Mercy      | 40% Coinsurance After |
| Dependency            | Network Only          | Deductible            |
|                       |                       |                       |
| -   Inpatient         | Covered In-Mercy      | 40% Coinsurance After |
|                       | Network Only          | Deductible            |
| -   Outpatient        |                       |                       |
+-----------------------+-----------------------+-----------------------+
| Mental Health         | Covered In-Mercy      | 40% Coinsurance After |
|                       | Network Only          | Deductible            |
| -   Inpatient         |                       |                       |
|                       | Covered In-Mercy      | 40% Coinsurance After |
| -   Outpatient        | Network Only          | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Routine Immunizations | Covered In-Mercy      | 40% Coinsurance After |
|                       | Network Only          | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Preventive care,      | Covered In-Mercy      | 40% Coinsurance After |
| including             | Network Only          | Deductible            |
| well-baby/child care  |                       |                       |
| and periodic          |                       |                       |
| check-ups             |                       |                       |
+-----------------------+-----------------------+-----------------------+
| Mammography           | Covered In-Mercy      | 40% Coinsurance After |
|                       | Network Only          | Deductible            |
+-----------------------+-----------------------+-----------------------+
| Outpatient            | Covered in PCS        | Covered in PCS        |
| Prescription Drug     | Network Only          | Network Only          |
|                       |                       |                       |
| -   Generic           | Covered in PCS        | Covered in PCS        |
|                       | Network Only          | Network Only          |
| -   Brand Name        |                       |                       |
|                       | Covered in PCS        | Covered in PCS        |
| -   Mail-Order        | Network Only          | Network Only          |
+-----------------------+-----------------------+-----------------------+

When you seek services from a Non-Plan Provider and/or fail to follow
pre-established guidelines, reimbursement for HMO Covered Services will
be made for \"Covered Services\". You will be required to share a larger
part of the \"Eligible Charges\" by satisfying the annual Deductible and
paying the required coinsurance. Preventive care or \"well care\" is not
covered **(Missouri Members only)**, along with other benefit
limitations described herein. Finally, when health care is received from
a Non-Plan Provider, you will be responsible for submitting a completed
claim form along with an itemized bill.

\"Covered Services\" means only the medical care, services and supplies
rendered under the following conditions: (a) prescribed by a Physician
for the therapeutic treatment of injury, illness or pregnancy; (b)
deemed Medically Necessary and appropriate in type, level, setting, and
length of service by the Plan; (c) rendered in accordance with generally
accepted medical practice and professionally recognized standards; (d)
not considered to be experimental, investigational, or which are
performed for research purposes.

Plan Allowance means the usual, customary and reasonable (UCR) Rate for
Covered Services rendered by a Provider reduced by any Non-compliance
Reduction.

In order to receive certain benefits, you are required to comply with
the specific pre-certification requirements described in connection with
the Utilization Management Program as outlined. You are responsible for
making sure the Plan is contacted before services are rendered. Failure
to comply with the requirement of the Utilization Management Program
described will result in a reduction in the Benefits Payable.

Services do not need to be obtained within the service area to be
eligible for coverage under POS.

**[Precertification]{.underline}**

For pre-certification of services call:

(Eastern and Central Missouri Regions): (314) 214-8196 or 1-800-327-0763

(Southwest Missouri Region): (417) 836-0402 or 1-800-836-0402

(Texas Region): (956) 723-7667 or 1-800-617-3433

You must obtain authorization before any service is rendered. It is your
responsibility to verify that the required pre-certifications have been
given by the Plan for coverage. This is called pre-certification. If
pre-certification is not given, or you fail to comply with the
requirements, eligible charges will be subject to the Non-compliance
reduction. Non-compliance reduction means the charges considered for
payment are reduced as a result of your failure to comply with the
pre-certification. These eligible charges will not be used to meet a
deductible or out-of-pocket maximum.

In the **[Missouri Regions]{.underline}**, Services Subject to
Pre-Certification Review and Non-compliance Reduction

+-------------------------------------+--------------------------------+
| 1\. Inpatient Hospitalization.      | 50% Reduction in Eligible      |
|                                     | Charges.                       |
+-------------------------------------+--------------------------------+
| 2\. Outpatient surgical procedures. | 50% Reduction in Eligible      |
|                                     | Charges (the Reduction applies |
|                                     | to both the facility and the   |
|                                     | professional charges).         |
+-------------------------------------+--------------------------------+
| 3\. Health Services provided during | 50% Reduction in Eligible      |
| Confinement.                        | Charges (the Reduction applies |
|                                     | to both facility and           |
|                                     | professional charges).         |
+-------------------------------------+--------------------------------+
| 4\. Home health care including Home | 50% Reduction in Eligible      |
| Infusion Intravenous (IV) Services. | Charges.                       |
+-------------------------------------+--------------------------------+
| 5\. MRI, RAST tests and CAT scans.  | 50% Reduction in Eligible      |
|                                     | Charges.                       |
+-------------------------------------+--------------------------------+
| 6\. Prosthetics.                    | 100% Reduction in Eligible     |
|                                     | Charges;                       |
|                                     |                                |
|                                     | No Benefit Payable.            |
+-------------------------------------+--------------------------------+
| 7\. Durable Medical Equipment.      | 100% Reduction in Eligible     |
|                                     | Charges;                       |
|                                     |                                |
|                                     | No Benefit Payable.            |
+-------------------------------------+--------------------------------+
| 8\. Physical Therapy, Occupational  | 100% Reduction in Eligible     |
| Therapy and Speech Therapy.         | Charges;                       |
|                                     |                                |
|                                     | No Benefit Payable.            |
+-------------------------------------+--------------------------------+
| 9\. Orthotics                       | 100% Reduction in Eligible     |
|                                     | Charges;                       |
|                                     |                                |
|                                     | No Benefit Payable.            |
+-------------------------------------+--------------------------------+
| 10\. Skilled Nursing                | 100% Reduction in Eligible     |
|                                     | Charges;                       |
|                                     |                                |
|                                     | No Benefit Payable.            |
+-------------------------------------+--------------------------------+
| 11\. Inpatient Rehabilitation       | 50% Reduction in Eligible      |
|                                     | Charges.                       |
+-------------------------------------+--------------------------------+

Note: It is your responsibility to verify that the required
certification has been given by the Plan. If certification is not given,
or you fail to comply with the requirements stated in this Section,
Eligible Charges will be subject to the Non-compliance Reduction and the
amount of the reduction will not apply toward your Out-of-Pocket Maximum
or Deductible.

Also, you are required to notify the Plan three (3) days in advance of
any hospital admission for a non-emergency. If it is not possible to
notify the Plan, you must obtain pre-certification review as soon as
reasonably practical prior to the provisions of the service and in no
event less than one (1) business day prior to the service. If you fail
to comply with the pre-certification requirements, there is a 50%
reduction of eligible charges for non-compliance.

Care rendered in connection with a Pregnancy will be treated as an
exception to the three (3) day prior notice requirement. The
Pre-certification Review requirement will be treated as satisfied if you
notify us no later than the fifth month of Pregnancy and you notify us
within one (1) business day after admission to the Hospital for
delivery.

In the **[Texas Region]{.underline}**, precertification is required for
the following services:

-   Inpatient confinement, including inpatient confinement for maternity
    care; and

-   Maternity Care

-   Transplant Services

You or your designated representative must notify the Plan to precertify
the admission, maternity care or transplant, as the case may be, prior
to receiving any of the services or supplies associated with that
admission, maternity care, or transplant.

To initiate the precertification process, call us at the telephone
number listed on your identification card. This call must be made as
follows:

-   For a non-emergency inpatient confinement, the call must be made at
    least seven (7) days prior to any planned admission into a Hospital.

-   For an inpatient confinement due to a Medical Emergency, the call
    must be made within two (2) working days after the time of the
    admission or as soon thereafter as reasonably possible; and

-   For maternity care, the call must be made within twenty-four (24)
    hours after the birth or as soon thereafter as possible.

You may request a review of the Precertification decision as described
in this brochure. (See Section 8, The Disputed Claims Process)

FAILURE TO PRECERTIFY WILL RESULT IN A 50% REDUCTION OF POS BENEFITS.

The additional percentage or dollar amount of the UCR, which would be
payable as a penalty for failure to obtain precertification under this
section is not a covered expense, and will not be applied to the
Deductible or the maximum out-of-pocket limit, if any.

**[Deductible]{.underline}**

\"Deductible\" means the amount of Eligible Charges payable by you or
your family before benefits are payable. No Benefit is payable for any
part of Eligible Charges used to meet a Deductible.

In the **[Missouri Regions]{.underline}**, you will pay a \$500
deductible per person per calendar year and \$1,000 deductible per
family per calendar year.

In the **[Texas Region]{.underline}**, you will pay a \$1,000 deductible
per person per calendar year and \$2,000 deductible per family per
calendar year.

**[Coinsurance]{.underline}**

\"Coinsurance\" means your share of the cost of Eligible Charges stated
as a percentage up to the Out-of-Pocket Maximum.

In the **[Missouri Regions]{.underline}**, you are responsible for 30%
coinsurance after the deductible.

The out-of-pocket maximum per person is \$3,500 (including the
deductible) and \$7,000 per family (including deductible). The lifetime
maximum benefit is \$2,500,000 per person. Your out-of-pocket expenses
under POS do not qualify for the Plan\'s in-network out-of-pocket
maximum.

In the **[Texas Region]{.underline}**, you and your family have
unlimited out-of-pocket maximums, as well as an unlimited lifetime
maximum benefit. Your out-of-pocket expenses under POS do not qualify
for the Plan\'s in-network out-of-pocket maximum.

You are responsible for a 40% coinsurance after the deductible.

When you use a non-participating provider and fail to follow
pre-certified guidelines, you are responsible for sharing a larger part
of the cost for the services. The benefit when a non-participating
hospital is used is shown in the POS outline of benefits. The Plan will
pay a participating hospital in full even though the POS benefit (and
non-Plan doctor) are being used. The hospital charge, sometimes called
facility charge, does not cover any charges for doctor\'s services.

True emergency care is always payable as a Plan in-network benefit.

Charges by a Provider in excess of the UCR Rate will not be covered by
us and will not be counted toward your Deductible or maximum
out-of-pocket limit, if any.

**[Maximum benefit]{.underline}**

The maximum limit is \$2,500,000 lifetime maximum per person in
**[Missouri Regions]{.underline}**.

In the **[Texas Region]{.underline}**, you have unlimited lifetime
maximums.

**[Hospital/extended care]{.underline}**

In the **[Missouri Regions]{.underline}**, you are responsible for 30%
coinsurance after the deductible.

In the **[Texas Region]{.underline}**, you are responsible for a 40%
coinsurance after the deductible.

**[Emergency benefits]{.underline}**

**Missouri Regions:** You will pay \$75 per visit, except Copayment
charge will be waived if you are admitted to an observation, outpatient
surgery, outpatient procedure or inpatient care setting.

**Texas Region:** You will pay a \$50 per visit, except Copayment charge
will be waived if you are admitted to an observation, outpatient
surgery, outpatient procedure or inpatient care setting.

**[What is not covered]{.underline}**

The following are not covered under the POS benefit in the **[Missouri
Regions]{.underline}**:

-   Chemotherapy, radiation therapy and inhalation therapy

-   Family Planning Services

-   Hospice Services

-   Eye and ear examinations to determine the need for vision and
    hearing correction

-   Alcoholism and drug abuse services, including but not limited to
    diagnosis and medical treatment and services.

-   Prescription drugs other than drugs provided by a hospital to a
    member as an inpatient

-   Chiropractic services

-   Hemodialysis and dialysis services

-   Preventative care, including well-child care and immunizations and
    periodic checkups

-   Services for treatment of mental or nervous disorders.

-   Mammography services

-   Promotion of conception including, but not limited to, treatment of
    impotency or infertility, in vitro fertilization, embryo
    transplantation, reproductive therapy, artificial insemination, or
    reversal of voluntarily induced sterility.

-   Smoking cessation services

-   Any organ transplant surgery or procedures, including services
    rendered on behalf of an organ recipient or an organ donor.

-   Charges in excess of the Plan Allowance for the service provided as
    determined by us, or any charges which exceed a calendar year
    maximum, or other benefit maximum.

-   Any types of services, supplies or treatment not specifically
    provided for herein.

The following are not covered under the POS benefit in the **[Texas
Region]{.underline}:**

-   HMO benefits received for the same service

-   Hospice care

-   Outpatient prescription drugs

-   Hearing aids, including fitting

-   If a Member is admitted to a Hospital on a Friday or Saturday and
    such admission is not Medically Necessary, hospital charges incurred
    on the day of admission and on the following day, if a Saturday, are
    not covered.

-   Services provided by your spouse, parent, child, grandparent,
    brother, sister or parent-in-law

-   Chiropractic Services

-   Smoking Cessation

**[How to obtain benefits]{.underline}**

-   Please see Section 7, Filing a Claim for Covered Services.

-   If a claim is denied, you may obtain a review of the denial through
    the disputed claims process in Section 8.

+-----------------------------------------------------------------------+
| ## **Section** 5(j) 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.                    |
|                                                                       |
| **[Wellness Programs]{.underline}**                                   |
|                                                                       |
| The following wellness programs are available at the Plan's           |
| participating hospitals. Program fees may apply. Members are          |
| encouraged to contact the participating hospital nearest you for more |
| information.                                                          |
|                                                                       |
| -   Health Screenings                                                 |
|                                                                       |
| -   Fitness and Weight Management                                     |
|                                                                       |
| -   Health Education                                                  |
|                                                                       |
| -   Support/Therapy Groups                                            |
|                                                                       |
| -   Parenting Classes                                                 |
|                                                                       |
| -   Birth/Baby Care Programs                                          |
|                                                                       |
| -   Children's Health Programs                                        |
|                                                                       |
| -   Senior Programs                                                   |
+-----------------------------------------------------------------------+

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

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

We do not cover the following:

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

-   Educational Services;

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

-   Services provided by a first degree relative;

-   Devices provided in connection with treatment to restore sexual
    function (i.e. penile implants);

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

-   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 gender transformations;

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

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

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

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

# Section 7. Filing a claim for covered services

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

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

+------------------+---------------------------------------------------+
| Medical,         | In most cases, providers and facilities file      |
| hospital and     | claims for you. Physicians must file on the form  |
| drug benefits    | HCFA-1500, Health Insurance Claim Form. Your      |
|                  | facility will file on the UB-92 form. For claims  |
|                  | questions and assistance, call us at              |
|                  |                                                   |
|                  | (Eastern and Central Missouri Regions):           |
|                  | 314-214-8196 or 1-800-327-0763                    |
|                  |                                                   |
|                  | (Southwest Missouri Region): 417-836-0402 or      |
|                  | 1-800-836-0402                                    |
|                  |                                                   |
|                  | (Texas Region): 956-723-7667 or 1-800-617-3433    |
|                  |                                                   |
|                  | When you must file a claim -- such as for         |
|                  | services you receive outside the Plan's service   |
|                  | area -- submit it on the HCFA-1500 or a claim     |
|                  | form that includes the information shown below.   |
|                  | Bills and receipts should be itemized and show:   |
|                  |                                                   |
|                  | -   Covered member's name and ID number;          |
|                  |                                                   |
|                  | -   Name and address of the physician or facility |
|                  |     that provided the service or supply;          |
|                  |                                                   |
|                  | -   Dates you received the services or supplies;  |
|                  |                                                   |
|                  | -   Diagnosis;                                    |
|                  |                                                   |
|                  | -   Type of each service or supply;               |
|                  |                                                   |
|                  | -   The charge for each service or supply;        |
|                  |                                                   |
|                  | -   A copy of the explanation of benefits,        |
|                  |     payments, or denial from any primary payer    |
|                  |     \--such as the Medicare Summary Notice (MSN); |
|                  |     and                                           |
|                  |                                                   |
|                  | -   Receipts, if you paid for your services.      |
|                  |                                                   |
|                  | **Submit your claims to:** Mercy Health           |
|                  | Plans/Premier Health Plans                        |
|                  |                                                   |
|                  | P.O. Box 4568                                     |
|                  |                                                   |
|                  | Springfield, MO 65808-4568                        |
+------------------+---------------------------------------------------+
| Deadline for     | Send us all of the documents for your claim as    |
| filing your      | soon as possible. You must submit the claim by    |
| claim            | December 31 of the year after the year you        |
|                  | received the service, unless timely filing was    |
|                  | prevented by administrative operations of         |
|                  | Government or legal incapacity, provided the      |
|                  | claim was submitted as soon as reasonably         |
|                  | possible.                                         |
+------------------+---------------------------------------------------+
| When we need     | Please reply promptly when we ask for additional  |
| more information | information. We may delay processing or deny your |
|                  | claim if you do not respond.                      |
+------------------+---------------------------------------------------+

# Section 8. The disputed claims process

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

+----+-----------------------------------------------------------------+
| St | Description                                                     |
| ep |                                                                 |
+----+-----------------------------------------------------------------+
| 1  | Ask us in writing to reconsider our initial decision. You must: |
|    |                                                                 |
|    | a)  Write to us within 6 months from the date of our decision;  |
|    |     and                                                         |
|    |                                                                 |
|    | b)  Send your request to us at:                                 |
|    |                                                                 |
|    | > Mercy Health Plans, 14528 South Outer 40, Suite 300,          |
|    | > Chesterfield, MO 63017 (Eastern and Central MO)               |
|    | >                                                               |
|    | > Mercy Health Plans, 5901 McPherson, Suites 1 & 2B, Laredo TX  |
|    | > 78041 (Texas)                                                 |
|    | >                                                               |
|    | > Premier Health Plans, One Corporate Centre, Suite 200, 1949   |
|    | > East Sunshine, Springfield, MO 65804 (Southwest MO)           |
|    |                                                                 |
|    | c)  Include a statement about why you believe our initial       |
|    |     decision was wrong, based on specific benefit provisions in |
|    |     this brochure; and                                          |
|    |                                                                 |
|    | d)  Include copies of documents that support your claim, such   |
|    |     as physicians\' letters, operative reports, bills, medical  |
|    |     records, and explanation of benefits (EOB) forms.           |
+----+-----------------------------------------------------------------+
| 2  | We have 30 days from the date we receive your request to:       |
|    |                                                                 |
|    | a)  Pay the claim (or, if applicable, arrange for the health    |
|    |     care provider to give you the care); or                     |
|    |                                                                 |
|    | b)  Write to you and maintain our denial − go to step 4; or     |
|    |                                                                 |
|    | c)  Ask you or your provider for more information. If we ask    |
|    |     your provider, we will send you a copy of our request---go  |
|    |     to step 3.                                                  |
+----+-----------------------------------------------------------------+
| 3  | You or your provider must send the information so that we       |
|    | receive it within 60 days of our request. We will then decide   |
|    | within 30 more days.                                            |
|    |                                                                 |
|    | If we do not receive the information within 60 days, we will    |
|    | decide within 30 days of the date the information was due. We   |
|    | will base our decision on the information we already have.      |
|    |                                                                 |
|    | We will write to you with our decision.                         |
+----+-----------------------------------------------------------------+
| 4  | If you do not agree with our decision, you may ask OPM to       |
|    | review it.                                                      |
+----+-----------------------------------------------------------------+
|    | You must write to OPM within:                                   |
|    |                                                                 |
|    | -   90 days after the date of our letter upholding our initial  |
|    |     decision; or                                                |
|    |                                                                 |
|    | -   120 days after you first wrote to us − if we did not answer |
|    |     that request in some way within 30 days; or                 |
|    |                                                                 |
|    | -   120 days after we asked for additional information.         |
+----+-----------------------------------------------------------------+
|    | Write to OPM at: United States Office of Personnel Management,  |
|    | Insurance Services Programs, Health Insurance Group 2, 1900 E   |
|    | Street, NW, Washington, DC 20415-3620.                          |
+----+-----------------------------------------------------------------+
| T  |                                                                 |
| he |                                                                 |
| di |                                                                 |
| sp |                                                                 |
| ut |                                                                 |
| ed |                                                                 |
| cl |                                                                 |
| ai |                                                                 |
| ms |                                                                 |
| p  |                                                                 |
| ro |                                                                 |
| ce |                                                                 |
| ss |                                                                 |
| *  |                                                                 |
| (c |                                                                 |
| on |                                                                 |
| ti |                                                                 |
| nu |                                                                 |
| ed |                                                                 |
| )* |                                                                 |
+----+-----------------------------------------------------------------+
|    | Send OPM the following information:                             |
|    |                                                                 |
|    | -   A statement about why you believe our decision was wrong,   |
|    |     based on specific benefit provisions in this brochure;      |
|    |                                                                 |
|    | -   Copies of documents that support your claim, such as        |
|    |     physicians\' letters, operative reports, bills, medical     |
|    |     records, and explanation of benefits (EOB) forms;           |
|    |                                                                 |
|    | -   Copies of all letters you sent to us about the claim;       |
|    |                                                                 |
|    | -   Copies of all letters we sent to you about the claim; and   |
|    |                                                                 |
|    | -   Your daytime phone number and the best time to call.        |
|    |                                                                 |
|    | Note: If you want OPM to review more than one claim, you must   |
|    | clearly identify which documents apply to which claim.          |
+----+-----------------------------------------------------------------+
|    | Note: You are the only person who has a right to file a         |
|    | disputed claim with OPM. Parties acting as your representative, |
|    | such as medical providers, must include a copy of your specific |
|    | written consent with the review request.                        |
|    |                                                                 |
|    | Note: The above deadlines may be extended if you show that you  |
|    | were unable to meet the deadline because of reasons beyond your |
|    | control.                                                        |
+----+-----------------------------------------------------------------+
| *  | OPM will review your disputed claim request and will use the    |
| *5 | information it collects from you and us to decide whether our   |
| ** | decision is correct. OPM will send you a final decision within  |
|    | 60 days. There are no other administrative appeals.             |
+----+-----------------------------------------------------------------+
|    | If you do not agree with OPM's decision, your only recourse is  |
|    | to sue. If you decide to sue, you must file the suit against    |
|    | OPM in Federal court by December 31 of the third year after the |
|    | year in which you received the disputed services, drugs, or     |
|    | supplies or from the year in which you were denied              |
|    | precertification or prior approval. This is the only deadline   |
|    | that may not be extended.                                       |
|    |                                                                 |
|    | OPM may disclose the information it collects during the review  |
|    | process to support their disputed claim decision. This          |
|    | information will become part of the court record.               |
+----+-----------------------------------------------------------------+
|    | You may not sue until you have completed the disputed claims    |
|    | process. Further, Federal law governs your lawsuit, benefits,   |
|    | and payment of benefits. The Federal court will base its review |
|    | on the record that was before OPM when OPM decided to uphold or |
|    | overturn our decision. You may recover only the amount of       |
|    | benefits in dispute.                                            |
+----+-----------------------------------------------------------------+

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

a)  We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at:

> (Eastern and Central Missouri Regions): 314-214-8196 or 1-800-327-0763
>
> (Southwest Missouri Region): 417-836-0402 or 1-800-836-0402
>
> (Texas Region): 957-723-7667 or 1-800-617-3433
>
> and we will expedite our review; or

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

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

-   You may call OPM's Health Insurance Group 2 at 202/606-3818 between
    8 a.m. and 5 p.m. eastern time.

# Section 9. Coordinating benefits with other coverage

+------------------+---------------------------------------------------+
| ### Whe          | You must tell us if you or a covered family       |
| n you have other | member have coverage under another group health   |
|  health coverage | plan or have automobile insurance that pays       |
|                  | health care expenses without regard to fault.     |
|                  | This is called "double coverage".                 |
|                  |                                                   |
|                  | When you have double coverage, one plan normally  |
|                  | pays its benefits in full as the primary payer    |
|                  | and the other plan pays a reduced benefit as the  |
|                  | secondary payer. We, like other insurers,         |
|                  | determine which coverage is primary according to  |
|                  | the National Association of Insurance             |
|                  | Commissioners' guidelines.                        |
|                  |                                                   |
|                  | When we are the primary payer, we will pay the    |
|                  | benefits described in this brochure.              |
|                  |                                                   |
|                  | When we are the secondary payer, we will          |
|                  | determine our allowance. After the primary plan   |
|                  | pays, we will pay what is left of our allowance,  |
|                  | up to our regular benefit. We will not pay more   |
|                  | than our allowance.                               |
+------------------+---------------------------------------------------+
| ### W            | Medicare is a Health Insurance Program for:       |
| hat is Medicare? |                                                   |
|                  | -   People 65 years of age or older.              |
|                  |                                                   |
|                  | -   Some people with disabilities under 65 years  |
|                  |     of age.                                       |
|                  |                                                   |
|                  | -   People with End-Stage Renal Disease           |
|                  |     (permanent kidney failure requiring dialysis  |
|                  |     or a transplant).                             |
|                  |                                                   |
|                  | Medicare has two parts:                           |
|                  |                                                   |
|                  | -   Part A (Hospital Insurance). Most people do   |
|                  |     not have to pay for Part A. If you or your    |
|                  |     spouse worked for at least 10 years in        |
|                  |     Medicare-covered employment, you should be    |
|                  |     able to qualify for premium-free Part A       |
|                  |     insurance. (Someone who was a Federal         |
|                  |     employee on January 1, 1983 or since          |
|                  |     automatically qualifies.) Otherwise, if you   |
|                  |     are age 65 or older, you may be able to buy   |
|                  |     it. Contact 1-800-MEDICARE for more           |
|                  |     information.                                  |
|                  |                                                   |
|                  | -   Part B (Medical Insurance). Most people pay   |
|                  |     monthly for Part B. Generally, Part B         |
|                  |     premiums are withheld from your monthly       |
|                  |     Social Security check or your retirement      |
|                  |     check.                                        |
+------------------+---------------------------------------------------+
| #                | The decision to enroll in Medicare is yours. We   |
| ### Should I enr | encourage you to apply for Medicare benefits 3    |
| oll in Medicare? | months before you turn age 65. It's easy. Just    |
|                  | call the Social Security Administration toll-free |
|                  | number 1-800-772-1213 to set up an appointment to |
|                  | apply. If you do not apply for one or both Parts  |
|                  | of Medicare, you can still be covered under the   |
|                  | FEHB Program.                                     |
|                  |                                                   |
|                  | If you can get premium-free Part A coverage, we   |
|                  | advise you to enroll in it. Most Federal          |
|                  | employees and annuitants are entitled to Medicare |
|                  | Part A at age 65 **without cost**. When you don't |
|                  | have to pay premiums for Medicare Part A, it      |
|                  | makes good sense to obtain the coverage. It can   |
|                  | reduce your out-of-pocket expenses as well as     |
|                  | costs to the FEHB, which can help keep FEHB       |
|                  | premiums down.                                    |
|                  |                                                   |
|                  | Everyone is charged a premium for Medicare Part B |
|                  | coverage. The Social Security Administration can  |
|                  | provide you with premium and benefit information. |
|                  | Review the information and decide if it makes     |
|                  | sense for you to buy the Medicare Part B          |
|                  | coverage.                                         |
|                  |                                                   |
|                  | If you are eligible for Medicare, you may have    |
|                  | choices in how you get your health care. Medicare |
|                  | Advantage is the term used to describe the        |
|                  | various private health plan choices available to  |
|                  | Medicare beneficiaries. The information in the    |
|                  | next few pages shows how we coordinate benefits   |
|                  | with Medicare, depending whether you are in the   |
|                  | Original Medicare Plan or a private Medicare      |
|                  | Advantage plan.                                   |
+------------------+---------------------------------------------------+

+------------------+---------------------------------------------------+
| ##               | The Original Medicare Plan (Original Medicare) is |
| ## The Original  | available everywhere in the United States. It is  |
| Medicare Plan (P | the way everyone used to get Medicare benefits    |
| art A or Part B) | and is the way most people get their Medicare     |
|                  | Part A and Part B benefits now. You may go to any |
|                  | doctor, specialist, or hospital that accepts      |
|                  | Medicare. The Original Medicare Plan pays its     |
|                  | share and you pay your share. Some things are not |
|                  | covered under Original Medicare, such as most     |
|                  | prescription drugs (but coverage through private  |
|                  | prescription drug plans will be available         |
|                  | starting in 2006).                                |
|                  |                                                   |
|                  | When you are enrolled in Original Medicare along  |
|                  | with this Plan, you still need to follow the      |
|                  | rules in this brochure for us to cover your care. |
|                  | Your care must continure to be authorized by your |
|                  | Plan PCP. We will not waive any of our            |
|                  | copayments, coinsurance, or deductibles.          |
+------------------+---------------------------------------------------+
|                  | **Claims process when you have the Original       |
|                  | Medicare Plan** -- You probably will never have   |
|                  | to file a claim form when you have both our Plan  |
|                  | and the Original Medicare Plan.                   |
|                  |                                                   |
|                  | -   When we are the primary payer, we process the |
|                  |     claim first.                                  |
|                  |                                                   |
|                  | -   When Original Medicare is the primary payer,  |
|                  |     Medicare processes your claim first. In most  |
|                  |     cases, your claim will be coordinated         |
|                  |     automatically and we will then provide        |
|                  |     secondary benefits for covered charges. You   |
|                  |     will not need to do anything. To find out if  |
|                  |     you need to do something to file your claim,  |
|                  |     call us at:                                   |
|                  |                                                   |
|                  | > Eastern and Central Missouri Regions:           |
|                  | > 314-214-8196 or 1-800-327-0763                  |
|                  | >                                                 |
|                  | > Southwest Missouri Region: 417-836-0402 or      |
|                  | > 1-800-836-0402                                  |
|                  | >                                                 |
|                  | > Texas Region: 956-723-7667 or 1-800-617-3433    |
|                  | >                                                 |
|                  | > or visit our Web site at                        |
|                  | > [www.mercyhe                                    |
|                  | althplans.com](http://www.mercyhealthplans.com/). |
|                  |                                                   |
|                  | **We do not waive any costs if the Original       |
|                  | Medicare Plan is your primary payer.**            |
+------------------+---------------------------------------------------+

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

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

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

+--------------------+-------------------------------------------------+
| ####               | If you are eligible for Medicare, you may       |
| Medicare Advantage | choose to enroll in and get your Medicare       |
|                    | benefits from a Medicare Advantage plan. These  |
|                    | are private health care choices (like HMOs) in  |
|                    | some areas of the country. In most Medicare     |
|                    | Advantage plans, you can only go to doctors,    |
|                    | specialists, or hospitals that are part of the  |
|                    | plan. Medicare Advantage plans provide all the  |
|                    | benefits that Original Medicare covers. Some    |
|                    | cover extras, like prescription drugs. To learn |
|                    | more about enrolling in a Medicare Advantage    |
|                    | plan, contact Medicare at 1-800-MEDICARE        |
|                    | (1-800-633-4227) or at                          |
|                    | [www.medicare.gov](http://www.medicare.gov/).   |
|                    |                                                 |
|                    | If you enroll in a Medicare Advantage plan, the |
|                    | following options are available to you:         |
|                    |                                                 |
|                    | **This Plan and our Medicare Advantage plan:**  |
|                    | You may enroll in our Medicare Advantage plan   |
|                    | and also remain enrolled in our FEHB plan. In   |
|                    | this case, we do not waive cost-sharing for     |
|                    | your FEHB coverage.                             |
|                    |                                                 |
|                    | **This Plan and another plan's Medicare         |
|                    | Advantage plan:** You may enroll in another     |
|                    | plan's Medicare Advantage plan and also remain  |
|                    | enrolled in our FEHB plan. We will still        |
|                    | provide benefits when your Medicare Advantage   |
|                    | plan is primary, even out of the Medicare       |
|                    | Advantage network and/or service area (if you   |
|                    | use our Plan providers), but we will not waive  |
|                    | any of our copayments, coinsurance, or          |
|                    | deductibles. If you enroll in a Medicare        |
|                    | Advantage plan, tell us. We will need to know   |
|                    | whether you are in the Original Medicare Plan   |
|                    | or in a Medicare Advantage plan so we can       |
|                    | correctly coordinate benefits with Medicare.    |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in a        |
|                    | Medicare Advantage plan:** If you are an        |
|                    | annuitant or former spouse, you can suspend     |
|                    | your FEHB coverage to enroll in a Medicare      |
|                    | Advantage plan, eliminating your FEHB premium.  |
|                    | (OPM does not contribute to your Medicare       |
|                    | Advantage plan premium.) For information on     |
|                    | suspending your FEHB enrollment, contact your   |
|                    | retirement office. If you later want to         |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next open season unless   |
|                    | you involuntarily lose coverage or move out of  |
|                    | the Medicare Advantage plan\'s service area.    |
+--------------------+-------------------------------------------------+
| ### T              | TRICARE is the health care program for eligible |
| RICARE and CHAMPVA | dependents of military persons, and retirees of |
|                    | the military. TRICARE includes the CHAMPUS      |
|                    | program. CHAMPVA provides health coverage to    |
|                    | disabled Veterans and their eligible            |
|                    | dependents. IF TRICARE or CHAMPVA and this Plan |
|                    | cover you, we pay first. See your TRICARE or    |
|                    | CHAMPVA Health Benefits Advisor if you have     |
|                    | questions about these programs.                 |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in TRICARE  |
|                    | or CHAMPVA:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these programs, eliminating    |
|                    | your FEHB premium. (OPM does not contribute to  |
|                    | any applicable plan premiums.) For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the       |
|                    | program.                                        |
+--------------------+-------------------------------------------------+

+--------------------+-------------------------------------------------+
| ### Wor            | We do not cover services that:                  |
| kers' Compensation |                                                 |
|                    | -   You need because of a workplace-related     |
|                    |     illness or injury that the Office of        |
|                    |     Workers' Compensation Programs (OWCP) or a  |
|                    |     similar Federal or State agency determines  |
|                    |     they must provide; or                       |
|                    |                                                 |
|                    | -   OWCP or a similar agency pays for through a |
|                    |     third-party injury settlement or other      |
|                    |     similar proceeding that is based on a claim |
|                    |     you filed under OWCP or similar laws.       |
|                    |                                                 |
|                    | Once OWCP or similar agency pays its maximum    |
|                    | benefits for your treatment, we will cover your |
|                    | care.                                           |
+--------------------+-------------------------------------------------+
| ### Medicaid       | When you have this Plan and Medicaid, we pay    |
|                    | first.                                          |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in Medicaid |
|                    | or a similar State-sponsored program of medical |
|                    | assistance:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these State programs,          |
|                    | eliminating your FEHB premium. For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the State |
|                    | program.                                        |
+--------------------+-------------------------------------------------+
| ### When o         | We do not cover services and supplies when a    |
| ther Government ag | local, State, or Federal government agency      |
| encies are respons | directly or indirectly pays for them.           |
| ible for your care |                                                 |
+--------------------+-------------------------------------------------+
| ### When           | When you receive money to compensate you for    |
|  others are respon | medical or hospital care for injuries or        |
| sible for injuries | illness caused by another person, you must      |
|                    | reimburse us for any expenses we paid. However, |
|                    | we will cover the cost of treatment that        |
|                    | exceeds the amount you received in the          |
|                    | settlement.                                     |
|                    |                                                 |
|                    | If you do not seek damages you must agree to    |
|                    | let us try. This is called subrogation. If you  |
|                    | need more information, contact us for our       |
|                    | subrogation procedures.                         |
+--------------------+-------------------------------------------------+

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

+------------------+---------------------------------------------------+
| Calendar year    | January 1 through December 31 of the same year.   |
|                  | For new enrollees, the calendar year begins on    |
|                  | the effective date of their enrollment and ends   |
|                  | on December 31 of the same year.                  |
+------------------+---------------------------------------------------+
| Coinsurance      | Coinsurance is the percentage of our allowance    |
|                  | that you must pay for your care. You may also be  |
|                  | responsible for additional amounts. See page 14.  |
+------------------+---------------------------------------------------+
| Copayment        | A copayment is a fixed amount of money you pay    |
|                  | when you receive covered services. See page 14.   |
+------------------+---------------------------------------------------+
| Covered services | Care we provide benefits for, as described in     |
|                  | this brochure.                                    |
+------------------+---------------------------------------------------+
| Custodial care   | Assistance with activities of daily living        |
|                  | (bathing, dressing, eating, etc.). Custodial care |
|                  | that lasts 90 days or more is sometimes known as  |
|                  | Long Term Care.                                   |
+------------------+---------------------------------------------------+
| Deductible       | A deductible is a fixed amount of covered         |
|                  | expenses you must incur for certain covered       |
|                  | services and supplies before we start paying      |
|                  | benefits for those services. See page 14.         |
+------------------+---------------------------------------------------+
| Experimental or  | "Experimental or Investigational Services" means  |
| investigational  | medical, surgical, diagnostic, psychiatric,       |
| services         | substance abuse or other health care services,    |
|                  | technologies, supplies, treatments, procedures,   |
|                  | drug therapies or devices that, at the time we    |
|                  | make a determination regarding coverage in a      |
|                  | particular case, are determined to be any of the  |
|                  | following:                                        |
|                  |                                                   |
|                  | -   Not approved by the U.S. Food and Drug        |
|                  |     Administration (FDA) to be lawfully marketed  |
|                  |     for the proposed use and not identified in    |
|                  |     the American Hospital Formulary Service or    |
|                  |     the United States Pharmacopoeia Dispensing    |
|                  |     Information as appropriate for the proposed   |
|                  |     use.                                          |
|                  |                                                   |
|                  | -   Subject to review and approval by any         |
|                  |     institutional review board for the proposed   |
|                  |     use.                                          |
|                  |                                                   |
|                  | -   The subject of an ongoing clinical trial that |
|                  |     meets the definition of a Phase 1, 2 or 3     |
|                  |     clinical trial set forth in the FDA           |
|                  |     regulations, regardless of whether the trial  |
|                  |     is actually subject to FDA oversight.         |
|                  |                                                   |
|                  | If you have a life-threatening sickness or        |
|                  | condition (one which is likely to cause death     |
|                  | within one year of the request for treatment) we  |
|                  | may, in our discretion, determine that an         |
|                  | Experimental or Investigational Service meets the |
|                  | definition of a Covered Service for that sickness |
|                  | or condition. For this to take place, we must     |
|                  | determine that the procedure or treatment is      |
|                  | promising, but unproven, and that the service     |
|                  | uses a specific research protocol that meets      |
|                  | standards equivalent to those defined by the      |
|                  | National Institutes of Health.                    |
+------------------+---------------------------------------------------+
| Group health     | Any plan on an insured or uninsured basis which   |
| coverage         | provides medical or dental benefits or services:  |
|                  | (a) group coverage, (b) services plan contracts,  |
|                  | (c) coverage under any trustee plans, welfare     |
|                  | plans or employee benefit organization plans, or  |
|                  | (d) benefits under Medicare.                      |
+------------------+---------------------------------------------------+
| Medical          | Medically necessary health care services are (1)  |
| necessity        | medically appropriate and necessary to meet the   |
|                  | basic health needs of the Member; (2) rendered in |
|                  | the most efficient manner and appropriate setting |
|                  | for the Covered Service; (3) consistent in type,  |
|                  | frequency and duration of treatment with          |
|                  | scientifically-based guidelines of national       |
|                  | medical, research, or health care coverage        |
|                  | organizations or governmental agencies that are   |
|                  | accepted by the Plan; (4) consistent with the     |
|                  | diagnosis of the conditions; (5) of demonstrated  |
|                  | medical value and (6) are not a part of or        |
|                  | associated with the scholastic education or       |
|                  | vocational training of the patient. Medically     |
|                  | Necessary does not include care that is provided  |
|                  | primarily for the convenience of the Member or a  |
|                  | Health Provider, or care that is rendered more    |
|                  | frequently than that accepted as medically        |
|                  | appropriate by the medical profession. While some |
|                  | health care services are medically acceptable,    |
|                  | they may not be medically necessary.              |
+------------------+---------------------------------------------------+

+------------------+---------------------------------------------------+
| Plan allowance   | The Plan's determination of charges for medical   |
|                  | care, services and supplies that do not exceed    |
|                  | the fees and prices generally approved for cases  |
|                  | of comparable nature and severity at the time and |
|                  | place. The Plan will use the following guidelines |
|                  | for determining usual, customary and reasonable   |
|                  | (UCR):                                            |
|                  |                                                   |
|                  | a.  The usual fee frequently charged by the       |
|                  |     provider for a service or supply;             |
|                  |                                                   |
|                  | b.  The widely accepted rate of fees charges in   |
|                  |     the same area by the health professionals of  |
|                  |     like training and experience; and             |
|                  |                                                   |
|                  | c.  Unusual circumstances or complication         |
|                  |     requiring additional time, skill and          |
|                  |     experience in connection with the provided    |
|                  |     services or supply.                           |
+------------------+---------------------------------------------------+
| Us/We            | Us and we refer to Mercy Health Plans/Premier     |
|                  | Health Plans.                                     |
+------------------+---------------------------------------------------+
| You              | You refers to the enrollee and each covered       |
|                  | family member.                                    |
+------------------+---------------------------------------------------+

# Section 11. FEHB Facts

### Coverage information

+------------------+---------------------------------------------------+
| #### No p        | We will not refuse to cover the treatment of a    |
| re-existing cond | condition you had before you enrolled in this     |
| ition limitation | Plan solely because you had the condition before  |
|                  | you enrolled.                                     |
+------------------+---------------------------------------------------+
| #### W           | See                                               |
| here you can get | [www.opm.gov/insure](http://www.opm.gov/insure).  |
|  information abo | Also, your employing or retirement office can     |
| ut enrolling in  | answer your questions, and give you a *Guide to   |
| the FEHB Program | Federal Employees Health Benefits Plans,*         |
|                  | brochures for other plans, and other materials    |
|                  | you need to make an informed decision about your  |
|                  | FEHB coverage. These materials tell you:          |
|                  |                                                   |
|                  | -   When you may change your enrollment;          |
|                  |                                                   |
|                  | -   How you can cover your family members;        |
|                  |                                                   |
|                  | -   What happens when you transfer to another     |
|                  |     Federal agency, go on leave without pay,      |
|                  |     enter military service, or retire;            |
|                  |                                                   |
|                  | -   When your enrollment ends; and                |
|                  |                                                   |
|                  | -   When the next open season for enrollment      |
|                  |     begins.                                       |
|                  |                                                   |
|                  | We don't determine who is eligible for coverage   |
|                  | and, in most cases, cannot change your enrollment |
|                  | status without information from your employing or |
|                  | retirement office.                                |
+------------------+---------------------------------------------------+
| #### Typ         | Self Only coverage is for you alone. Self and     |
| es of coverage a | Family coverage is for you, your spouse, and your |
| vailable for you | unmarried dependent children under age 22,        |
|  and your family | including any foster children or stepchildren     |
|                  | your employing or retirement office authorizes    |
|                  | coverage for. Under certain circumstances, you    |
|                  | may also continue coverage for a disabled child   |
|                  | 22 years of age or older who is incapable of      |
|                  | self-support.                                     |
|                  |                                                   |
|                  | If you have a Self Only enrollment, you may       |
|                  | change to a Self and Family enrollment if you     |
|                  | marry, give birth, or add a child to your family. |
|                  | You may change your enrollment 31 days before to  |
|                  | 60 days after that event. The Self and Family     |
|                  | enrollment begins on the first day of the pay     |
|                  | period in which the child is born or becomes an   |
|                  | eligible family member. When you change to Self   |
|                  | and Family because you marry, the change is       |
|                  | effective on the first day of the pay period that |
|                  | begins after your employing office receives your  |
|                  | enrollment form; benefits will not be available   |
|                  | to your spouse until you marry.                   |
|                  |                                                   |
|                  | Your employing or retirement office will **not**  |
|                  | notify you when a family member is no longer      |
|                  | eligible to receive benefits, nor will we. Please |
|                  | tell us immediately when you add or remove family |
|                  | members from your coverage for any reason,        |
|                  | including divorce, or when your child under age   |
|                  | 22 marries or turns 22.                           |
|                  |                                                   |
|                  | If you or one of your family members is enrolled  |
|                  | in one FEHB plan, that person may not be enrolled |
|                  | in or covered as a family member by another FEHB  |
|                  | plan.                                             |
+------------------+---------------------------------------------------+
| #### Child       | OPM has implemented the Federal Employees Health  |
| ren's Equity Act | Benefits Children's Equity Act of 2000. This law  |
|                  | mandates that you be enrolled for Self and Family |
|                  | coverage in the FEHB Program, if you are an       |
|                  | employee subject to a court or administrative     |
|                  | order requiring you to provide health benefits    |
|                  | for your child(ren).                              |
|                  |                                                   |
|                  | If this law applies to you, you must enroll for   |
|                  | Self and Family coverage in a health plan that    |
|                  | provides full benefits in the area where your     |
|                  | children live or provide documentation to your    |
|                  | employing office that you have obtained other     |
|                  | health benefits coverage for your children. If    |
|                  | you do not do so, your employing office will      |
|                  | enroll you involuntarily as follows:              |
|                  |                                                   |
|                  | -   If you have no FEHB coverage, your employing  |
|                  |     office will enroll you for Self and Family    |
|                  |     coverage in the Blue Cross and Blue Shield    |
|                  |     Service Benefit Plan's Basic Option;          |
|                  |                                                   |
|                  | -   If you have a Self Only enrollment in a       |
|                  |     fee-for-service plan or in an HMO that serves |
|                  |     the area where your children live, your       |
|                  |     employing office will change your enrollment  |
|                  |     to Self and Family in the same option of the  |
|                  |     same plan; or                                 |
|                  |                                                   |
|                  | -   If you are enrolled in an HMO that does not   |
|                  |     serve the area where the children live, your  |
|                  |     employing office will change your enrollment  |
|                  |     to Self and Family in the Blue Cross and Blue |
|                  |     Shield Service Benefit Plan's Basic Option.   |
|                  |                                                   |
|                  | As long as the court/administrative order is in   |
|                  | effect, and you have at least one child           |
|                  | identified in the order who is still eligible     |
|                  | under the FEHB Program, you cannot cancel your    |
|                  | enrollment, change to Self Only, or change to a   |
|                  | plan that doesn't serve the area in which your    |
|                  | children live, unless you provide documentation   |
|                  | that you have other coverage for the children. If |
|                  | the court/administrative order is still in effect |
|                  | when you retire, and you have at least one child  |
|                  | still eligible for FEHB coverage, you must        |
|                  | continue your FEHB coverage into retirement (if   |
|                  | eligible) and cannot cancel your coverage, change |
|                  | to Self Only, or change to a plan that doesn't    |
|                  | serve the area in which your children live as     |
|                  | long as the court/administrative order is in      |
|                  | effect. Contact your employing office for further |
|                  | information.                                      |
+------------------+---------------------------------------------------+
| ####             | The benefits in this brochure are effective       |
| When benefits an | January 1. If you joined this Plan during Open    |
| d premiums start | Season, your coverage begins on the first day of  |
|                  | your first pay period that starts on or after     |
|                  | January 1. If you changed plans or plan options   |
|                  | during Open Season and you receive care between   |
|                  | January 1 and the effective date of coverage      |
|                  | under your new plan or option, your claims will   |
|                  | be paid according to the 2005 benefits of your    |
|                  | old plan or option. However, if your old plan     |
|                  | left the FEHB Program at the end of the year, you |
|                  | are covered under that plan's 2004 benefits until |
|                  | the effective date of your coverage with your new |
|                  | plan. Annuitants' coverage and premiums begin on  |
|                  | January 1. If you joined at any other time during |
|                  | the year, your employing office will tell you the |
|                  | effective date of coverage.                       |
+------------------+---------------------------------------------------+
| ####             | When you retire, you can usually stay in the FEHB |
|  When you retire | Program. Generally, you must have been enrolled   |
|                  | in the FEHB Program for the last five years of    |
|                  | your Federal service. If you do not meet this     |
|                  | requirement, you may be eligible for other forms  |
|                  | of coverage, such as Temporary Continuation of    |
|                  | Coverage (TCC).                                   |
+------------------+---------------------------------------------------+

### When you lose benefits

+------------------+---------------------------------------------------+
| #### When FE     | You will receive an additional 31 days of         |
| HB coverage ends | coverage, for no additional premium, when:        |
|                  |                                                   |
|                  | -   Your enrollment ends, unless you cancel your  |
|                  |     enrollment, or                                |
|                  |                                                   |
|                  | -   You are a family member no longer eligible    |
|                  |     for coverage.                                 |
|                  |                                                   |
|                  | You may be eligible for spouse equity coverage or |
|                  | Temporary Continuation of Coverage (TCC), or a    |
|                  | conversion policy (a non-FEHB individual policy.) |
+------------------+---------------------------------------------------+
| #### Spouse      | If you are divorced from a Federal employee or    |
|  equity coverage | annuitant, you may not continue to get benefits   |
|                  | under your former spouse's enrollment. This is    |
|                  | the case even when the court has ordered your     |
|                  | former spouse to provide health coverage to you.  |
|                  | But, you may be eligible for your own FEHB        |
|                  | coverage under the spouse equity law or Temporary |
|                  | Continuation of Coverage (TCC). If you are        |
|                  | recently divorced or are anticipating a divorce,  |
|                  | contact your ex-spouse's employing or retirement  |
|                  | office to get RI 70-5, the *Guide To Federal      |
|                  | Employees Health Benefits Plans for Temporary     |
|                  | Continuation of Coverage and Former Spouse        |
|                  | Enrollees,* or other information about your       |
|                  | coverage choices. You can also download the guide |
|                  | from OPM's Web site,                              |
|                  | [www.opm.gov/insure](http://www.opm.gov/insure).  |
+------------------+---------------------------------------------------+
| #### Temporar    | If you leave Federal service, or if you lose      |
| y Continuation o | coverage because you no longer qualify as a       |
| f Coverage (TCC) | family member, you may be eligible for Temporary  |
|                  | Continuation of Coverage (TCC). For example, you  |
|                  | can receive TCC if you are not able to continue   |
|                  | your FEHB enrollment after you retire, if you     |
|                  | lose your Federal job, if you are a covered       |
|                  | dependent child and you turn 22 or marry, etc.    |
|                  |                                                   |
|                  | You may not elect TCC if you are fired from your  |
|                  | Federal job due to gross misconduct.              |
|                  |                                                   |
|                  | **Enrolling in TCC.** Get the RI 79-27, which     |
|                  | describes TCC, and the RI 70-5, the *Guide to     |
|                  | Federal Employees Health Benefits Plans for       |
|                  | Temporary Continuation of Coverage and Former     |
|                  | Spouse Enrollees,* from your employing or         |
|                  | retirement office or from                         |
|                  | [www.opm.gov/insure](http://www.opm/gov/insure).  |
|                  | It explains what you have to do to enroll.        |
+------------------+---------------------------------------------------+
| #### C           | You may convert to a non-FEHB individual policy   |
| onverting to ind | if:                                               |
| ividual coverage |                                                   |
|                  | -   Your coverage under TCC or the spouse equity  |
|                  |     law ends (If you canceled your coverage or    |
|                  |     did not pay your premium, you cannot          |
|                  |     convert);                                     |
|                  |                                                   |
|                  | -   You decided not to receive coverage under TCC |
|                  |     or the spouse equity law; or                  |
|                  |                                                   |
|                  | -   You are not eligible for coverage under TCC   |
|                  |     or the spouse equity law.                     |
|                  |                                                   |
|                  | If you leave Federal service, your employing      |
|                  | office will notify you of your right to convert.  |
|                  | You must apply in writing to us within 31 days    |
|                  | after you receive this notice. However, if you    |
|                  | are a family member who is losing coverage, the   |
|                  | employing or retirement office will **not**       |
|                  | notify you. You must apply in writing to us       |
|                  | within 31 days after you are no longer eligible   |
|                  | for coverage.                                     |
|                  |                                                   |
|                  | Your benefits and rates will differ from those    |
|                  | under the FEHB Program; however, you will not     |
|                  | have to answer questions about your health, and   |
|                  | we will not impose a waiting period or limit your |
|                  | coverage due to pre-existing conditions.          |
+------------------+---------------------------------------------------+
| #### Get         | The Health Insurance Portability and              |
| ting a Certifica | Accountability Act of 1996 (HIPAA) is a Federal   |
| te of Group Heal | law that offers limited Federal protections for   |
| th Plan Coverage | health coverage availability and continuity to    |
|                  | people who lose employer group coverage. If you   |
|                  | leave the FEHB Program, we will give you a        |
|                  | Certificate of Group Health Plan Coverage that    |
|                  | indicates how long you have been enrolled with    |
|                  | us. You can use this certificate when getting     |
|                  | health insurance or other health care coverage.   |
|                  | Your new plan must reduce or eliminate waiting    |
|                  | periods, limitations, or exclusions for health    |
|                  | related conditions based on the information in    |
|                  | the certificate, as long as you enroll within 63  |
|                  | days of losing coverage under this Plan. If you   |
|                  | have been enrolled with us for less than 12       |
|                  | months, but were previously enrolled in other     |
|                  | FEHB plans, you may also request a certificate    |
|                  | from those plans.                                 |
|                  |                                                   |
|                  | For more information, get OPM pamphlet RI 79-27,  |
|                  | *Temporary Continuation of Coverage* *(TCC) under |
|                  | the FEHB Program*. See also the FEHB Web site at  |
|                  | [www.opm.gov/                                     |
|                  | insure/health](http://www.opm.gov/insure/health); |
|                  | refer to the "TCC and HIPAA" frequently asked     |
|                  | questions. These highlight HIPAA rules, such as   |
|                  | the requirement that Federal employees must       |
|                  | exhaust any TCC eligibility as one condition for  |
|                  | guaranteed access to individual health coverage   |
|                  | under HIPAA, and information about Federal and    |
|                  | State agencies you can contact for more           |
|                  | information.                                      |
+------------------+---------------------------------------------------+

# Section 12. Two Federal Programs complement FEHB benefits

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

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

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

+------------------+--------------------------------+--------+--------+
| -   What is an   | It is a tax-favored benefit    |        |        |
|     FSA?         | that allows you to set aside   |        |        |
|                  | pre-tax money from your        |        |        |
|                  | paychecks to pay for a variety |        |        |
|                  | of eligible expenses. *By      |        |        |
|                  | using an FSA, you can reduce   |        |        |
|                  | your taxes while paying for    |        |        |
|                  | services you would have to pay |        |        |
|                  | for anyway, producing a        |        |        |
|                  | discount that can be over      |        |        |
|                  | 40%.*                          |        |        |
|                  |                                |        |        |
|                  | There are two types of FSAs    |        |        |
|                  | offered by FSAFEDS:            |        |        |
+------------------+--------------------------------+--------+--------+
| Health Care      | -   Covers eligible health     |        |        |
| Flexible         |     care expenses not          |        |        |
| Spending Account |     reimbursed by this Plan,   |        |        |
| (HCFSA)          |     or any other medical,      |        |        |
|                  |     dental, or vision care     |        |        |
|                  |     plan you or your           |        |        |
|                  |     dependents may have.       |        |        |
|                  |                                |        |        |
|                  | -   Eligible dependents for    |        |        |
|                  |     this account include       |        |        |
|                  |     anyone you claim on your   |        |        |
|                  |     Federal Income Tax return  |        |        |
|                  |     as a qualified dependent   |        |        |
|                  |     under the U.S. Internal    |        |        |
|                  |     Revenue Service (IRS)      |        |        |
|                  |     definition and/or with     |        |        |
|                  |     whom you jointly file your |        |        |
|                  |     Federal Income Tax return, |        |        |
|                  |     even if you don't have     |        |        |
|                  |     self and family health     |        |        |
|                  |     benefits coverage. *Note:* |        |        |
|                  |     The IRS has a broader      |        |        |
|                  |     definition of a "family    |        |        |
|                  |     member" than is used under |        |        |
|                  |     the FEHB Program to        |        |        |
|                  |     provide benefits by your   |        |        |
|                  |     FEHB Plan.                 |        |        |
|                  |                                |        |        |
|                  | -   The maximum annual amount  |        |        |
|                  |     that can be allotted for   |        |        |
|                  |     the HCFSA is \$4,000.      |        |        |
|                  |     *Note:* The Federal        |        |        |
|                  |     workforce includes a       |        |        |
|                  |     number of employees        |        |        |
|                  |     married to each other. If  |        |        |
|                  |     each spouse/employee is    |        |        |
|                  |     eligible for FEHB          |        |        |
|                  |     coverage, both may enroll  |        |        |
|                  |     for a HCFSA up to the      |        |        |
|                  |     maximum of \$4,000 each    |        |        |
|                  |     (\$8,000 total). Both are  |        |        |
|                  |     covered under each other's |        |        |
|                  |     HCFSA.The minimum annual   |        |        |
|                  |     amount is \$250.           |        |        |
+------------------+--------------------------------+--------+--------+
| Dependent Care   | -   Covers eligible dependent  |        |        |
| Flexible         |     care expenses incurred so  |        |        |
| Spending Account |     you, and your spouse, if   |        |        |
| (DCFSA)          |     married, can work, look    |        |        |
|                  |     for work, or attend school |        |        |
|                  |     full-time.                 |        |        |
|                  |                                |        |        |
|                  | -   Qualifying dependents for  |        |        |
|                  |     this account include your  |        |        |
|                  |     dependent children under   |        |        |
|                  |     age 13, or any person of   |        |        |
|                  |     any age whom you claim as  |        |        |
|                  |     a dependent on your        |        |        |
|                  |     Federal Income Tax return  |        |        |
|                  |     (and who is mentally or    |        |        |
|                  |     physically incapable of    |        |        |
|                  |     self care).                |        |        |
|                  |                                |        |        |
|                  | -   The maximum annual amount  |        |        |
|                  |     that can be allotted for   |        |        |
|                  |     the DCFSA is \$5,000. The  |        |        |
|                  |     minimum annual amount is   |        |        |
|                  |     \$250. *Note:* The IRS     |        |        |
|                  |     limits contributions to a  |        |        |
|                  |     DCFSA. For single          |        |        |
|                  |     taxpayers and taxpayers    |        |        |
|                  |     filing a joint return, the |        |        |
|                  |     maximum is \$5,000 per     |        |        |
|                  |     year. For taxpayers who    |        |        |
|                  |     file their taxes           |        |        |
|                  |     separately with a spouse,  |        |        |
|                  |     the maximum is \$2,500 per |        |        |
|                  |     year. The limit includes   |        |        |
|                  |     any child care subsidy you |        |        |
|                  |     may receive.               |        |        |
+------------------+--------------------------------+--------+--------+
| -   Enroll       | You **must make an election**  |        |        |
|     during Open  | to enroll in an FSA during the |        |        |
|     Season       | 2005 FEHB Open Season. Even if |        |        |
|                  | you enrolled during 2004, you  |        |        |
|                  | must make a new election to    |        |        |
|                  | continue participating in      |        |        |
|                  | 2005. Enrollment is easy!      |        |        |
|                  |                                |        |        |
|                  | -   **Online: visit            |        |        |
|                  |     [www.FSAFEDS               |        |        |
|                  | .com](http://www.FSAFEDS.com/) |        |        |
|                  |     and click on               |        |        |
|                  |     [Enroll]{.underline}.**    |        |        |
|                  |                                |        |        |
|                  | -   Telephone: call an FSAFEDS |        |        |
|                  |     Benefits Counselor         |        |        |
|                  |     toll-free number at        |        |        |
|                  |     1-877-FSAFEDS (372-3337),  |        |        |
|                  |     Monday through Friday,     |        |        |
|                  |     from 9 a.m. until 9 p.m.,  |        |        |
|                  |     Eastern Time. TTY:         |        |        |
|                  |     1-800-952-0450.            |        |        |
+------------------+--------------------------------+--------+--------+
| What is SHPS?    | SHPS is a third-party          |        |        |
|                  | administrator hired by OPM to  |        |        |
|                  | manage the FSAFEDS Program.    |        |        |
|                  | SHPS is the largest FSA        |        |        |
|                  | administrator in the nation    |        |        |
|                  | and is responsible for         |        |        |
|                  | enrollment, claims processing, |        |        |
|                  | customer service, and          |        |        |
|                  | day-to-day operations of       |        |        |
|                  | FSAFEDS.                       |        |        |
+------------------+--------------------------------+--------+--------+
| Who is eligible  | If you are a Federal employee  |        |        |
| to enroll?       | eligible for FEHB -- even if   |        |        |
|                  | you're not enrolled in FEHB -- |        |        |
|                  | you can choose to participate  |        |        |
|                  | in either, or both, of the     |        |        |
|                  | FSAs. *However, if you enroll  |        |        |
|                  | in a High Deductible Health    |        |        |
|                  | Plan (HDHP) with a Health      |        |        |
|                  | Savings Account (HSA), you are |        |        |
|                  | not eligible to participate in |        |        |
|                  | an HCFSA.*                     |        |        |
|                  |                                |        |        |
|                  | Almost all Federal employees   |        |        |
|                  | are eligible to enroll for a   |        |        |
|                  | DCFSA. The only exception is   |        |        |
|                  | intermittent (also called      |        |        |
|                  | "when actually employed"       |        |        |
|                  | \[WAE\]) employees expected to |        |        |
|                  | work fewer than 180 days       |        |        |
|                  | during the year.               |        |        |
|                  |                                |        |        |
|                  | *Note:* FSAFEDS is the FSA     |        |        |
|                  | Program established for all    |        |        |
|                  | Executive Branch employees and |        |        |
|                  | Legislative Branch employees   |        |        |
|                  | whose employers have signed on |        |        |
|                  | to participate. Under IRS law, |        |        |
|                  | FSAs are not available to      |        |        |
|                  | annuitants. Also, the U.S.     |        |        |
|                  | Postal Service and the         |        |        |
|                  | Judicial Branch, among others, |        |        |
|                  | have their own plans with      |        |        |
|                  | slightly different rules.      |        |        |
|                  | However, the advantages of     |        |        |
|                  | having an FSA are the same     |        |        |
|                  | regardless of the agency for   |        |        |
|                  | which you work.                |        |        |
+------------------+--------------------------------+--------+--------+
| -   How much     | Plan carefully when deciding   |        |        |
|     should I     | how much to contribute to an   |        |        |
|     contribute   | FSA. Because of the tax        |        |        |
|     to my FSA?   | benefits an FSA provides, the  |        |        |
|                  | IRS places strict guidelines   |        |        |
|                  | on how the money can be used.  |        |        |
|                  | Under current IRS tax rules,   |        |        |
|                  | you are required to forfeit    |        |        |
|                  | any money for which you did    |        |        |
|                  | not incur an eligible expense  |        |        |
|                  | under your FSA account(s)      |        |        |
|                  | during the Plan Year. This is  |        |        |
|                  | known as the                   |        |        |
|                  | "Use-it-or-Lose-it" rule. You  |        |        |
|                  | will have until April 30,      |        |        |
|                  | following the end of the Plan  |        |        |
|                  | Year to submit claims for your |        |        |
|                  | eligible expenses incurred     |        |        |
|                  | from January 1 through         |        |        |
|                  | December 31. For example if    |        |        |
|                  | you enroll in FSAFEDS for the  |        |        |
|                  | 2005 Plan Year, you will have  |        |        |
|                  | until April 30, 2006, to       |        |        |
|                  | submit claims for eligible     |        |        |
|                  | expenses.                      |        |        |
|                  |                                |        |        |
|                  | The [FSAFEDS                   |        |        |
|                  | Calculator]{.underline} at     |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.FSAFEDS.com/) |        |        |
|                  | will help you plan your FSA    |        |        |
|                  | allocations and provide an     |        |        |
|                  | estimate of your tax savings   |        |        |
|                  | based on your individual       |        |        |
|                  | situation.                     |        |        |
+------------------+--------------------------------+--------+--------+
| -   What can my  | Every FEHB plan includes cost  |        |        |
|     HCFSA pay    | sharing features, such as      |        |        |
|     for?         | deductibles you must meet      |        |        |
|                  | before the Plan provides       |        |        |
|                  | benefits, coinsurance or       |        |        |
|                  | copayments that you pay when   |        |        |
|                  | you and the Plan share costs,  |        |        |
|                  | and medical services and       |        |        |
|                  | supplies that are not covered  |        |        |
|                  | by the Plan and for which you  |        |        |
|                  | must pay. These out-of-pocket  |        |        |
|                  | costs are summarized on page   |        |        |
|                  | 75-76 and detailed throughout  |        |        |
|                  | this brochure. Your HCFSA will |        |        |
|                  | reimburse you when those costs |        |        |
|                  | are for qualified medical care |        |        |
|                  | that you, your spouse and/or   |        |        |
|                  | your dependents receive that   |        |        |
|                  | is NOT covered or reimbursed   |        |        |
|                  | by this FEHB Plan or any other |        |        |
|                  | coverage that you have.        |        |        |
|                  |                                |        |        |
|                  | Under this Plan, typical       |        |        |
|                  | out-of-pocket expenses         |        |        |
|                  | include: copayments for        |        |        |
|                  | physician's office visits,     |        |        |
|                  | coinsurance for Infertility    |        |        |
|                  | services or treatment,         |        |        |
|                  | coinsurance for orthopedic and |        |        |
|                  | prosthetic devices, eyeglasses |        |        |
|                  | and contact lenses,            |        |        |
|                  | orthodontics (braces), and     |        |        |
|                  | vision correction surgery.     |        |        |
|                  |                                |        |        |
|                  | 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>. |        |        |
|                  | The FSAFEDS Web site also has  |        |        |
|                  | a comprehensive list of        |        |        |
|                  | eligible expenses at           |        |        |
|                  | [www.FSAFE                     |        |        |
|                  | DS.com/fsafeds/eligibleexpense |        |        |
|                  | s.asp](http://www.FSAFEDS.com/ |        |        |
|                  | fsafeds/eligibleexpenses.asp). |        |        |
|                  | If you do not see your service |        |        |
|                  | or expense listed, please call |        |        |
|                  | an FSAFEDS Benefits Counselor  |        |        |
|                  | at 1-877-FSAFEDS (372-3337),   |        |        |
|                  | who will be able to answer     |        |        |
|                  | your specific questions.       |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax savings  | An FSA lets you allot money    |        |        |
|     with an FSA  | for eligible expenses          |        |        |
|                  | ***before*** your agency       |        |        |
|                  | deducts taxes from your        |        |        |
|                  | paycheck. This means the       |        |        |
|                  | amount of income that your     |        |        |
|                  | taxes are based on will be     |        |        |
|                  | lower, so your tax liability   |        |        |
|                  | will be less. Without an FSA,  |        |        |
|                  | you would still pay for these  |        |        |
|                  | expenses, but you would do so  |        |        |
|                  | using money remaining in your  |        |        |
|                  | paycheck after Federal (and    |        |        |
|                  | often state and local) taxes   |        |        |
|                  | are deducted. The following    |        |        |
|                  | chart illustrates a typical    |        |        |
|                  | tax savings example:           |        |        |
+------------------+--------------------------------+--------+--------+
|                  | **Annual Tax Savings Example** | **With | **Wi   |
|                  |                                | FSA**  | thout\ |
|                  |                                |        | FSA**  |
+------------------+--------------------------------+--------+--------+
|                  | If your taxable income is:     | \$     | \$     |
|                  |                                | 50,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | And you deposit this amount    | \      | -\$0-  |
|                  | into an FSA:                   | $2,000 |        |
+------------------+--------------------------------+--------+--------+
|                  | Your taxable income is now:    | \$     | \$     |
|                  |                                | 48,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | Subtract Federal & Social      | \$     | \$     |
|                  | Security taxes:                | 13,807 | 14,383 |
+------------------+--------------------------------+--------+--------+
|                  | If you spend after-tax dollars | -\$0-  | \      |
|                  | for expenses:                  |        | $2,000 |
+------------------+--------------------------------+--------+--------+
|                  | Your real spendable income is: | \$     | \$     |
|                  |                                | 34,193 | 33,617 |
+------------------+--------------------------------+--------+--------+
|                  | **Your tax savings:**          | **\    | **-    |
|                  |                                | $576** | \$0-** |
+------------------+--------------------------------+--------+--------+
|                  | **Note:** This example is      |        |        |
|                  | intended to demonstrate a      |        |        |
|                  | typical tax savings based on   |        |        |
|                  | 27% Federal and 7.65% FICA     |        |        |
|                  | taxes. Actual savings will     |        |        |
|                  | vary based upon the retirement |        |        |
|                  | system in which you are        |        |        |
|                  | enrolled (CSRS or FERS), your  |        |        |
|                  | state of residence, and your   |        |        |
|                  | individual tax situation. In   |        |        |
|                  | this example, the individual   |        |        |
|                  | received \$2,000 in services   |        |        |
|                  | for \$1,424 - a discount of    |        |        |
|                  | almost 36%! You may also wish  |        |        |
|                  | to consult a tax professional  |        |        |
|                  | for more information on the    |        |        |
|                  | tax implications of an FSA.    |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax credits  | You *cannot* claim expenses on |        |        |
|     and          | your Federal Income Tax return |        |        |
|     deductions   | if you receive reimbursement   |        |        |
|                  | for them from your HCFSA or    |        |        |
|                  | DCFSA. Below are some          |        |        |
|                  | guidelines that may help you   |        |        |
|                  | decide whether to participate  |        |        |
|                  | in FSAFEDS.                    |        |        |
+------------------+--------------------------------+--------+--------+
| Health care      | The HCFSA is Federal Income    |        |        |
| expenses         | Tax-free from the first        |        |        |
|                  | dollar. In addition, you may   |        |        |
|                  | be reimbursed from your HCFSA  |        |        |
|                  | at any time during the year    |        |        |
|                  | for expenses up to the annual  |        |        |
|                  | amount you've elected to       |        |        |
|                  | contribute.                    |        |        |
|                  |                                |        |        |
|                  | Only health care expenses      |        |        |
|                  | exceeding 7.5% of your         |        |        |
|                  | adjusted gross income are      |        |        |
|                  | eligible to be deducted on     |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return. Using the example      |        |        |
|                  | shown above, only health care  |        |        |
|                  | expenses exceeding \$3,750     |        |        |
|                  | (7.5% of \$50,000) would be    |        |        |
|                  | eligible to be deducted on     |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return. In addition, money set |        |        |
|                  | aside through an HCFSA is also |        |        |
|                  | exempt from FICA taxes. This   |        |        |
|                  | exemption is not available on  |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return.                        |        |        |
+------------------+--------------------------------+--------+--------+
| Dependent care   | The DCFSA generally allows     |        |        |
| expenses         | many families to save more     |        |        |
|                  | than they would with the       |        |        |
|                  | Federal tax credit for         |        |        |
|                  | dependent care expenses. Note  |        |        |
|                  | that you may only be           |        |        |
|                  | reimbursed from the DCFSA up   |        |        |
|                  | to your current account        |        |        |
|                  | balance. If you file a claim   |        |        |
|                  | for more than your current     |        |        |
|                  | balance, it will be held until |        |        |
|                  | additional payroll allotments  |        |        |
|                  | have been added to your        |        |        |
|                  | account.                       |        |        |
|                  |                                |        |        |
|                  | Visit                          |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.FSAFEDS.com/) |        |        |
|                  | and download the [Dependent    |        |        |
|                  | Care Tax Credit                |        |        |
|                  | Worksheet]{.underline} from    |        |        |
|                  | the Forms and Literature page  |        |        |
|                  | to help you determine what is  |        |        |
|                  | best for your situation. You   |        |        |
|                  | may also wish to consult a tax |        |        |
|                  | professional for more details. |        |        |
+------------------+--------------------------------+--------+--------+
| -   Does it cost | No. Section 1127 of the        |        |        |
|     me anything  | National Defense Authorization |        |        |
|     to           | Act (Public Law 108-136)       |        |        |
|     participate  | requires agencies that offer   |        |        |
|     in FSAFEDS?  | FSAFEDS to employees to cover  |        |        |
|                  | the administrative fee(s) on   |        |        |
|                  | behalf of their employees.     |        |        |
|                  | However, remember that         |        |        |
|                  | participating in FSAFEDS can   |        |        |
|                  | cost you money if you don't    |        |        |
|                  | spend your entire account      |        |        |
|                  | balance by the end of the Plan |        |        |
|                  | Year, resulting in the         |        |        |
|                  | forfeiture of funds remaining  |        |        |
|                  | in your account (the IRS       |        |        |
|                  | "use-it-or-lose-it" rule).     |        |        |
+------------------+--------------------------------+--------+--------+
| -   Contact us   | To learn more or to enroll,    |        |        |
|                  | please visit the **FSAFEDS Web |        |        |
|                  | site** at                      |        |        |
|                  | [www.FSAFEDS.                  |        |        |
|                  | com](http://www.FSAFEDS.com/), |        |        |
|                  | or contact SHPS directly via   |        |        |
|                  | email or by phone. FSAFEDS     |        |        |
|                  | Benefits Counselors are        |        |        |
|                  | available Monday through       |        |        |
|                  | Friday, from 9:00 a.m. until   |        |        |
|                  | 9:00 p.m. Eastern Time.        |        |        |
|                  |                                |        |        |
|                  | -   E-mail: <FSAFEDS@shps.net> |        |        |
|                  |                                |        |        |
|                  | -   Telephone: 1-877-FSAFEDS   |        |        |
|                  |     (1-877-372-3337)           |        |        |
|                  |                                |        |        |
|                  | -   TTY: 1-800-952-0450        |        |        |
+------------------+--------------------------------+--------+--------+

### The Federal Long Term Care Insurance Program

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

# Index

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

Accidental injury 24, 31, 47

Allergy tests 22

Allogeneic (donor) bone marrow transplant 33

Alternative treatments 29

Ambulance 35, 37, 40

Anesthesia 5, 29, 30

Autologous bone marrow transplant 23, 33

Biopsy 30

Blood and blood plasma 36

Casts 27, 35, 36

Catastrophic protection out-of-pocket maximum 14, 55, 76

Changes for 2005 8

Chemotherapy 23, 53

Chiropractic 29

Cholesterol tests 19

Circumcision 21

Claims 9, 57, 58, 62, 68, 70

Coinsurance 6, 9, 48, 57, 63, 65, 71

Colorectal cancer screening 19

Congenital anomalies 30, 31

Contraceptive drugs and devices 21, 44

Covered charges 61

Covered providers 9

Covered services 14

Crutches 27

Deductible 6, 9, 12, 14, 15, 18, 30, 35, 38, 41, 47, 48, 51, 52, 53, 55,
57, 63, 71

Definitions 18, 30, 35, 38, 41, 43, 47, 48, 65, 75

Dental care 47, 75

Diagnostic services 18, 35, 41, 75

Disputed claims review 46

Donor expenses 22, 33

Dressings 35, 36

Durable medical equipment 27

Educational classes and programs 29

Effective date of enrollment 9, 11, 67

Emergency 6, 38, 39, 48, 56, 57, 75

Experimental or investigational 56, 65

Eyeglasses 25

Family planning 21

Fecal occult blood test 19

Fraud 3, 4

General exclusions 56

Hearing services 24

Home health services 28

Hospice care 37

Hospital 4, 5, 6, 10, 11, 30, 31, 33, 35, 36, 39, 40, 42, 47, 48, 57,
61, 63, 64, 75

Immunizations 6, 20

Infertility 22

Inpatient hospital benefits 57

Insulin 27, 44

Magnetic Resonance Imagings (MRIs) 19

Mail Order Prescription Drugs 43, 44

Mammograms 19

Maternity benefits 21, 28, 35, 48

Medicaid 64

Medically necessary 18, 21, 23, 30, 35, 38, 41, 43, 47, 48, 56

Medicare 41, 60, 62

Medicare Advantage 63

Original 61, 63

Members

Associate 77

Family 67

Plan 9, 55

Mental Health/Substance Abuse Benefits 41

Newborn care 21

Non-FEHB benefits 55

Nurse

Licensed Practical Nurse (LPN) 28

Nurse Anesthetist (NA) 35

Registered Nurse 46

Obstetrical care 21

Occupational therapy 23

Ocular injury 25

Office visits 6, 14

Oral and maxillofacial surgical 32

Orthopedic devices 26

Out-of-pocket expenses 60

Oxygen 27, 28, 35, 36

Pap test 19, 20

Physical examination 19

Physical therapy 23

Physician 30

Point of Service (POS) 48, 76

Precertification 48, 51, 59

Prescription drugs 23, 57, 63, 75

Preventive care, adult 19

Preventive care, children 20

Preventive services 6

Prior approval 12, 59

Prosthetic devices 26, 30

Psychologist 41

Radiation therapy 23, 53

Room and board 35

Second surgical opinion 18

Skilled nursing facility care 11, 18

Smoking cessation 29, 53, 54

Social worker 41

Speech therapy 24

Splints 27, 35

Sterilization procedures 21, 30

Subrogation 64

Substance abuse 41, 42, 75

Surgery 5, 21, 23, 26

Anesthesia 36

Oral 32

Outpatient 36

Reconstructive 30, 31

Syringes 44

Temporary Continuation of Coverage (TCC) 68

Transplants 23, 33

Treatment therapies 23

Vision care 25, 76

Wheelchairs 27

Workers Compensation 64

X-rays 19, 35, 36

# Summary of benefits for the Mercy Health Plans/Premier Health Plans *-* 2005

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

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

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

+----------------------------------------+-----------------------+----+
| **Benefits**                           | **You pay**           | ** |
|                                        |                       | Pa |
|                                        |                       | ge |
|                                        |                       | ** |
+----------------------------------------+-----------------------+----+
| Medical services provided by           | **[Missouri           | 18 |
| physicians:                            | Region]{.underline}** |    |
|                                        |                       |    |
| -   Diagnostic and treatment services  | \$10 per visit to     |    |
|     provided in the office             | your primary care     |    |
|                                        | physician             |    |
|                                        |                       |    |
|                                        | \$20 per visit to a   |    |
|                                        | specialist            |    |
|                                        |                       |    |
|                                        | **[Texas              |    |
|                                        | Region]{.underline}** |    |
|                                        |                       |    |
|                                        | \$10 per visit to     |    |
|                                        | your primary care     |    |
|                                        | physician             |    |
|                                        |                       |    |
|                                        | \$10 per visit to a   |    |
|                                        | specialist            |    |
+----------------------------------------+-----------------------+----+
| Services provided by a hospital:       | Nothing               | 35 |
|                                        |                       |    |
| -   Inpatient                          | Nothing               | 36 |
|                                        |                       |    |
| -   Outpatient                         |                       |    |
+----------------------------------------+-----------------------+----+
| Emergency benefits                     | **[Missouri           | 39 |
|                                        | Region]{.underline}** |    |
| -   In-area                            |                       |    |
|                                        | \$75 per visit,       |    |
| -   Out-of-area                        | except Copayment      |    |
|                                        | charge will be waived |    |
|                                        | if you are admitted   |    |
|                                        | to an observation,    |    |
|                                        | outpatient surgery,   |    |
|                                        | outpatient procedure  |    |
|                                        | or inpatient care     |    |
|                                        |                       |    |
|                                        | **[Texas              |    |
|                                        | Region]{.underline}** |    |
|                                        |                       |    |
|                                        | \$50 per visit,       |    |
|                                        | except Copayment      |    |
|                                        | charge will be waived |    |
|                                        | if you are admitted   |    |
|                                        | to an observation,    |    |
|                                        | outpatient surgery,   |    |
|                                        | outpatient procedure  |    |
|                                        | or inpatient care     |    |
+----------------------------------------+-----------------------+----+
| Mental health and substance abuse      | Regular cost sharing  | 4  |
| treatment                              |                       | 1- |
|                                        |                       | 42 |
+----------------------------------------+-----------------------+----+
| Prescription drugs                     | **[Missouri           | 44 |
|                                        | Region]{.underline}** |    |
|                                        |                       |    |
|                                        | \$10/\$20/\$35        |    |
|                                        | Copayment             |    |
|                                        |                       |    |
|                                        | **[Texas              |    |
|                                        | Region]{.underline}** |    |
|                                        |                       |    |
|                                        | \$7/\$12/\$25         |    |
|                                        | Copayment             |    |
+----------------------------------------+-----------------------+----+
| Dental care .                          | Discounted fee        | 47 |
|                                        | schedule              |    |
+----------------------------------------+-----------------------+----+
| Vision care .                          | One pair of           | 25 |
|                                        | eyeglasses or contact |    |
|                                        | lenses to correct an  |    |
|                                        | impairment directly   |    |
|                                        | caused by accidental  |    |
|                                        | ocular injury or      |    |
|                                        | intraocular surgery   |    |
|                                        | (such as cataracts)   |    |
|                                        |                       |    |
|                                        | **[Missouri           |    |
|                                        | Region]{.underline}** |    |
|                                        |                       |    |
|                                        | \$10 per visit to     |    |
|                                        | your primary care     |    |
|                                        | physician             |    |
|                                        |                       |    |
|                                        | \$20 per visit to a   |    |
|                                        | specialist            |    |
|                                        |                       |    |
|                                        | **[Texas              |    |
|                                        | Region]{.underline}** |    |
|                                        |                       |    |
|                                        | \$10 per visit to     |    |
|                                        | your primary care     |    |
|                                        | physician             |    |
|                                        |                       |    |
|                                        | \$10 per visit to a   |    |
|                                        | specialist            |    |
+----------------------------------------+-----------------------+----+
| Special features:                      |                       | 46 |
|                                        |                       |    |
| -   Flexible benefits option           |                       |    |
|                                        |                       |    |
| -   24 hour nurse line (not available  |                       |    |
|     in Texas)                          |                       |    |
|                                        |                       |    |
| -   Services for deaf and hearing      |                       |    |
|     impaired                           |                       |    |
+----------------------------------------+-----------------------+----+
| Point of Service benefits -- Yes       |                       | 48 |
+----------------------------------------+-----------------------+----+
| Protection against catastrophic costs  | Nothing after         | 1  |
|                                        | \$2,200/Self Only or  | 4- |
| (your catastrophic protection          | \$6,600/Family        | 15 |
| out-of-pocket maximum)                 | (Missouri Regions) or |    |
|                                        | \$1,000/Self Only or  |    |
|                                        | \$2,000/Family (Texas |    |
|                                        | Region) enrollment    |    |
|                                        | per year.             |    |
|                                        |                       |    |
|                                        | Some costs do not     |    |
|                                        | count toward this     |    |
|                                        | protection            |    |
+----------------------------------------+-----------------------+----+

# 2005 Rate Information for Mercy Health Plans/Premier Health Plans

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

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

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

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

Missouri Regions (see page 7 for service area)

  --------------- --------- -------------- -------------- -------------- -------------- -------------- --------------
  **Self Only**   **7M1**   **\$131.08**   **\$85.69**    **\$284.01**   **\$185.66**   **\$154.74**   **\$62.03**

  **Self and      **7M2**   **\$298.23**   **\$170.00**   **\$646.17**   **\$368.33**   **\$352.08**   **\$116.15**
  Family**                                                                                             
  --------------- --------- -------------- -------------- -------------- -------------- -------------- --------------

Texas Region (see page 7 for service area)

  --------------- --------- -------------- -------------- -------------- -------------- -------------- -------------
  **Self Only**   **HM1**   **\$130.58**   **\$43.53**    **\$282.93**   **\$94.31**    **\$154.52**   **\$19.59**

  **Self and      **HM2**   **\$298.23**   **\$137.06**   **\$646.17**   **\$296.96**   **\$352.08**   **\$83.21**
  Family**                                                                                             
  --------------- --------- -------------- -------------- -------------- -------------- -------------- -------------

[]{#_Introduction .anchor}