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Piedmont Community HealthCare

[http://www.pchp.net](http://www.pchp.net/)

**2004**

**A Health Maintenance Organization**

**with a point of service product**

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height="1.6006944444444444in"}

**Serving:** The Virginia cities of Bedford and Lynchburg; the Virginia
counties of Albemarle, Amherst, Appomattox, Bedford, Buckingham,
Campbell, Charlotte, Cumberland, Halifax, Lunenburg, Nelson, Nottoway,
Pittsylvania, and Prince Edward.

**Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 8 for requirements.**

**Enrollment codes for this Plan:**

**2C1 Self Only**

**2C2 Self and Family**

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**RI 73-799**

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Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

> Sincerely,
>
> ![](media/image6.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

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# Notice of the Office of Personnel Management's

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

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  Table of Contents
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Introduction............................................................................
4

Plain
Language........................................................................
4

Stop Health Care Fraud!
........................................................................
4

Preventing medical mistakes 5

Section 1. Facts about this HMO plan 7

We also have point-of service (POS) benefits 7

How we pay providers 7

Your Rights 7

Service Area 8

Section 2. How we change for
2004............................................... 9

Program-wide changes 9

Changes to this Plan 9

Section 3. How you get care ............\... 10

Identification cards 10

Where you get covered care 10

• Plan providers 10

• Plan facilities 10

What you must do to get covered care 10

• Primary care 10

• Specialty care 10

• Hospital care 11

Circumstances beyond our control 12

Services requiring our prior approval 12

Section 4. Your costs for covered services 13

• Copayments 13

• Deductible 13

• Coinsurance 13

Your out-of-pocket maximum 13

Section 5.
Benefits..................................................................
14

Overview 14

(a) Medical services and supplies provided by physicians and other
    health care professionals 15

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 24

(c) Services provided by a hospital or other facility, and ambulance
    services 28

(d) Emergency services/accidents 31

(e) Mental health and substance abuse benefits 33

(f) Prescription drug benefits 35

(g) Special features 37

-   Flexible benefits option

-   Local Service and Assistance

-   Eyewear Discounts

    h.  Dental benefits 38

    i.  Point of service product 39

Section 6. General exclusions \-- things we don\'t cover 41

Section 7. Filing a claim for covered services 42

Section 8. The disputed claims process 43

Section 9. Coordinating benefits with other coverage 45

When you have other health coverage 45

-   What is Medicare? 45

-   Medicare + Choice 48

-   TRICARE and CHAMPVA 48

-   Workers' Compensation 48

-   Medicaid 49

-   Other Government agencies 49

Section 10. Definitions of terms we use in this brochure 50

Section 11. FEHB facts 52

Coverage information 52

• No pre-existing condition limitation 52

• Where you get information about enrolling in the FEHB Program 52

• Types of coverage available for you and your family 52

• Children's Equity Act 52

> • When benefits and premiums start 53

• When you retire 53

When you lose benefits 53

• When FEHB coverage ends 53

• Spouse equity coverage 53

• Temporary Continuation of Coverage (TCC) 53

• Converting to individual coverage 54

• Getting a Certificate of Group Health Plan Coverage 54

Two new Federal Programs complement FEHB benefits 55

The Federal Flexible Spending Account Program -- FSAFEDS 55

The Federal Long Term Care Insurance Program 58

IIndex 59

Summary of benefits 60

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

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  Introduction

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This brochure describes the benefits of Piedmont Community HealthCare
under our contract (CS 2858) with the Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. The
address for Piedmont Community HealthCare administrative offices is:

Piedmont community HealthCare Benefit Plan

2512 Langhorne Road

Lynchburg, VA 24501

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

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

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and changes are summarized on
page 60. Rates are shown at the end of this brochure.

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  Plain Language

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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
    Piedmont Community HealthCare*.*

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

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

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

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  Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at
    (434)947-4463 and explain the situation.

-   If we do not resolve the issue:

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

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

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

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

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-   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.

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  Preventing Medical Mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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

    Want more information on patient safety?

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

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

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

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

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

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

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

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

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

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

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

**We also have Point-of-Service (POS) benefits:**

Our HMO offers Point-of-Service (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

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 Piedmont Community HealthCare physician provides your health care.
Your primary care physician will coordinate all of your health care
needs. Please note that a referral from your primary care physician is
not necessary for emergency services or for up to two office visits each
year for female members to a Plan OB/GYN physician.

**Your Rights**

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

-   Piedmont Community HealthCare, Inc. has been in existence six years,

-   Piedmont Community HealthCare, Inc. is a for profit company,

-   Customer satisfaction surveys are conducted each year for Piedmont
    Community HealthCare in conjunction with the parent company,
    Piedmont Community Health Plan, Inc.,

-   The network providers include approximately 130 primary care
    physicians and 450 specialists, and

-   Providers are compensated based on our fee schedule and have agreed
    to a 20 percent withhold from their payments.

If you want more information about us, call 434/947-4463, or write to
Piedmont Community HealthCare, P.O. Box 2455, Lynchburg, VA 24501. You
may also contact us by fax at 434/947-4465 or visit our website at
www.pchp.net.

**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: the cities of
Bedford and Lynchburg; the counties of Albemarle, Amherst, Appomattox,
Bedford, Buckingham, Campbell, Charlotte, Cumberland, Halifax,
Lunenburg, Nelson, Nottoway, Pittsylvania, and Prince Edward.

Ordinarily, you should get your care from providers who contract with
us. If you receive care outside our service area, we will pay only for
emergency care or point-of-service benefits.

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. Children in college are
covered for emergency and urgent care, however, routine care is not
covered at the higher point-of-service level while outside of our
service area. 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.

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program - *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 55.

-   We added information regarding Preventing medical mistakes. See
    pages 5 and 6.

-   We added information regarding enrolling in Medicare. See page 45.

-   We revised the Medicare Primary Payer Chart. See page 47.

**Changes to this Plan**

-   Your share of the non-Postal premium decrease by 21% for Self Only
    or 20% for Self and Family.

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-   An in-plan deductible of \$500 per person and \$1000 per family was
    added.

-   The out-of-plan deductible amount increased to \$1500 per person and
    \$3000 per family.

-   The \$20 copayment for an office visit has increased to a \$25
    copayment.

-   The \$50 emergency room copayment increased to a \$100 copayment.

-   The prescription drug copayment for generic prescriptions filled at
    the pharmacy, 30-day supply or 100-units, increased from a \$10
    copayment to a \$15 copayment.

-   The prescription drug copayment for brand name prescriptions filled
    at the pharmacy, 30-day supply or 100-units, increased from a \$20
    copayment to a \$30 copayment.

-   The prescription drug copayment for generic prescriptions filled
    through the mail order, 90-day supply or 300-units, increased from a
    \$20 copayment to a \$30 copayment

-   The prescription drug copayment for brand name prescriptions filled
    through the mail order, 90-day supply or 300-units, increased from a
    \$40 copayment to a \$60 copayment.

-   The in-plan out-of-pocket maximum increased from \$1000 per person
    to \$3000; and from \$2000 per family to \$6000 per family.

-   The out-of-plan out-of-pocket maximum increased from \$2000 per
    person to \$6000; and from \$4000 per family to \$12,000.

[]{.mark}

[]{.mark}

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  Section 3. How you get care
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**Identification cards** We will send you an identification (ID) card.
You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a
prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health
benefits enrollment confirmation (for annuitants), or your Employee
Express confirmation letter.

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
888/674-3368.

**Where you get covered care** You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, or coinsurance, and you
will not have to file claims. 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. In
those instances, you will have a deductible and higher coinsurance with
no copayments.

**• Plan providers** Plan providers are physicians, specialists 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.

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

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

**What you must do**

**to get covered care** It depends on the type of care you need. First,
you and each family member must choose a primary care physician. This
decision is important since your primary care physician provides or
arranges for most of your health care. Simply complete the primary care
physician selection form and return it to us.

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

**• Specialty care** Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your
primary care physician, you must return to the primary care physician
after the consultation, unless your primary care physician authorized a
certain number of visits without additional referrals. The primary care
physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives
you a referral. However, you may see participating OB/GYN physicians
twice a year without a referral.

Here are other things you should know about specialty care:

• If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician will
work with your specialist and us to 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, you will receive point-of-service
benefits when you see a specialist who does not participate with our
Plan.

• If you are seeing a specialist and your specialist leaves the Plan,
call your primary care physician, who will arrange for you to see
another specialist. You may receive services from your current
specialist until we can make arrangements for you to see someone else.

• If you have a chronic or disabling condition and lose access to your
specialist because we:

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

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

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

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

If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 1-888-674-3368. 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 hospital benefits of the hospitalized
person.

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

**Services requiring our**

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

We call this review and approval process *precertification.* Except for
services rendered under our Point of Service benefits, your physician
must obtain precertification for the following services such as:

-   referrals for covered services to non-participating providers

-   transplants

-   non-emergency ambulance or air ambulance transportation

-   physical therapy, occupational therapy, and speech therapy

-   drugs to treat sexual dysfunction

Your primary care physician will submit a referral to us for these
services. We will establish that the appropriate criteria have been met
and provide an authorization to your primary care physician and to the
provider to whom you have been referred. Without the proper
authorization, services may be paid at the out-of-network benefit level
or not covered at all.

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

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

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

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

Example: When you see your primary care physician you pay a copayment of
\$25 per office visit.

**• 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. The calendar
year deductible is \$500 per individual and \$1,000 per family for
in-plan benefits. A \$1,500 individual and \$3,000 family deductible
applies to out-of-plan benefits.

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 applies to all services
except for office visits and emergency/urgent care services*.*

Example: In our Plan, you pay 20% of our allowance for all hospital
related services including inpatient, outpatient and diagnostic
testing*,* infertility services and durable medical equipment.

**Your out-of-pocket maximum** After your copayments and coinsurance
total \$3,000 per person or \$6,000 per family enrollment in any
calendar year, you do not have to pay any more for covered services
received in-plan*.* However, copayments or coinsurance for the following
services do not count toward your out-of-pocket maximum, and you must
continue to pay copayments or coinsurance for these services:

-   Prescription drug copayments

-   Vision exam copayments

Be sure to keep accurate records of your copayments and coinsurance
since you are responsible for informing us when you reach the maximum.
Please note that your out-of-pocket maximum for Point of Service
benefits total to \$6,000 per person and \$12,000 per family. (See page
39)

+-----------------------------------------------------------------------+
| ####### Section 5. Benefits \-- OVERVIEW                              |
|                                                                       |
| ***(See page 9 for how our benefits changed this year and page 60 for |
| a benefits summary.)***                                               |
+-----------------------------------------------------------------------+

**NOTE**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claims forms,
claims filing advice, or more information about our benefits, contact us
at 888-674-3368 or at our website at
[www.pchp.net](http://www.pchp.net/)*.*

(a) Medical services and supplies provided by physicians and other
    health care professionals 15-23

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 24-27

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

(c) Services provided by a hospital or other facility, and ambulance
    services 28-30

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

(d) Emergency services/accidents 31-32

> • Medical emergency • Ambulance

(e) Mental health and substance abuse benefits 33-34

(f) Prescription drug benefits 35-36

(g) Special features 37\
    • Flexible benefits option\
    • Local service and assistance\
    • Eyewear discounts

(h) Dental benefits 38

(i) Point of service benefits 39-40

Summary of benefits 60

Rates Back Cover

+---+---+-------------------------------------+----------------+---+----+
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| * |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
|   | * | **Here are some important things to |                | * |    |
|   | * | keep in mind about these            |                | * |    |
|   | I | benefits:**                         |                | I |    |
|   | * |                                     |                | * |    |
|   | * | -   Please remember that all        |                | * |    |
|   |   |     benefits are subject to the     |                |   |    |
|   | * |     definitions, limitations, and   |                | * |    |
|   | * |     exclusions in this brochure and |                | * |    |
|   | M |     are payable only when we        |                | M |    |
|   | * |     determine they are medically    |                | * |    |
|   | * |     necessary.                      |                | * |    |
|   |   |                                     |                |   |    |
|   | * | -   Plan physicians must provide or |                | * |    |
|   | * |     arrange your care.              |                | * |    |
|   | P |                                     |                | P |    |
|   | * | -   The calendar year deductible is |                | * |    |
|   | * |     \$500 per individual and        |                | * |    |
|   |   |     \$1,000 per family for in-plan  |                |   |    |
|   | * |     benefits.                       |                | * |    |
|   | * |                                     |                | * |    |
|   | O | ```{=html}                          |                | O |    |
|   | * | <!-- -->                            |                | * |    |
|   | * | ```                                 |                | * |    |
|   |   | -   Be sure to read Section 4,      |                |   |    |
|   | * |     *Your costs for covered         |                | * |    |
|   | * |     services,* for valuable         |                | * |    |
|   | R |     information about how cost      |                | R |    |
|   | * |     sharing works. Also read        |                | * |    |
|   | * |     Section 9 about coordinating    |                | * |    |
|   |   |     benefits with other coverage,   |                |   |    |
|   | * |     including with Medicare.        |                | * |    |
|   | * |                                     |                | * |    |
|   | T |                                     |                | T |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
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|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
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|   | * |                                     |                | * |    |
|   | T |                                     |                | T |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | **You pay**    |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| # |   |                                     |                |   |    |
| # |   |                                     |                |   |    |
| # |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$25 per     |   |    |
|   |   |                                     | > office visit |   |    |
| P |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$25 per     |   |    |
|   |   |                                     | > office visit |   |    |
| P |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
| c |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| n |   |                                     |                |   |    |
| t |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| r |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| - |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
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| d |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
| c |   |                                     |                |   |    |
| o |   |                                     |                |   |    |
| n |   |                                     |                |   |    |
| s |   |                                     |                |   |    |
| u |   |                                     |                |   |    |
| l |   |                                     |                |   |    |
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| n |   |                                     |                |   |    |
| s |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
| - |   |                                     | > 20% of       |   |    |
|   |   |                                     | > allowable    |   |    |
|   |   |                                     | > charge       |   |    |
|   |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$25 per     |   |    |
|   |   |                                     | > physician    |   |    |
| A |   |                                     | > visit        |   |    |
| t |   |                                     | >              |   |    |
| > |   |                                     | > 20% of       |   |    |
|   |   |                                     | > allowable    |   |    |
| h |   |                                     | > charge for   |   |    |
| o |   |                                     | > home health  |   |    |
| m |   |                                     | > services     |   |    |
| e |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
| # |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > Nothing if   |   |    |
|   |   |                                     | > you receive  |   |    |
| T |   |                                     | > these        |   |    |
| e |   |                                     | > services     |   |    |
| s |   |                                     | > during your  |   |    |
| t |   |                                     | > office       |   |    |
| s |   |                                     | > visit;       |   |    |
| , |   |                                     | > otherwise,   |   |    |
| > |   |                                     | > \$25 per     |   |    |
|   |   |                                     | > visit        |   |    |
| s |   |                                     | >              |   |    |
| u |   |                                     | > 20% of       |   |    |
| c |   |                                     | > allowable    |   |    |
| h |   |                                     | > charge for   |   |    |
| > |   |                                     | > services     |   |    |
|   |   |                                     | > performed at |   |    |
| a |   |                                     | > a hospital   |   |    |
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| n |   |                                     |                |   |    |
| d |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| # |   |                                     |                |   |    |
| # |   |                                     |                |   |    |
| # |   |                                     |                |   |    |
| # |   |                                     |                |   |    |
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| v |   |                                     |                |   |    |
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| c |   |                                     |                |   |    |
| a |   |                                     |                |   |    |
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| , |   |                                     |                |   |    |
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| l |   |                                     |                |   |    |
| t |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | \$25 per       |   |    |
|   |   |                                     | office visit   |   |    |
| R |   |                                     |                |   |    |
| o |   |                                     |                |   |    |
| u |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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+---+---+-------------------------------------+----------------+---+----+
| # |   |                                     | **You pay**    |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$25 per     |   |    |
|   |   |                                     | > visit        |   |    |
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| > |   |                                     | > require no   |   |    |
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| > |   |                                     | > \$25 per     |   |    |
|   |   |                                     | > office visit |   |    |
| A |   |                                     | >              |   |    |
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| > |   |                                     | > \$25 per     |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > *All         |   |    |
|   |   |                                     | > charges.*    |   |    |
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| # |   |                                     | **You pay**    |   |    |
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| - |   |                                     | > \$25 per     |   |    |
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| - |   |                                     | > \$25 per     |   |    |
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| 9 |   |                                     |                |   |    |
| 0 |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| s |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| s |   |                                     |                |   |    |
| s |   |                                     |                |   |    |
| i |   |                                     |                |   |    |
| o |   |                                     |                |   |    |
| n |   |                                     |                |   |    |
| s |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > *All         |   |    |
|   |   |                                     | > charges.*    |   |    |
| * |   |                                     |                |   |    |
| N |   |                                     |                |   |    |
| o |   |                                     |                |   |    |
| t |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| t |   |                                     |                |   |    |
| h |   |                                     |                |   |    |
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| r |   |                                     |                |   |    |
| a |   |                                     |                |   |    |
| p |   |                                     |                |   |    |
| y |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| - |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| x |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| r |   |                                     |                |   |    |
| c |   |                                     |                |   |    |
| i |   |                                     |                |   |    |
| s |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| p |   |                                     |                |   |    |
| r |   |                                     |                |   |    |
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| g |   |                                     |                |   |    |
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| a |   |                                     |                |   |    |
| m |   |                                     |                |   |    |
| s |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| S |   |                                     |                |   |    |
| p |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
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| c |   |                                     |                |   |    |
| h |   |                                     |                |   |    |
| > |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
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| y |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
| - |   |                                     | > \$25 per     |   |    |
|   |   |                                     | > visit        |   |    |
|   |   |                                     | > (office      |   |    |
|   |   |                                     | > visit)       |   |    |
| 9 |   |                                     | >              |   |    |
| 0 |   |                                     | > 20% of       |   |    |
|   |   |                                     | > allowable    |   |    |
|   |   |                                     | > charge       |   |    |
|   |   |                                     | > (inpatient   |   |    |
|   |   |                                     | > or           |   |    |
| v |   |                                     | > outpatient   |   |    |
| i |   |                                     | > facility)    |   |    |
| s |   |                                     |                |   |    |
| i |   |                                     |                |   |    |
| t |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
| \ |   |                                     |                |   |    |
| $ |   |                                     |                |   |    |
| 1 |   |                                     |                |   |    |
| 0 |   |                                     |                |   |    |
| 0 |   |                                     |                |   |    |
| 0 |   |                                     |                |   |    |
| > |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
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| e |   |                                     |                |   |    |
| m |   |                                     |                |   |    |
| b |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
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| a |   |                                     |                |   |    |
| l |   |                                     |                |   |    |
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| n |   |                                     |                |   |    |
| d |   |                                     |                |   |    |
| a |   |                                     |                |   |    |
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| a |   |                                     |                |   |    |
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| . |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | #########      |   |    |
|   |   |                                     |  *All Charges* |   |    |
| * |   |                                     |                |   |    |
| N |   |                                     |                |   |    |
| o |   |                                     |                |   |    |
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| d |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     |                |   |    |
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| ) |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
| - |   |                                     | > \$25 per     |   |    |
|   |   |                                     | > office visit |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| - |   |                                     | > \$25 per     |   |    |
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| > |   |                                     | > 20% of       |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
|   | * | > **Here are some important things  |                | * |   |
|   | * | > to keep in mind about these       |                | * |   |
|   | I | > benefits:**                       |                | I |   |
|   | * |                                     |                | * |   |
|   | * | -   Please remember that all        |                | * |   |
|   |   |     benefits are subject to the     |                |   |   |
|   | * |     definitions, limitations, and   |                | * |   |
|   | * |     exclusions in this brochure and |                | * |   |
|   | M |     are payable only when we        |                | M |   |
|   | * |     determine they are medically    |                | * |   |
|   | * |     necessary.                      |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Plan physicians must provide or |                | * |   |
|   | * |     arrange your care.              |                | * |   |
|   | P |                                     |                | P |   |
|   | * | ```{=html}                          |                | * |   |
|   | * | <!-- -->                            |                | * |   |
|   |   | ```                                 |                |   |   |
|   | * | -   The calendar year deductible is |                | * |   |
|   | * |     \$500 per individual and        |                | * |   |
|   | O |     \$1,000 per family for in-plan  |                | O |   |
|   | * |     benefits.                       |                | * |   |
|   | * |                                     |                | * |   |
|   |   | ```{=html}                          |                |   |   |
|   | * | <!-- -->                            |                | * |   |
|   | * | ```                                 |                | * |   |
|   | R | -   Be sure to read Section 4,      |                | R |   |
|   | * |     *Your costs for covered         |                | * |   |
|   | * |     services,* for valuable         |                | * |   |
|   |   |     information about how cost      |                |   |   |
|   | * |     sharing works. Also read        |                | * |   |
|   | * |     Section 9 about coordinating    |                | * |   |
|   | T |     benefits with other coverage,   |                | T |   |
|   | * |     including with Medicare.        |                | * |   |
|   | * |                                     |                | * |   |
|   |   | -   The amounts listed below are    |                |   |   |
|   | * |     for the charges billed by a     |                | * |   |
|   | * |     physician or other health care  |                | * |   |
|   | A |     professional for your surgical  |                | A |   |
|   | * |     care. Look in Section 5 (c) for |                | * |   |
|   | * |     charges associated with the     |                | * |   |
|   |   |     facility.                       |                |   |   |
|   | * |                                     |                | * |   |
|   | * | ```{=html}                          |                | * |   |
|   | N | <!-- -->                            |                | N |   |
|   | * | ```                                 |                | * |   |
|   | * | -   YOU OR YOUR PRIMARY CARE        |                | * |   |
|   |   |     PHYSICIAN MUST GET              |                |   |   |
|   | * |     PRECERTIFICATION OF SOME        |                | * |   |
|   | * |     SURGICAL PROCEDURES. Please     |                | * |   |
|   | T |     refer to the precertification   |                | T |   |
|   | * |     information shown in Section 3  |                | * |   |
|   | * |     to be sure which services       |                | * |   |
|   |   |     require precertification and    |                |   |   |
|   |   |     identify which surgeries        |                |   |   |
|   |   |     require precertification.       |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | **You pay**    |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     | **After the    |   |   |
| * |   |                                     | calendar year  |   |   |
| B |   |                                     | d              |   |   |
| e |   |                                     | eductible...** |   |   |
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| > |   |                                     | > 20% of       |   |   |
|   |   |                                     | > allowable    |   |   |
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| e |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| g |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| f |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| m |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| . |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+

*Surgical procedures continued on next page.*

+---------------------------------------------+------------------------+
| > **Surgical procedures** *(Continued)*     | > **You pay**          |
+---------------------------------------------+------------------------+
| -   Voluntary sterilization (e.g., Tubal    | > 20% of allowable     |
|     ligation, Vasectomy)                    | > charge               |
|                                             |                        |
| -   Treatment of burns                      |                        |
|                                             |                        |
| > Note: Generally, we pay for internal      |                        |
| > prostheses (devices) according to where   |                        |
| > the procedure is done. For example, we    |                        |
| > pay Hospital benefits for a pacemaker and |                        |
| > Surgery benefits for insertion of the     |                        |
| > pacemaker.                                |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Reversal of voluntary sterilization*   |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Routine treatment of conditions of the |                        |
|     foot; see Foot care.*                   |                        |
|                                             |                        |
| -   *Dorsal rhizotomy to treat spasticity*  |                        |
+---------------------------------------------+------------------------+
| > **Reconstructive surgery**                |                        |
+---------------------------------------------+------------------------+
| -   Surgery to correct a functional defect  | 20% of allowable       |
|                                             | charge                 |
| -   Surgery to correct a condition caused   |                        |
|     by injury or illness if:                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   the condition produced a major effect   |                        |
|     on the member's appearance and          |                        |
|                                             |                        |
| -   the condition can reasonably be         |                        |
|     expected to be corrected by such        |                        |
|     surgery                                 |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Surgery to correct a condition that     |                        |
|     existed at or from birth and is a       |                        |
|     significant deviation from the common   |                        |
|     form or norm. Examples of congenital    |                        |
|     anomalies are: protruding ear           |                        |
|     deformities; cleft lip; cleft palate;   |                        |
|     birth marks; webbed fingers; and webbed |                        |
|     toes.                                   |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   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 on an        |                        |
| > inpatient basis and remain in the         |                        |
| > hospital up to 48 hours after the         |                        |
| > procedure.                                |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Cosmetic surgery -- any surgical       |                        |
|     procedure (or any portion of a          |                        |
|     procedure) performed primarily to       |                        |
|     improve physical appearance through     |                        |
|     change in bodily form, except repair of |                        |
|     accidental injury*                      |                        |
|                                             |                        |
| -   *Surgeries related to sex               |                        |
|     transformation*                         |                        |
+---------------------------------------------+------------------------+
| > **Oral and maxillofacial surgery**        |                        |
+---------------------------------------------+------------------------+
| > Oral surgical procedures, limited to:     | > 20% of allowable     |
|                                             | > charge               |
| -   Reduction of fractures of the jaws or   |                        |
|     facial bones;                           |                        |
|                                             |                        |
| -   Surgical correction of cleft lip, cleft |                        |
|     palate or severe functional             |                        |
|     malocclusion;                           |                        |
|                                             |                        |
| -   Removal of stones from salivary ducts;  |                        |
|                                             |                        |
| -   Excision of leukoplakia or              |                        |
|     malignancies;                           |                        |
|                                             |                        |
| -   Excision of cysts and incision of       |                        |
|     abscesses when done as independent      |                        |
|     procedures; and                         |                        |
|                                             |                        |
| -   Other surgical procedures that do not   |                        |
|     involve the teeth or their supporting   |                        |
|     structures.                             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Oral implants and transplants*         |                        |
|                                             |                        |
| -   *Procedures that involve the teeth or   |                        |
|     their supporting structures (such as    |                        |
|     the periodontal membrane, gingiva, and  |                        |
|     alveolar bone)*                         |                        |
+---------------------------------------------+------------------------+
| > **Organ/tissue transplants**              | > **You pay**          |
+---------------------------------------------+------------------------+
| > Limited to:                               | > 20% of allowable     |
|                                             | > charge               |
| -   Cornea                                  |                        |
|                                             |                        |
| -   Heart                                   |                        |
|                                             |                        |
| -   Heart/lung                              |                        |
|                                             |                        |
| -   Kidney                                  |                        |
|                                             |                        |
| -   Kidney/Pancreas                         |                        |
|                                             |                        |
| -   Liver                                   |                        |
|                                             |                        |
| -   Allogeneic bone marrow transplants      |                        |
|                                             |                        |
| -   Autologous bone marrow transplants      |                        |
|     (autologous stem cell and peripheral    |                        |
|     stem cell support) for the following    |                        |
|     conditions: acute lymphocytic or        |                        |
|     non-lymphocytic leukemia; advanced      |                        |
|     Hodgkin\'s lymphoma; advanced           |                        |
|     non-Hodgkin\'s lymphoma; advanced       |                        |
|     neuroblastoma; breast cancer; multiple  |                        |
|     myeloma; epithelial ovarian cancer; and |                        |
|     testicular, mediastinal,                |                        |
|     retroperitoneal and ovarian germ cell   |                        |
|     tumors                                  |                        |
|                                             |                        |
| -   Intestinal transplants (small           |                        |
|     intestine) and the small intestine with |                        |
|     the liver or small intestine with       |                        |
|     multiple organs such as the liver,      |                        |
|     stomach, and pancreas.                  |                        |
|                                             |                        |
| > Limited Benefits - Treatment for breast   |                        |
| > cancer, multiple myeloma, and epithelial  |                        |
| > ovarian cancer may be provided in an NCI- |                        |
| > or NIH-approved clinical trial at a       |                        |
| > Plan-designated center of excellence and  |                        |
| > if approved by the Plan's medical         |                        |
| > director in accordance with the Plan's    |                        |
| > protocols.                                |                        |
| >                                           |                        |
| > Note: We cover related medical and        |                        |
| > hospital expenses of the donor when we    |                        |
| > cover the recipient.                      |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Donor screening tests and donor search |                        |
|     expenses, except those performed for    |                        |
|     the actual donor*                       |                        |
|                                             |                        |
| -   *Implants of artificial organs*         |                        |
|                                             |                        |
| > *Transplants not listed as covered*       |                        |
+---------------------------------------------+------------------------+
| > **Anesthesia**                            | > **You pay**          |
+---------------------------------------------+------------------------+
| > Professional services provided in --      | > 20% of allowable     |
|                                             | > charge               |
| -   Hospital (inpatient)                    | >                      |
|                                             | > 20% of allowable     |
| > Professional services provided in --      | > charge               |
|                                             |                        |
| -   Hospital outpatient department          |                        |
|                                             |                        |
| -   Skilled nursing facility                |                        |
|                                             |                        |
| -   Ambulatory surgical center              |                        |
+---------------------------------------------+------------------------+

+----+---+-----------------------------------+---+-------------+---+-----+
| >  |   |                                   |   |             |   |     |
|  * |   |                                   |   |             |   |     |
| *S |   |                                   |   |             |   |     |
| ec |   |                                   |   |             |   |     |
| ti |   |                                   |   |             |   |     |
| on |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  5 |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| (c |   |                                   |   |             |   |     |
| ). |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| Se |   |                                   |   |             |   |     |
| rv |   |                                   |   |             |   |     |
| ic |   |                                   |   |             |   |     |
| es |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| pr |   |                                   |   |             |   |     |
| ov |   |                                   |   |             |   |     |
| id |   |                                   |   |             |   |     |
| ed |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| by |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  a |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| ho |   |                                   |   |             |   |     |
| sp |   |                                   |   |             |   |     |
| it |   |                                   |   |             |   |     |
| al |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| or |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  o |   |                                   |   |             |   |     |
| th |   |                                   |   |             |   |     |
| er |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  f |   |                                   |   |             |   |     |
| ac |   |                                   |   |             |   |     |
| il |   |                                   |   |             |   |     |
| it |   |                                   |   |             |   |     |
| y, |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  a |   |                                   |   |             |   |     |
| nd |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  a |   |                                   |   |             |   |     |
| mb |   |                                   |   |             |   |     |
| ul |   |                                   |   |             |   |     |
| an |   |                                   |   |             |   |     |
| ce |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| se |   |                                   |   |             |   |     |
| rv |   |                                   |   |             |   |     |
| ic |   |                                   |   |             |   |     |
| es |   |                                   |   |             |   |     |
| ** |   |                                   |   |             |   |     |
+----+---+-----------------------------------+---+-------------+---+-----+
|    | * | > **Here are some important       |   |             | * |     |
|    | * | > things to remember about these  |   |             | * |     |
|    | I | > benefits:**                     |   |             | I |     |
|    | * |                                   |   |             | * |     |
|    | * | -   Please remember that all      |   |             | * |     |
|    |   |     benefits are subject to the   |   |             |   |     |
|    | * |     definitions, limitations, and |   |             | * |     |
|    | * |     exclusions in this brochure   |   |             | * |     |
|    | M |     and are payable only when we  |   |             | M |     |
|    | * |     determine they are medically  |   |             | * |     |
|    | * |     necessary.                    |   |             | * |     |
|    |   |                                   |   |             |   |     |
|    | * | -   Plan physicians must provide  |   |             | * |     |
|    | * |     or arrange your care and you  |   |             | * |     |
|    | P |     must be hospitalized in a     |   |             | P |     |
|    | * |     Plan facility.                |   |             | * |     |
|    | * |                                   |   |             | * |     |
|    |   | ```{=html}                        |   |             |   |     |
|    | * | <!-- -->                          |   |             | * |     |
|    | * | ```                               |   |             | * |     |
|    | O | -   The calendar year deductible  |   |             | O |     |
|    | * |     is \$500 per individual and   |   |             | * |     |
|    | * |     \$1,000 per family for        |   |             | * |     |
|    |   |     in-plan benefits.             |   |             |   |     |
|    | * |                                   |   |             | * |     |
|    | * | ```{=html}                        |   |             | * |     |
|    | R | <!-- -->                          |   |             | R |     |
|    | * | ```                               |   |             | * |     |
|    | * | -   Be sure to read Section 4,    |   |             | * |     |
|    |   |     *Your costs for covered       |   |             |   |     |
|    | * |     services,* for valuable       |   |             | * |     |
|    | * |     information about how cost    |   |             | * |     |
|    | T |     sharing works. Also read      |   |             | T |     |
|    | * |     Section 9 about coordinating  |   |             | * |     |
|    | * |     benefits with other coverage, |   |             | * |     |
|    |   |     including with Medicare.      |   |             |   |     |
|    | * |                                   |   |             | * |     |
|    | * | -   The amounts listed below are  |   |             | * |     |
|    | A |     for the charges billed by the |   |             | A |     |
|    | * |     facility (i.e., hospital or   |   |             | * |     |
|    | * |     surgical center) or ambulance |   |             | * |     |
|    |   |     service for your surgery or   |   |             |   |     |
|    | * |     care. Any costs associated    |   |             | * |     |
|    | * |     with the professional charge  |   |             | * |     |
|    | N |     (i.e., physicians, etc.) are  |   |             | N |     |
|    | * |     covered in Sections 5(a) or   |   |             | * |     |
|    | * |     (b).                          |   |             | * |     |
|    |   |                                   |   |             |   |     |
|    | * | ```{=html}                        |   |             | * |     |
|    | * | <!-- -->                          |   |             | * |     |
|    | T | ```                               |   |             | T |     |
|    | * | -   **YOU or YOUR PRIMARY CARE    |   |             | * |     |
|    | * |     PHYSICIAN MUST GET            |   |             | * |     |
|    |   |     PRECERTIFICATION OF HOSPITAL  |   |             |   |     |
|    |   |     STAYS.** Please refer to      |   |             |   |     |
|    |   |     Section 3 to be sure which    |   |             |   |     |
|    |   |     services require              |   |             |   |     |
|    |   |     precertification.             |   |             |   |     |
+----+---+-----------------------------------+---+-------------+---+-----+
| >  |   |                                   | * |             |   |     |
|  * |   |                                   | * |             |   |     |
| *B |   |                                   | Y |             |   |     |
| en |   |                                   | o |             |   |     |
| ef |   |                                   | u |             |   |     |
| it |   |                                   | p |             |   |     |
| >  |   |                                   | a |             |   |     |
|  D |   |                                   | y |             |   |     |
| es |   |                                   | * |             |   |     |
| cr |   |                                   | * |             |   |     |
| ip |   |                                   |   |             |   |     |
| ti |   |                                   |   |             |   |     |
| on |   |                                   |   |             |   |     |
| ** |   |                                   |   |             |   |     |
+----+---+-----------------------------------+---+-------------+---+-----+
| ## |   |                                   |   |             |   |     |
| #  |   |                                   |   |             |   |     |
+----+---+-----------------------------------+---+-------------+---+-----+
| #  |   |                                   |   | ########    |   |     |
| ## |   |                                   |   |             |   |     |
| ## |   |                                   |   |             |   |     |
| ## |   |                                   |   |             |   |     |
| #  |   |                                   |   |             |   |     |
| In |   |                                   |   |             |   |     |
| pa |   |                                   |   |             |   |     |
| ti |   |                                   |   |             |   |     |
| en |   |                                   |   |             |   |     |
| t  |   |                                   |   |             |   |     |
| ho |   |                                   |   |             |   |     |
| sp |   |                                   |   |             |   |     |
| it |   |                                   |   |             |   |     |
| al |   |                                   |   |             |   |     |
+----+---+-----------------------------------+---+-------------+---+-----+
| >  |   |                                   |   | > 20% of    |   |     |
| Ro |   |                                   |   | > allowable |   |     |
| om |   |                                   |   | > charge    |   |     |
| >  |   |                                   |   |             |   |     |
|  a |   |                                   |   |             |   |     |
| nd |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| bo |   |                                   |   |             |   |     |
| ar |   |                                   |   |             |   |     |
| d, |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| su |   |                                   |   |             |   |     |
| ch |   |                                   |   |             |   |     |
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|    |   |                                   |   |             |   |     |
| -  |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|  w |   |                                   |   |             |   |     |
| ar |   |                                   |   |             |   |     |
| d, |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
| se |   |                                   |   |             |   |     |
| mi |   |                                   |   |             |   |     |
| pr |   |                                   |   |             |   |     |
| iv |   |                                   |   |             |   |     |
| at |   |                                   |   |             |   |     |
| e, |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
| or |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|  i |   |                                   |   |             |   |     |
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| en |   |                                   |   |             |   |     |
| si |   |                                   |   |             |   |     |
| ve |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
| ca |   |                                   |   |             |   |     |
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|    |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
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|    |   |                                   |   |             |   |     |
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| e. |   |                                   |   |             |   |     |
+----+---+-----------------------------------+---+-------------+---+-----+

Inpatient hospital continued on next page.

+---------------------------------------------+------------------------+
| ######## Inpatient hospital *(Continued)*   | ######## You pay       |
+---------------------------------------------+------------------------+
| #### Oth                                    | > 20% of allowable     |
| er hospital services and supplies, such as: | > charge               |
|                                             |                        |
| -   Operating, recovery, maternity, and     |                        |
|     other treatment rooms                   |                        |
|                                             |                        |
| -   Prescribed drugs and medicines          |                        |
|                                             |                        |
| -   Diagnostic laboratory tests and X-rays  |                        |
|                                             |                        |
| -   Administration of blood and blood       |                        |
|     products                                |                        |
|                                             |                        |
| -   Blood or blood plasma, if not donated   |                        |
|     or replaced                             |                        |
|                                             |                        |
| -   Dressings, splints, casts, and sterile  |                        |
|     tray services                           |                        |
|                                             |                        |
| -   Medical supplies and equipment,         |                        |
|     including oxygen                        |                        |
|                                             |                        |
| -   Anesthetics, including nurse            |                        |
|     anesthetist services                    |                        |
|                                             |                        |
| -   Take-home items                         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Medical supplies, appliances, medical   |                        |
|     equipment, and any covered items billed |                        |
|     by a hospital for use at home           |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Custodial care*                        |                        |
|                                             |                        |
| -   *Non-covered facilities, such as        |                        |
|     nursing homes, extended care            |                        |
|     facilities, schools*                    |                        |
|                                             |                        |
| -   *Personal comfort items, such as        |                        |
|     telephone, television, barber services, |                        |
|     guest meals and beds*                   |                        |
|                                             |                        |
| -   *Private nursing care*                  |                        |
+---------------------------------------------+------------------------+
| #### **Outpatie                             | ####                   |
| nt hospital or ambulatory surgical center** |                        |
+---------------------------------------------+------------------------+
| -   Operating, recovery, and other          | > 20% of allowable     |
|     treatment rooms                         | > charge               |
|                                             |                        |
| #### 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 bl                | > *All charges*        |
| ood derivatives not replaced by the member* |                        |
+---------------------------------------------+------------------------+
| ######## Extended care bene                 | ######## You pay       |
| fits/skilled nursing care facility benefits |                        |
+---------------------------------------------+------------------------+
| > Skilled nursing facility (SNF): limited   | > 20% of allowable     |
| > to 100 days per member per calendar year  | > charge               |
+---------------------------------------------+------------------------+
| > Not covered: custodial care               | > *All charges*        |
+---------------------------------------------+------------------------+
| #### **Hospice care**                       | ####                   |
+---------------------------------------------+------------------------+
| > Hospice services include supportive or    | > 20% of allowable     |
| > palliative care for a terminally ill      | > charge               |
| > member in the home or a hospice facility. |                        |
| > Services include inpatient and outpatient |                        |
| > care, and family counseling; these        |                        |
| > services are provided under the direction |                        |
| > of a Plan doctor who certifies that the   |                        |
| > patient is in the terminal stages of      |                        |
| > illness, with a life expectancy of        |                        |
| > approximately six months or less.         |                        |
+---------------------------------------------+------------------------+
| > *Not covered: Independent nursing,        | > *All charges*        |
| > homemaker services*                       |                        |
+---------------------------------------------+------------------------+
| ######## Ambulance                          | ########               |
+---------------------------------------------+------------------------+
| -   Local professional ambulance service    | > 20% of allowable     |
|     when medically appropriate              | > charge               |
+---------------------------------------------+------------------------+

+---+---+------------------------------------------------------+---+---+
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
|   |   |                                                      |   |   |
| S |   |                                                      |   |   |
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| c |   |                                                      |   |   |
| t |   |                                                      |   |   |
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| n |   |                                                      |   |   |
|   |   |                                                      |   |   |
| 5 |   |                                                      |   |   |
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| d |   |                                                      |   |   |
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| m |   |                                                      |   |   |
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| r |   |                                                      |   |   |
| g |   |                                                      |   |   |
| e |   |                                                      |   |   |
| n |   |                                                      |   |   |
| c |   |                                                      |   |   |
| y |   |                                                      |   |   |
|   |   |                                                      |   |   |
| s |   |                                                      |   |   |
| e |   |                                                      |   |   |
| r |   |                                                      |   |   |
| v |   |                                                      |   |   |
| i |   |                                                      |   |   |
| c |   |                                                      |   |   |
| e |   |                                                      |   |   |
| s |   |                                                      |   |   |
| / |   |                                                      |   |   |
| a |   |                                                      |   |   |
| c |   |                                                      |   |   |
| c |   |                                                      |   |   |
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| n |   |                                                      |   |   |
| t |   |                                                      |   |   |
| s |   |                                                      |   |   |
|   |   |                                                      |   |   |
+---+---+------------------------------------------------------+---+---+
|   | * | > Here are some important things to keep in mind     | * | # |
|   | * | > about these benefits:                              | * | # |
|   | I |                                                      | I | # |
|   | * | -   Please remember that all benefits are subject to | * | # |
|   | * |     the definitions, limitations, and exclusions in  | * | # |
|   |   |     this brochure.                                   |   |   |
|   | * |                                                      | * |   |
|   | * | ```{=html}                                           | * |   |
|   | M | <!-- -->                                             | M |   |
|   | * | ```                                                  | * |   |
|   | * | -   The calendar year deductible is \$500 per        | * |   |
|   |   |     individual and \$1,000 per family for in-plan    |   |   |
|   | * |     benefits.                                        | * |   |
|   | * |                                                      | * |   |
|   | P | ```{=html}                                           | P |   |
|   | * | <!-- -->                                             | * |   |
|   | * | ```                                                  | * |   |
|   |   | -   Be sure to read Section 4, *Your costs for       |   |   |
|   | * |     covered services,* for valuable information      | * |   |
|   | * |     about how cost sharing works. Also read Section  | * |   |
|   | O |     9 about coordinating benefits with other         | O |   |
|   | * |     coverage, including with Medicare.               | * |   |
|   | * |                                                      | * |   |
|   |   | #####                                                |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | R |                                                      | R |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | T |                                                      | T |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | A |                                                      | A |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | N |                                                      | N |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | T |                                                      | T |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
+---+---+------------------------------------------------------+---+---+
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| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| a |   |                                                      |   |   |
| c |   |                                                      |   |   |
| t |   |                                                      |   |   |
| i |   |                                                      |   |   |
| o |   |                                                      |   |   |
| n |   |                                                      |   |   |
| . |   |                                                      |   |   |
+---+---+------------------------------------------------------+---+---+

**What to do in case of emergency:**

**Emergencies within our service area:**

a.  Medical care is available through your primary care physician 7 days
    a week, 24 hours a day. If you need medical care, you should call
    your primary care physician immediately for instructions on how to
    receive care.

b.  If the emergency is such that immediate medical attention is needed,
    you should be taken to the nearest appropriate medical facility.

c.  The Plan covers services rendered by providers other than
    participating Piedmont providers when the condition treated is an
    emergency as defined above.

d.  A telephone call from you to your primary care physician while at an
    urgent care center or emergency room will not be treated as a proper
    referral for urgent care or other non-emergency services.

e.  Emergency services provided within our service area shall include
    covered services from non-participating Piedmont providers only when
    a delay in receiving care from a participating Piedmont Provider
    could reasonably be expected to cause your condition to worsen if
    left unattended.

**Emergencies outside our service area:**

a.  Urgent care and emergency services outside the service area are
    covered services if you sustain an injury or become ill while
    temporarily away from the service area. Accordingly, benefits for
    these services are limited to care which is required immediately and
    unexpectedly. Neither elective care nor care required as a result of
    circumstances which could reasonably have been foreseen prior to
    departure from the service area is a covered service. Benefits for
    maternity care do not cover normal term delivery outside the service
    area, but do include earlier complications of pregnancy or
    unexpected delivery occurring outside the service area.

b.  If an emergency or urgent situation occurs when you are temporarily
    outside the service area, you should obtain care at the nearest
    medical facility. You or your representative are responsible for
    notifying your primary care physician on the next working day or
    within 48 hours. Failure to do so may result in reduced benefits or
    no benefits.

c.  Benefits for continuing or follow-up treatment must be pre-arranged
    by your primary care physician and provided in the service area.

+-------------------------------------------------+--------------------+
| > **Benefit Description**                       | **You pay**        |
+-------------------------------------------------+--------------------+
| > **Emergency within our service area**         |                    |
+-------------------------------------------------+--------------------+
| -   Emergency care at a doctor\'s office        | > \$25 per visit   |
|                                                 | >                  |
| -   Emergency care at an urgent care center     | > \$25 per visit   |
|                                                 | >                  |
| -   Emergency care as an outpatient or          | > \$100 per visit, |
|     inpatient at a hospital, including          | > (waived if       |
|     doctors\' services                          | > admitted         |
|                                                 | > )subject to      |
|                                                 | > inpatient        |
|                                                 | > coinsurance      |
+-------------------------------------------------+--------------------+
| > *Not covered: Elective care or non-emergency  | > *All charges.*   |
| > care*                                         |                    |
+-------------------------------------------------+--------------------+
| ######## Emergency outside our service area     |                    |
+-------------------------------------------------+--------------------+
| -   Emergency care at a doctor\'s office        | > \$25 per visit   |
|                                                 | >                  |
| -   Emergency care at an urgent care center     | > \$25 per visit   |
|                                                 | >                  |
| -   Emergency care as an outpatient or          | > \$100 per visit, |
|     inpatient at a hospital, including          | > (waived if       |
|     doctors\' services                          | > admitted)        |
|                                                 | > subject to       |
| ########                                        | > inpatient        |
|                                                 | > coinsurance      |
+-------------------------------------------------+--------------------+
| > *Not covered:*                                | > *All charges.*   |
|                                                 |                    |
| -   *Elective care or non-emergency care*       |                    |
|                                                 |                    |
| -   *Emergency care provided outside the        |                    |
|     service area if the need for care could     |                    |
|     have been foreseen before leaving the       |                    |
|     service area*                               |                    |
|                                                 |                    |
| ```{=html}                                      |                    |
| <!-- -->                                        |                    |
| ```                                             |                    |
| -   *Medical and hospital costs resulting from  |                    |
|     a normal full-term delivery of a baby       |                    |
|     outside the service area*                   |                    |
|                                                 |                    |
| ########                                        |                    |
+-------------------------------------------------+--------------------+
| > **Ambulance**                                 |                    |
+-------------------------------------------------+--------------------+
| > Professional ambulance service when medically | > 20% of allowable |
| > appropriate.                                  | > charge           |
| >                                               |                    |
| > Air ambulance when medically necessary.       |                    |
| >                                               |                    |
| > See 5(c) for non-emergency service.           |                    |
+-------------------------------------------------+--------------------+

+---+---+-----------------------------------------+----------------+---+---+
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| S |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
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| t |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| o |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| 5 |   |                                         |                |   |   |
| ( |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| ) |   |                                         |                |   |   |
| . |   |                                         |                |   |   |
| M |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| l |   |                                         |                |   |   |
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| e |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| l |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| h |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| d |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| u |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
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| e |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| u |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
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| f |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+
|   | * | > When you get our approval for         |                | * |   |
|   | * | > services and follow a treatment plan  |                | * |   |
|   | I | > 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 | > **Here are some important things to   |                | M |   |
|   | * | > keep in mind about these benefits:**  |                | * |   |
|   | * | >                                       |                | * |   |
|   |   | > • All benefits are subject to the     |                |   |   |
|   | * | > definitions, limitations, and         |                | * |   |
|   | * | > exclusions in this brochure.          |                | * |   |
|   | P |                                         |                | P |   |
|   | * | -   The calendar year deductible is     |                | * |   |
|   | * |     \$500 per individual and \$1,000    |                | * |   |
|   |   |     per family for in-plan benefits.    |                |   |   |
|   | * |                                         |                | * |   |
|   | * | > • Be sure to read Section 4, *Your    |                | * |   |
|   | O | > costs for covered services,* for      |                | O |   |
|   | * | > valuable information about how cost   |                | * |   |
|   | * | > sharing works. Also read Section 9    |                | * |   |
|   |   | > about coordinating benefits with      |                |   |   |
|   | * | > other coverage, including with        |                | * |   |
|   | * | > Medicare.                             |                | * |   |
|   | R | >                                       |                | R |   |
|   | * | > • **YOU MUST GET PREAUTHORIZATION OF  |                | * |   |
|   | * | > THESE SERVICES.** See the             |                | * |   |
|   |   | > instructions after the benefits       |                |   |   |
|   | * | > description below.                    |                | * |   |
|   | * |                                         |                | * |   |
|   | T |                                         |                | T |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   |   |                                         |                |   |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   | A |                                         |                | A |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   |   |                                         |                |   |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   | N |                                         |                | N |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   |   |                                         |                |   |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   | T |                                         |                | T |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
+---+---+-----------------------------------------+----------------+---+---+
| > |   |                                         | **You pay**    |   |   |
|   |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| B |   |                                         |                |   |   |
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| n |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+
| # |   |                                         | ###            |   |   |
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
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| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+
| > |   |                                         | > Your cost    |   |   |
|   |   |                                         | > sharing      |   |   |
| A |   |                                         | > re           |   |   |
| l |   |                                         | sponsibilities |   |   |
| l |   |                                         | > are no       |   |   |
| > |   |                                         | > greater than |   |   |
|   |   |                                         | > for other    |   |   |
| d |   |                                         | > illness or   |   |   |
| i |   |                                         | > conditions.  |   |   |
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+---+---+-----------------------------------------+----------------+---+---+
| - |   |                                         | > \$25 per     |   |   |
|   |   |                                         | > office visit |   |   |
|   |   |                                         |                |   |   |
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| s |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| - |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
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| e |   |                                         |                |   |   |
| d |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| c |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| o |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| m |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| g |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| m |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+

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

+----------------------------------------------+-----------------------+
| ### **Mental health a                        | ### **You pay**       |
| nd substance abuse benefits** *(Continued)*  |                       |
+----------------------------------------------+-----------------------+
| -   Diagnostic tests                         | > \$25 per office     |
|                                              | > visit               |
|                                              | >                     |
|                                              | > 20% of allowable    |
|                                              | > charge for services |
|                                              | > performed at a      |
|                                              | > hospital or         |
|                                              | > facility            |
+----------------------------------------------+-----------------------+
| -   Services provided by a hospital or other | > 20% of allowable    |
|     facility                                 | > charge              |
|                                              |                       |
| -   Services in approved alternative care    |                       |
|     settings such as partial                 |                       |
|     hospitalization, half-way house,         |                       |
|     residential treatment, full-day          |                       |
|     hospitalization, facility based          |                       |
|     intensive outpatient treatment           |                       |
+----------------------------------------------+-----------------------+
| ##                                           | > *All charges.*      |
|  Not covered: Services we have not approved. |                       |
|                                              |                       |
| ## Note: OP                                  |                       |
| M will base its review of disputes about tre |                       |
| atment plans on the treatment plan\'s clinic |                       |
| al appropriateness. OPM will generally not o |                       |
| rder us to pay or provide one clinically app |                       |
| ropriate treatment plan in favor of another. |                       |
+----------------------------------------------+-----------------------+
| **Preauthorization** To be eligible to       |                       |
| receive these benefits you must obtain a     |                       |
| treatment plan and follow all of the         |                       |
| following authorization processes:           |                       |
|                                              |                       |
| Contact Piedmont Community HealthCare for    |                       |
| authorizaton. PCHP can be reached locally at |                       |
| (434) 947-4463 or toll free at               |                       |
| 1-800-400-7247.                              |                       |
+----------------------------------------------+-----------------------+

+-----+---+------------------------------------------------+---+-------+
| **S |   |                                                |   |       |
| ect |   |                                                |   |       |
| ion |   |                                                |   |       |
| 5   |   |                                                |   |       |
| (   |   |                                                |   |       |
| f). |   |                                                |   |       |
| Pre |   |                                                |   |       |
| scr |   |                                                |   |       |
| ipt |   |                                                |   |       |
| ion |   |                                                |   |       |
| d   |   |                                                |   |       |
| rug |   |                                                |   |       |
| b   |   |                                                |   |       |
| ene |   |                                                |   |       |
| fit |   |                                                |   |       |
| s** |   |                                                |   |       |
+-----+---+------------------------------------------------+---+-------+
|     | * | **Here are some important things to keep in    | * |       |
|     | * | mind about these benefits:**                   | * |       |
|     | I |                                                | I |       |
|     | * | -   We cover prescribed drugs and medications, | * |       |
|     | * |     as described in the chart beginning on the | * |       |
|     |   |     next page.                                 |   |       |
|     | * |                                                | * |       |
|     | * | -   All benefits are subject to the            | * |       |
|     | M |     definitions, limitations and exclusions in | M |       |
|     | * |     this brochure and are payable only when we | * |       |
|     | * |     determine they are medically necessary.    | * |       |
|     |   |                                                |   |       |
|     | * | ```{=html}                                     | * |       |
|     | * | <!-- -->                                       | * |       |
|     | 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    | * |       |
|     | O |     with Medicare.                             | O |       |
|     | * |                                                | * |       |
|     | * |                                                | * |       |
|     |   |                                                |   |       |
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|     | . |                                                |   |       |
+-----+---+------------------------------------------------+---+-------+

*Prescription drug benefits begin on the next page.*

+---------------------------------------------+------------------------+
| > **Benefit Description**                   | **You pay**            |
+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      |                        |
+---------------------------------------------+------------------------+
| > We cover the following medications and    | > \$15 per generic     |
| > supplies prescribed by a Plan physician   | > (30-day supply)      |
| > and obtained from a Plan pharmacy or      | >                      |
| > through our mail order program:           | > \$30 per brand name  |
|                                             | > (30-day supply)      |
| -   Drugs and medicines that by Federal law | >                      |
|     of the United States require a          | > \$30 per generic     |
|     physician's prescription for their      | > (90-day supply       |
|     purchase, except as excluded below.     | > through mail         |
|                                             | > service)             |
| -   Insulin                                 | >                      |
|                                             | > \$60 per brand name  |
| -   Disposable needles and syringes for the | > (90-day supply       |
|     administration of covered medications   | > through mail         |
|                                             | > service)             |
| -   Drugs for sexual dysfunction (see Prior | >                      |
|     authorization on page 12)               | > Note: If there is no |
|                                             | > generic equivalent   |
| ```{=html}                                  | > available, you will  |
| <!-- -->                                    | > still have to pay    |
| ```                                         | > the brand name       |
| -   Contraceptive drugs and devices         | > copay.               |
|                                             |                        |
| -   Fertility drugs                         |                        |
|                                             |                        |
| -   Growth Hormone drugs                    |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All Charges*        |
|                                             |                        |
| -   *Drugs and supplies for cosmetic        |                        |
|     purposes*                               |                        |
|                                             |                        |
| -   *Drugs to enhance athletic performance* |                        |
|                                             |                        |
| -   *Vitamins, nutrients and food           |                        |
|     supplements even if a physician         |                        |
|     prescribes or administers them*         |                        |
|                                             |                        |
| -   *Nonprescription medicines*             |                        |
|                                             |                        |
| -   *Drugs obtained from a non-Plan         |                        |
|     pharmacy, unless emergency*             |                        |
|                                             |                        |
| -   *Tobacco cessation products*            |                        |
|                                             |                        |
| -   *Anorexiants*                           |                        |
|                                             |                        |
| -   *Drugs and medications not approved by  |                        |
|     the FDA*                                |                        |
|                                             |                        |
| -   *DESI drugs (i.e. drugs which are of    |                        |
|     questionable therapeutic value as       |                        |
|     designated by the FDA's Federal Drug    |                        |
|     Efficacy Study)*                        |                        |
|                                             |                        |
| -   *Any other drug deemed not medically    |                        |
|     necessary by the Plan.*                 |                        |
+---------------------------------------------+------------------------+

+-----------------------------------------------------------------------+
| > Section 5 (g). Special features                                     |
+=======================================================================+
+-----------------------------------------------------------------------+

+----------------------+-----------------------------------------------+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| > **Flexible         | > Under the flexible benefits option, we      |
| > 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.                                  |
+----------------------+-----------------------------------------------+
| > **Local Service    | > As a company located in the heart of its    |
| > and Assistance**   | > service area, which spans across the        |
|                      | > Central Virginia area only, we can offer    |
|                      | > our members local service and assistance.   |
|                      | > We are in the same community with you and   |
|                      | > work with your medical providers on a daily |
|                      | > basis. Customer service representatives and |
|                      | > medical management staff are in the office  |
|                      | > and available to assist you.                |
+----------------------+-----------------------------------------------+
| > **Eyewear          | > By presenting your Piedmont Community       |
| > Discounts**        | > HealthCare identification card at these     |
|                      | > Lynchburg locations: AG Jefferson, Inc.;    |
|                      | > Cooper & Elder Optical; Virginia Eye        |
|                      | > Clinic-Dr. Timothy J. Wilson and            |
|                      | > Associates, Optometrists; Elegance in       |
|                      | > Eyewear; Dr. David a. West, OD; Dr. Victor  |
|                      | > Weatherholt; McBride & Blackburn Opticians, |
|                      | > Inc.; Sears Optical and Pearle Vision, you  |
|                      | > will receive discounts on eyewear.          |
+----------------------+-----------------------------------------------+

+---+---+--------------------------------------+----------+---+--------+
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| S |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
| c |   |                                      |          |   |        |
| t |   |                                      |          |   |        |
| i |   |                                      |          |   |        |
| o |   |                                      |          |   |        |
| n |   |                                      |          |   |        |
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| 5 |   |                                      |          |   |        |
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| ( |   |                                      |          |   |        |
| h |   |                                      |          |   |        |
| ) |   |                                      |          |   |        |
| . |   |                                      |          |   |        |
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| D |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
| n |   |                                      |          |   |        |
| t |   |                                      |          |   |        |
| a |   |                                      |          |   |        |
| l |   |                                      |          |   |        |
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| b |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
| n |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
| f |   |                                      |          |   |        |
| i |   |                                      |          |   |        |
| t |   |                                      |          |   |        |
| s |   |                                      |          |   |        |
+===+===+======================================+==========+===+========+
|   | * | **Here are some important things to  |          | * |        |
|   | * | keep in mind about these benefits:** |          | * |        |
|   | I |                                      |          | I |        |
|   | * | -   We do not provide dental         |          | * |        |
|   | * |     benefits except for accidental   |          | * |        |
|   |   |     injury.                          |          |   |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   | M |                                      |          | M |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   |   |                                      |          |   |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   | P |                                      |          | P |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   |   |                                      |          |   |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   | O |                                      |          | O |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   |   |                                      |          |   |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   | R |                                      |          | R |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   |   |                                      |          |   |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   | T |                                      |          | T |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   |   |                                      |          |   |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   | A |                                      |          | A |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   |   |                                      |          |   |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   | N |                                      |          | N |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   |   |                                      |          |   |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   | T |                                      |          | T |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
+---+---+--------------------------------------+----------+---+--------+
| # |   |                                      |          |   |        |
| # |   |                                      |          |   |        |
| # |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
| A |   |                                      |          |   |        |
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| c |   |                                      |          |   |        |
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|   |   |                                      |          |   |        |
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| n |   |                                      |          |   |        |
| j |   |                                      |          |   |        |
| u |   |                                      |          |   |        |
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| y |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| b |   |                                      |          |   |        |
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| n |   |                                      |          |   |        |
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| f |   |                                      |          |   |        |
| i |   |                                      |          |   |        |
| t |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
+---+---+--------------------------------------+----------+---+--------+
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| W |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
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| a |   |                                      |          |   |        |
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+---+---+--------------------------------------+----------+---+--------+
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
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| n |   |                                      |          |   |        |
| t |   |                                      |          |   |        |
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| t |   |                                      |          |   |        |
| s |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
+---+---+--------------------------------------+----------+---+--------+
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
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| e |   |                                      |          |   |        |
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|   |   |                                      |          |   |        |
| h |   |                                      |          |   |        |
| a |   |                                      |          |   |        |
| v |   |                                      |          |   |        |
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| n |   |                                      |          |   |        |
| t |   |                                      |          |   |        |
| a |   |                                      |          |   |        |
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|   |   |                                      |          |   |        |
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| n |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
| f |   |                                      |          |   |        |
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| . |   |                                      |          |   |        |
+---+---+--------------------------------------+----------+---+--------+

+----+---+-------------------------------------------------+---+-----+---+
| *  |   |                                                 |   |     |   |
| *S |   |                                                 |   |     |   |
| ec |   |                                                 |   |     |   |
| ti |   |                                                 |   |     |   |
| on |   |                                                 |   |     |   |
| 5  |   |                                                 |   |     |   |
| (i |   |                                                 |   |     |   |
| ). |   |                                                 |   |     |   |
| P  |   |                                                 |   |     |   |
| oi |   |                                                 |   |     |   |
| nt |   |                                                 |   |     |   |
| of |   |                                                 |   |     |   |
| s  |   |                                                 |   |     |   |
| er |   |                                                 |   |     |   |
| vi |   |                                                 |   |     |   |
| ce |   |                                                 |   |     |   |
| be |   |                                                 |   |     |   |
| ne |   |                                                 |   |     |   |
| fi |   |                                                 |   |     |   |
| ts |   |                                                 |   |     |   |
| ** |   |                                                 |   |     |   |
+----+---+-------------------------------------------------+---+-----+---+
|    | * | > **Here are some important things to remember  | * |     |   |
|    | * | > about these benefits:**                       | * |     |   |
|    | I |                                                 | I |     |   |
|    | * | -   Please remember that all benefits are       | * |     |   |
|    | * |     subject to the definitions, limitations,    | * |     |   |
|    |   |     and exclusions in this brochure and are     |   |     |   |
|    | * |     payable only when we determine they are     | * |     |   |
|    | * |     medically necessary.                        | * |     |   |
|    | M |                                                 | M |     |   |
|    | * | -   Point of service benefits or out-of-network | * |     |   |
|    | * |     benefits will be provided when you receive  | * |     |   |
|    |   |     services from providers other than your     |   |     |   |
|    | * |     primary care physician without a referral   | * |     |   |
|    | * |     from your primary care physician.           | * |     |   |
|    | P |     Exceptions are emergency care and two       | P |     |   |
|    | * |     visits per year to participating Plan       | * |     |   |
|    | * |     OB/GYN physicians.                          | * |     |   |
|    |   |                                                 |   |     |   |
|    | * | -   The calendar year deductible is \$1,500 per | * |     |   |
|    | * |     individual and \$3,000 per family for       | * |     |   |
|    | O |     out-of-network benefits.                    | O |     |   |
|    | * |                                                 | * |     |   |
|    | * | -   Be sure to read Section 4, *Your costs for  | * |     |   |
|    |   |     covered services,* for valuable information |   |     |   |
|    | * |     about how cost sharing works. Also read     | * |     |   |
|    | * |     Section 9 about coordinating benefits with  | * |     |   |
|    | R |     other coverage, including with Medicare.    | R |     |   |
|    | * |                                                 | * |     |   |
|    | * | -   The amounts listed below are for the        | * |     |   |
|    |   |     charges billed by the facility (i.e.,       |   |     |   |
|    | * |     hospital or surgical center) or ambulance   | * |     |   |
|    | * |     service for your surgery or care. Any costs | * |     |   |
|    | T |     associated with the professional charge     | T |     |   |
|    | * |     (i.e., physicians, etc.) are covered in     | * |     |   |
|    | * |     Section 5(a) or (b).                        | * |     |   |
|    |   |                                                 |   |     |   |
|    | * |                                                 | * |     |   |
|    | * |                                                 | * |     |   |
|    | A |                                                 | A |     |   |
|    | * |                                                 | * |     |   |
|    | * |                                                 | * |     |   |
|    |   |                                                 |   |     |   |
|    | * |                                                 | * |     |   |
|    | * |                                                 | * |     |   |
|    | N |                                                 | N |     |   |
|    | * |                                                 | * |     |   |
|    | * |                                                 | * |     |   |
|    |   |                                                 |   |     |   |
|    | * |                                                 | * |     |   |
|    | * |                                                 | * |     |   |
|    | T |                                                 | T |     |   |
|    | * |                                                 | * |     |   |
|    | * |                                                 | * |     |   |
+----+---+-------------------------------------------------+---+-----+---+

[Point of Service (POS) Benefits]{.underline}

[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 or a Plan
doctor without a referral from your primary care physician, you are
subject to the deductibles, coinsurance and maximum benefit stated
below.

[What is covered]{.underline}

All medical services listed as covered in the previous sections are
covered services under the point of service or out-of-plan benefit.

Once you receive services from a non-Plan provider or without a referral
from your primary care physician, then all charges related to those
services are paid at the point of service or out-of-plan level. For
example, if you see a specialist, Plan specialist or non-Plan
specialist, without a referral from your primary care physician and then
that specialist send you to a facility, Plan facility or non-Plan
facility, then all of those charges will be paid at the point of service
or out-of-plan level. Therefore, point of service coverage may be
obtained in the service area or out of the service area.

###### Precertification 

Precertification is not required for point of service or out-of-plan
benefits.

[Deductible]{.underline}

\$1,500 per individual per calendar year, \$3,000 per family per
calendar year.

[Coinsurance]{.underline}

You pay 40% of the allowable charge after the deductible for all covered
services.

[Maximum benefit]{.underline}

There is no maximum benefit under the point of service benefits;
however, you do have an out-of-pocket maximum of \$6,000 per individual
per calendar year, and \$12,000 per family per calendar year. Amounts
over the allowable charge amounts, outpatient mental health services,
prescription drug copayments and the vision exam copayment do not count
towards the out-of-pocket maximum.

[Hospital/extended care]{.underline}

The same covered services listed in the previous sections are covered
under the point of service benefits. The same limitations apply. The
allowable charge for facilities is the same as the actual charge so you
will be responsible for 40% of those facility charges. The facility
charge does not cover any charges for doctors' services.

[Emergency benefits]{.underline}

Non-emergent conditions treated at an emergency room are always payable
as out-of-plan benefits.

[What is not covered]{.underline}

The same services listed as not covered in the previous sections, are
not covered under the point of service or out-of-plan benefits either.
In addition, all charges over the allowable charge amount are not
covered.

[How to obtain benefits]{.underline}

You may be required to file claim forms for services received from
non-Plan providers. Contact customer service at 888-674-3368 to request
claim forms. Complete the form, attach your receipt and mail in to the
address on the form.

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

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

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

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

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

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

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

-   Experimental/Investigative medical or surgical procedures and drugs,
    as determined by the Plan, in its sole discretion

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

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

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

  -----------------------------------------------------------------------
  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.
Check with the provider. If you need to file the claim, here is the
process:

**Medical and hospital benefits** In most cases, providers and
facilities file claims for you. Physicians must file on the form
HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at
888-674-3368.

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

-   Covered member's name and ID number;

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

-   Dates you received the services or supplies;

-   Diagnosis;

-   Type of each service or supply;

-   The charge for each service or supply;

```{=html}
<!-- -->
```
-   A copy of the explanation of benefits, payments, or denial from any
    primary payer \--such as the Medicare Summary Notice (MSN); and

-   Receipts, if you paid for your services.

> **Submit your claims to: Piedmont Community HealthCare, P.O. Box
> 14408, Cincinatti, Ohio 45250-0408**

**Prescription drugs** Prescriptions must be received from Plan
pharmacies in order to be covered. Plan pharmacies file the claims for
you. If for some reason you need to file a claim, contact customer
service at 800-966-5772 to request a claim form, complete the form and
mail it to the address below.

> **Submit your claims to: PCS Health Systems, Inc., PO Box 52116,
> Phoenix, Arizona 85072-2116**

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

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

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

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

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

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) Write to us within 6 months from the date of our decision;   |
| * |     and                                                          |
| * |                                                                  |
|   | (b) Send your request to us at: Piedmont Community HealthCare,   |
|   |     P.O. Box 2455, Lynchburg, VA 24501, ATTN: Operations         |
|   |     Manager; and                                                 |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or, or if applicable, arrange for the health  |
| * |     care provider to give you the care); or                      |
| * |                                                                  |
|   | (b) Write to you and maintain our denial \-- go to step 4; or    |
|   |                                                                  |
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request---go   |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us \-- if we did not       |
|   |     answer that request in some way within 30 days; or           |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: Office of Personnel Management, Insurance       |
|   | Services Programs, Health Insurance Group 3, 1900 E Street, NW,  |
|   | Washington, D.C. 20415-3630.                                     |
+---+------------------------------------------------------------------+
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must include a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | If you do not agree with OPM's decision, your only recourse is   |
|   | to sue. If you decide to sue, you must file the suit against OPM |
|   | in Federal court by December 31 of the third year after the year |
|   | in which you received the disputed services, drugs, or supplies  |
|   | or from the year in which you were denied precertification or    |
|   | prior approval. This is the only deadline that may not be        |
|   | extended.                                                        |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support their disputed claim decision. This           |
|   | information will become part of the court record.                |
+---+------------------------------------------------------------------+
|   | You may not sue until you have completed the disputed claims     |
|   | process. Further, Federal law governs your lawsuit, benefits,    |
|   | and payment of benefits. The Federal court will base its review  |
|   | on the record that was before OPM when OPM decided to uphold or  |
|   | overturn our decision. You may recover only the amount of        |
|   | benefits in dispute.                                             |
+---+------------------------------------------------------------------+

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

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at 434-947-4463 or
    800-400-7247 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 III at 202/606-0755
    between 8 a.m. and 5 p.m. eastern time.

  -----------------------------------------------------------------------
  Section 9. Coordinating benefits with other coverage

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

**When you have other health coverage** You must tell us if you or a
covered family member have coverage under another group health plan or
have automobile insurance that pays medical 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.
Limitations work the same way. We will not exceed our number of visits
where applicable.

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

• People 65 years of age and older.

• Some people with disabilities, under 65 years of age.

> • People with End-Stage Renal Disease (permanent kidney failure
> requiring dialysis or a transplant).

Medicare has two parts:

> • Part A (Hospital Insurance). Most people do not have to pay for Part
> A. If you or your spouse worked for at least 10 years in
> Medicare-covered employment, you should be able to qualify for
> premium-free Part A insurance. (Someone who was a Federal employee on
> January 1, 1983 or since automatically qualifies.) Otherwise, if you
> are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE
> for more information.
>
> • Part B (Medical Insurance). Most people pay monthly for Part B.
> Generally, Part B premiums are withheld from your monthly Social
> Security check or your retirement check
>
> The decision to enroll in Medicare is yours. We encourage you to apply
> for Medicare benefits 3 months before you turn age 65. It's easy. Just
> call the Social Security Administration toll-free number
> 1-800-772-1213 to set up an appointment to apply. If you do not apply
> for one or both Parts of Medicare, you can still be covered under the
> FEHB Program.
>
> If you can get premium-free Part A coverage, we advise you to enroll
> in it. Most Federal employees and annuitants are entitled to Medicare
> Part A at age 65 **without cost**. When you don't have to pay premiums
> for Medicare Part A, it makes good sense to obtain the coverage. It
> can reduce your out-of-pocket expenses as well as costs to the FEHB,
> which can help keep FEHB premiums down.
>
> Everyone is charged a premium for Medicare Part B coverage. The Social
> Security Administration can provide you with premium and benefit
> information. Review the information and decide if it makes sense for
> you to buy the Medicare Part B coverage.
>
> If you are eligible for Medicare, you may have choices in how you get
> your health care. Medicare + Choice is the term used to describe the
> various health plan choices available to Medicare beneficiaries. The
> information in the next few pages shows how we coordinate benefits
> with Medicare, depending on the type of Medicare managed care plan you
> have.

**•The Original Medicare Plan**

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

When you are enrolled in Original Medicare along with this plan, you
still need to follow the rules in this brochure for us to cover your
care. Your care must continue to be authorized by your Plan PCP, or
precertified as required. We will waive some copayments, coinsurance,
and deductibles, as follows:

If Medicare pays more on the claim than the Plan, then you will not be
required to pay your copayments, coinsurance, and deductibles under the
Plan benefits.

**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 up to the maximum benefit under our plan. You will
    not need to do anything. To find out if you need to do something
    about filing your claim, call us at 1-888-674-3368 or contact us at
    [www.pchp.net](http://www.pchp.net/)

> **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   | **  |   |          |
| 65 or over and have Medicare and you...**          | The |   |          |
|                                                    | p   |   |          |
|                                                    | rim |   |          |
|                                                    | ary |   |          |
|                                                    | pa  |   |          |
|                                                    | yer |   |          |
|                                                    | for |   |          |
|                                                    | the |   |          |
|                                                    | i   |   |          |
|                                                    | ndi |   |          |
|                                                    | vid |   |          |
|                                                    | ual |   |          |
|                                                    | w   |   |          |
|                                                    | ith |   |          |
|                                                    | Me  |   |          |
|                                                    | dic |   |          |
|                                                    | are |   |          |
|                                                    | i   |   |          |
|                                                    | s.. |   |          |
|                                                    | .** |   |          |
+----------------------------------------------------+-----+---+----------+
|                                                    | **M |   | **This   |
|                                                    | edi |   | Plan**   |
|                                                    | car |   |          |
|                                                    | e** |   |          |
+----------------------------------------------------+-----+---+----------+
| 1)  Are an active employee with the Federal        |     |   |         |
|     government and**...**                          |     |   |          |
|                                                    |     |   |          |
|     -   You have FEHB coverage on your own or      |     |   |          |
|         through your spouse who is also an active  |     |   |          |
|         employee                                   |     |   |          |
+----------------------------------------------------+-----+---+----------+
| -   You have FEHB coverage through your spouse who |    |   |          |
|     is an annuitant                                |     |   |          |
+----------------------------------------------------+-----+---+----------+
| 2)  Are an annuitant and**...**                    |    |   |          |
|                                                    |     |   |          |
|     -   You have FEHB coverage on your own or      |     |   |          |
|         through your spouse who is also an         |     |   |          |
|         annuitant                                  |     |   |          |
+----------------------------------------------------+-----+---+----------+
| -   You have FEHB coverage through your spouse who |     |   | >       |
|     is an active employee                          |     |   |          |
+----------------------------------------------------+-----+---+----------+
| 3)  Are a reemployed annuitant with the Federal    | \* |   |          |
|     government and your position is excluded from  |     |   |          |
|     the FEHB (your employing office will know if   |     |   |          |
|     this is the case)                              |     |   |          |
+----------------------------------------------------+-----+---+----------+
| 4)  Are a reemployed annuitant with the Federal    |     |   | >       |
|     government and your position is not excluded   |     |   |          |
|     from the FEHB (your employing office will know |     |   |          |
|     if this is the case) and**...**                |     |   |          |
|                                                    |     |   |          |
|     -   You have FEHB coverage on your own or      |     |   |          |
|         through your spouse who is also an active  |     |   |          |
|         employee                                   |     |   |          |
+----------------------------------------------------+-----+---+----------+
| -   You have FEHB coverage through your spouse who |    |   |          |
|     is an annuitant                                |     |   |          |
+----------------------------------------------------+-----+---+----------+
| 5)  Are a Federal judge who retired under title    | #   |   |          |
|     28, U.S.C., or a Tax Court judge who retired   | ### |   |          |
|     under Section 7447 of title 26, U.S.C. (or if  | ##  |   |          |
|     your covered spouse is this type of judge)     | \* |   |          |
+----------------------------------------------------+-----+---+----------+
| 6)  Are enrolled in Part B only, regardless of     |    |   |  for    |
|     your employment status                         | for |   | other    |
|                                                    | P   |   | services |
|                                                    | art |   |          |
|                                                    | B   |   |          |
|                                                    | se  |   |          |
|                                                    | rvi |   |          |
|                                                    | ces |   |          |
+----------------------------------------------------+-----+---+----------+
| 7)  Are a former Federal employee receiving        | \  |   |          |
|     Workers' Compensation and the Office of        | *\* |   |          |
|     Workers' Compensation Programs has determined  |     |   |          |
|     that you are unable to return to duty)         |     |   |          |
+----------------------------------------------------+-----+---+----------+
| **B. When you or a covered family member...**      |     |   |          |
+----------------------------------------------------+-----+---+----------+
| ###### Have Medicare solely                        |     |  |          |
| based on end stage renal disease (ESRD) and**...** |     |   |          |
|                                                    |     |   |          |
| ###### It is within the firs                       |     |   |          |
| t 30 months of eligibility for or entitlement to M |     |   |          |
| edicare due to ESRD (30-month coordination period) |     |   |          |
+----------------------------------------------------+-----+---+----------+
| -   It is beyond the 30-month coordination period  |    |   |          |
|     and you or a family member are still entitled  |     |   |          |
|     to Medicare due to ESRD                        |     |   |          |
+----------------------------------------------------+-----+---+----------+
| 1)  Become eligible for Medicare due to ESRD while |     |  |          |
|     already a Medicare beneficiary and**...**      |     | f |          |
|                                                    |     | o |          |
| -   This Plan was the primary payer before         |     | r |          |
|     eligibility due to ESRD                        |     | 3 |          |
|                                                    |     | 0 |          |
|                                                    |     | - |          |
|                                                    |     | m |          |
|                                                    |     | o |          |
|                                                    |     | n |          |
|                                                    |     | t |          |
|                                                    |     | h |          |
|                                                    |     | c |          |
|                                                    |     | o |          |
|                                                    |     | o |          |
|                                                    |     | r |          |
|                                                    |     | d |          |
|                                                    |     | i |          |
|                                                    |     | n |          |
|                                                    |     | a |          |
|                                                    |     | t |          |
|                                                    |     | i |          |
|                                                    |     | o |          |
|                                                    |     | n |          |
|                                                    |     | p |          |
|                                                    |     | e |          |
|                                                    |     | r |          |
|                                                    |     | i |          |
|                                                    |     | o |          |
|                                                    |     | d |          |
+----------------------------------------------------+-----+---+----------+
| -   Medicare was the primary payer before          |    |   |          |
|     eligibility due to ESRD                        |     |   |          |
+----------------------------------------------------+-----+---+----------+
| **C. When either you or your spouse are eligible   |     |   |          |
| for Medicare solely due to disability and you**    |     |   |          |
+----------------------------------------------------+-----+---+----------+
| 1)  Are an active employee with the Federal        |     |  |          |
|     government and**...**                          |     |   |          |
|                                                    |     |   |          |
|     -   You have FEHB coverage on your own or      |     |   |          |
|         through your spouse who is also an active  |     |   |          |
|         employee                                   |     |   |          |
+----------------------------------------------------+-----+---+----------+
| -   You have FEHB coverage through your spouse who |    |   |          |
|     is an annuitant                                |     |   |          |
+----------------------------------------------------+-----+---+----------+
| 2)  Are an annuitant and**...**                    |    | [ |          |
|                                                    |     | ] |          |
|     -   You have FEHB coverage on your own or      |     | { |          |
|         through your spouse who is also an         |     | . |          |
|         annuitant                                  |     | m |          |
|                                                    |     | a |          |
|                                                    |     | r |          |
|                                                    |     | k |          |
|                                                    |     | } |          |
+----------------------------------------------------+-----+---+----------+
| -   You have FEHB coverage through your spouse who |     |  |          |
|     is an active employee                          |     |   |          |
+----------------------------------------------------+-----+---+----------+
| **D. Are covered under the FEHB Spouse Equity      |    |   |          |
| provision as a former spouse**                     |     |   |          |
+----------------------------------------------------+-----+---+----------+

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

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

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

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

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

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

**TRICARE and CHAMPVA** TRICARE is the health care program for eligible
dependents of military persons, and retirees of the military. TRICARE
includes the 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 a one of these programs, eliminating your FEHB premium. (OPM
does not contribute to any applicable plan premiums.) For information on
suspending your FEHB enrollment, contact your retirement office. If you
later want to re-enroll in the FEHB Program, generally you may do so
only at the next Open Season unless you involuntarily lose coverage
under the program.

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

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

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

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

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

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

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

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

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

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

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care. See page 13.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 13.

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

**Custodial care** Custodial care is care (including room and board
needed to provide that care) that is given principally for personal
hygiene or for assistance in daily activities and can, according to
generally accepted medical standards, be performed by persons who have
no medical training. Examples of custodial care are help in walking and
getting out of bed; assistance in bathing, dressing, feeding; or
supervision over medication which could normally be self-administered.
Custodial care that lasts 90 days or more is sometimes known as Long
term care. Please see page 58 for your specific benefit.

**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 13.

**Experimental or**

**Investigational services** Experimental or investigative means any
service or supply which is determined to be experimental or
investigative in the Plan's sole discretion. The Plan will apply the
following criteria in exercising its discretion:

1.  Any supply or drug used must have received final approval to market
    by the United States Food and Drug Administration;

2.  There must be sufficient information in the peer reviewed medical
    and scientific literature to enable the Plan to make conclusions
    about safety and efficacy;

3.  The available scientific evidence must demonstrate a beneficial
    effect on health outcomes outside a research setting; and

4.  The service or supply must be a safe and effective outside a
    research setting as existing diagnostic or therapeutic alternatives.

> A service or supply will be experimental or investigative if the Plan
> determines that any one of the four criteria is not satisfied.

**Medically necessary** Medically necessary services mean those covered
services received are consistent with the diagnosis and treatment of the
member's condition , are efficacious, are in accordance with standards
of good medical practice, are not simply for the convenience of the
member of provider and are performed in the most cost-effective setting
available to the member. We will determine the medical necessity of a
given service or procedure.

**Plan allowance** Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Plans determine their
allowances in different ways. We determine our allowance by a set fee
schedule for covered services. Our allowable charge means the amount
determined by the Plan for a specified covered service or the provider's
actual charge for that service, whichever is less. We will never pay
more than our allowable charge for any covered service.

**Us/We** Us and we refer to Piedmont Community HealthCare.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

**premiums start** this Plan during Open Season, your coverage begins on
the first day of your first pay period that starts on or after
January 1. Annuitants' coverage and premiums begin on January 1. If you
joined at any other time during the year, your employing office will
tell you the effective date of coverage.

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

**When you lose benefits**

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

> • Your enrollment ends, unless you cancel your enrollment, or
>
> • You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation
of Coverage.

(TCC), or a conversion policy (a non-FEHB individual policy).

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

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

**• Temporary continuation of**

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

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

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

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

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

> • You decided not to receive coverage under TCC or the spouse equity
> law; or
>
> • You are not eligible for coverage under TCC or the spouse equity
> law.

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

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

**Getting a Certificate of** The Health Insurance Portability and
Accountability Act of 1996.

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

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

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

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

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

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

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

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

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

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

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

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

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```
-   Covers eligible dependent care expenses incurred so you can work, or
    if you are married, so you and your spouse can work, or your spouse
    can look for work or attend school full-time.

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

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

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

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

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

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

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

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

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

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

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

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

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

> you and the Plan share costs, and medical services and supplies that
> are not covered by the Plan and for which you must pay. These
> out-of-pocket costs are summarized on page 13 and detailed throughout
> this brochure. Your HCFSA will reimburse you for such costs when they
> are for tax deductible medical care for you and your dependents that
> is NOT covered by this FEHB Plan or any other coverage that you have.
>
> The IRS governs expenses reimbursable by a HCFSA. See Publication 502
> for a comprehensive list of tax-deductible medical expenses.  **Note:
> While you will see insurance premiums listed in Publication 502, they
> are NOT a reimbursable expense for FSA purposes**.  Publication 502
> can be found on the IRS Web site at
> <http://www.irs.gov/pub/irs-pdf/p502.pdf>.  If you do not see your
> service or expense listed in Publication 502, please call a FSAFEDS
> Benefit Counselor at 1-877-FSAFEDS (372-3337), who will be able to
> answer your specific questions.

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

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

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

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

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

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

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

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

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

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

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

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

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

> may help you decide whether to participate in FSAFEDS.

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

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

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

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

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

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

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

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

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

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

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

**The Federal Long Term Care Insurance Program**

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

Program:

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

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

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

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

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

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

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

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

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

**A**ccidental injury 20, 25, 38

Allergy 14, 18

Alternative treatment 14, 23, 50

Allogenetic (donor) bone marrow transplant 26

Ambulance 2, 12, 14, 28, 30, 32, 39

Anesthesia 2, 6, 14, 24, 27, 29

Autologous bone marrow transplant 19, 26

Blood and blood plasma 15, 16, 29

Breast cancer screening 16

Casts 29

Changes for 2004 9

Chemotherapy 19

Cholesterol tests 16

Claims 3, 10, 14, 35, 37, 42, 43, 44, 46, 47, 55, 56

Coinsurance 2, 7, 10, 13, 32, 39, 42, 46, 48, 50, 56

Colorectal cancer screening 16

Congenital anomalies 24, 25

Contraceptive devices and drugs 17, 36

Coordination of benefits 45

Covered charges 46

Crutches 22

**D**eductible 2, 7, 9, 10, 13, 15, 24, 28, 31, 33, 39, 42, 46, 48, 50,
56

Definitions 3, 15, 24, 28, 31, 33, 35, 39, 50

Dental care 3, 14, 21, 29, 38, 41, 55

Diagnostic services 12, 13, 14, 15, 17, 29, 33, 34, 50, 60

Disputed claims review 3, 37, 43, 44

Dressings 29

Durable medical equipment (DME) 13, 14, 22

**E**ducational classes and programs 14, 23

Emergency 2, 7, 8, 9, 12, 13, 14, 31, 32, 35, 36, 39, 40, 42, 60

Experimental or investigational 41, 50

Eyeglasses 20, 22

**F**amily planning 14, 17

Fecal occult blood test 16

**G**eneral Exclusions 3, 14, 41

**H**earing services 14, 16, 20, 58

Home health services 14, 15, 22

Hospice care 14, 30

Hospital 2, 5, 6, 7, 10-15, 17, 21, 22, 25, 26, 27, 28, 29, 32, 34, 39,
40, 42, 45, 46, 48

**I**mmunizations 7, 16

Infertility 13, 14, 18

Inpatient Hospital Benefits 14, 17, 25, 28, 29, 30, 32

Insulin 35, 36

**L**aboratory and pathological services 29

Magnetic Resonance Imagings (MRIs) 15

Mail Order Prescription Drugs 9, 35, 36

Mammograms 16

Maternity Benefits 14, 17, 29, 31

Medicaid 3, 49

Medically necessary 12, 15, 17, 19, 24, 28, 32, 35, 36, 39, 41, 50

Medicare 3, 9, 15, 24, 28, 31, 33, 35, 39, 42, 45, 46, 47, 48, 54

Members 2, 5, 7, 10, 24, 37, 52, 61

Mental Conditions/Substance Abuse Benefits 2, 14, 19, 33, 34, 39

Newborn care 17

Nurse

Licensed Practical Nurse 22

Nurse Anesthetist 29

Registered Nurse 22

Nursery charges 17

**O**bstetrical care 17

Occupational therapy 12, 19

Ocular injury 20

Office visits 7, 13

Oral and maxillofacial surgery 14, 26

Orthopedic devices 14, 20, 21, 22, 24

Ostomy and catheter supplies 22

Out-of-pocket expenses 3, 7, 9, 13, 39, 45, 56, 60

Oxygen 22, 29

**P**ap test 15, 16

Physical therapy 12, 19

Physician 2, 7, 10-15, 22, 24, 28, 31, 35, 36, 39, 42, 43, 44, 60

Point of service (POS) 3, 12, 13, 14, 39, 40, 60

Precertification 12, 17, 24, 28, 39, 44

Preventive care, adult 7, 14, 16

Preventive care, children 7, 14, 16, 20

Prescription drugs 2, 5, 9, 10, 13, 14, 17, 18, 19, 35, 36, 39, 42, 46,
48, 60

Prior approval 2, 12, 44

Prosthetic devices 14, 20, 21, 22, 24, 25

Psychologist 33

**R**adiation therapy 19

Renal dialysis 19, 22, 45

Room and board 28, 50

**S**econd surgical opinion 15

Skilled nursing facility care 11, 14, 15, 27, 29

Speech therapy 12, 14, 20

Splints 22, 29

Sterilization procedures 17, 25

Substance abuse 2, 14, 19, 33, 34, 60

Surgery 5, 6, 14, 17, 19, 20, 21, 22, 24, 25, 26, 28, 39

-   Anesthesia 2, 6, 14, 24, 27, 29,

```{=html}
<!-- -->
```
-   Oral 26

-   Outpatient 14, 29

-   Reconstructive 14, 24, 25

    Syringes 35, 36

    Transplants 12, 14, 19, 26

Treatment therapies 14, 19

**V**ision services 13, 14, 16, 20, 39, 55, 60

Wheelchairs 22

**X**-rays 15, 29

  -----------------------------------------------------------------------
  **Summary of benefits for the *Piedmont Community Health Plan* --
  2004**

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

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

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

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

+----------------------------------+---+-----------------+---+-------------+
| **Benefits**                     | * |                 | * |             |
|                                  | * |                 | * |             |
|                                  | Y |                 | P |             |
|                                  | o |                 | a |             |
|                                  | u |                 | g |             |
|                                  | P |                 | e |             |
|                                  | a |                 | * |             |
|                                  | y |                 | * |             |
|                                  | * |                 |   |             |
|                                  | * |                 |   |             |
+----------------------------------+---+-----------------+---+-------------+
| Medical services provided by     | O |                 | > |             |
| physicians:                      | f |                 |   |             |
|                                  | f |                 | 1 |             |
| -   Diagnostic and treatment     | i |                 | 5 |             |
|     services provided in the     | c |                 |   |             |
|     office                       | e |                 |   |             |
|                                  | v |                 |   |             |
|                                  | i |                 |   |             |
|                                  | s |                 |   |             |
|                                  | i |                 |   |             |
|                                  | t |                 |   |             |
|                                  | c |                 |   |             |
|                                  | o |                 |   |             |
|                                  | p |                 |   |             |
|                                  | a |                 |   |             |
|                                  | y |                 |   |             |
|                                  | : |                 |   |             |
|                                  | \ |                 |   |             |
|                                  | $ |                 |   |             |
|                                  | 2 |                 |   |             |
|                                  | 5 |                 |   |             |
|                                  | p |                 |   |             |
|                                  | e |                 |   |             |
|                                  | r |                 |   |             |
|                                  | o |                 |   |             |
|                                  | f |                 |   |             |
|                                  | f |                 |   |             |
|                                  | i |                 |   |             |
|                                  | c |                 |   |             |
|                                  | e |                 |   |             |
|                                  | v |                 |   |             |
|                                  | i |                 |   |             |
|                                  | s |                 |   |             |
|                                  | i |                 |   |             |
|                                  | t |                 |   |             |
+----------------------------------+---+-----------------+---+-------------+
| Services provided by a hospital: | 2 |                 | > |             |
|                                  | 0 |                 |   |             |
| -   Inpatient                    | % |                 | 2 |             |
|                                  | o |                 | 8 |             |
| -   Outpatient                   | f |                 | > |             |
|                                  | a |                 | > |             |
|                                  | l |                 |   |             |
|                                  | l |                 | 2 |             |
|                                  | o |                 | 9 |             |
|                                  | w |                 |   |             |
|                                  | a |                 |   |             |
|                                  | b |                 |   |             |
|                                  | l |                 |   |             |
|                                  | e |                 |   |             |
|                                  | c |                 |   |             |
|                                  | h |                 |   |             |
|                                  | a |                 |   |             |
|                                  | r |                 |   |             |
|                                  | g |                 |   |             |
|                                  | e |                 |   |             |
|                                  |   |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | 2 |                 |   |             |
|                                  | 0 |                 |   |             |
|                                  | % |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | o |                 |   |             |
|                                  | f |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | a |                 |   |             |
|                                  | l |                 |   |             |
|                                  | l |                 |   |             |
|                                  | o |                 |   |             |
|                                  | w |                 |   |             |
|                                  | a |                 |   |             |
|                                  | b |                 |   |             |
|                                  | l |                 |   |             |
|                                  | e |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | c |                 |   |             |
|                                  | h |                 |   |             |
|                                  | a |                 |   |             |
|                                  | r |                 |   |             |
|                                  | g |                 |   |             |
|                                  | e |                 |   |             |
+----------------------------------+---+-----------------+---+-------------+
| Emergency benefits:              | > |                 | > |             |
|                                  |   |                 |   |             |
| -   In-area                      | \ |                 | 3 |             |
|                                  | $ |                 | 1 |             |
| -   Out-of-area                  | 1 |                 | > |             |
|                                  | 0 |                 | > |             |
|                                  | 0 |                 |   |             |
|                                  | > |                 | 3 |             |
|                                  |   |                 | 1 |             |
|                                  | p |                 |   |             |
|                                  | e |                 |   |             |
|                                  | r |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | v |                 |   |             |
|                                  | i |                 |   |             |
|                                  | s |                 |   |             |
|                                  | i |                 |   |             |
|                                  | t |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | ( |                 |   |             |
|                                  | w |                 |   |             |
|                                  | a |                 |   |             |
|                                  | i |                 |   |             |
|                                  | v |                 |   |             |
|                                  | e |                 |   |             |
|                                  | d |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | i |                 |   |             |
|                                  | f |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | a |                 |   |             |
|                                  | d |                 |   |             |
|                                  | m |                 |   |             |
|                                  | i |                 |   |             |
|                                  | t |                 |   |             |
|                                  | t |                 |   |             |
|                                  | e |                 |   |             |
|                                  | d |                 |   |             |
|                                  | ) |                 |   |             |
|                                  | > |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | \ |                 |   |             |
|                                  | $ |                 |   |             |
|                                  | 1 |                 |   |             |
|                                  | 0 |                 |   |             |
|                                  | 0 |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | p |                 |   |             |
|                                  | e |                 |   |             |
|                                  | r |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | v |                 |   |             |
|                                  | i |                 |   |             |
|                                  | s |                 |   |             |
|                                  | i |                 |   |             |
|                                  | t |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | ( |                 |   |             |
|                                  | w |                 |   |             |
|                                  | a |                 |   |             |
|                                  | i |                 |   |             |
|                                  | v |                 |   |             |
|                                  | e |                 |   |             |
|                                  | d |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | i |                 |   |             |
|                                  | f |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | a |                 |   |             |
|                                  | d |                 |   |             |
|                                  | m |                 |   |             |
|                                  | i |                 |   |             |
|                                  | t |                 |   |             |
|                                  | t |                 |   |             |
|                                  | e |                 |   |             |
|                                  | d |                 |   |             |
|                                  | ) |                 |   |             |
+----------------------------------+---+-----------------+---+-------------+
| > Mental health and substance    | > |                 | > |             |
| > abuse treatment                |   |                 |   |             |
|                                  | R |                 | 3 |             |
|                                  | e |                 | 3 |             |
|                                  | g |                 |   |             |
|                                  | u |                 |   |             |
|                                  | l |                 |   |             |
|                                  | a |                 |   |             |
|                                  | r |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | c |                 |   |             |
|                                  | o |                 |   |             |
|                                  | s |                 |   |             |
|                                  | t |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | s |                 |   |             |
|                                  | h |                 |   |             |
|                                  | a |                 |   |             |
|                                  | r |                 |   |             |
|                                  | i |                 |   |             |
|                                  | n |                 |   |             |
|                                  | g |                 |   |             |
|                                  | . |                 |   |             |
+----------------------------------+---+-----------------+---+-------------+
| Prescription drugs               | > |                 | > |             |
|                                  |   |                 |   |             |
|                                  | [ |                 | 3 |             |
|                                  | 3 |                 | 5 |             |
|                                  | 0 |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | d |                 |   |             |
|                                  | a |                 |   |             |
|                                  | y |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | s |                 |   |             |
|                                  | u |                 |   |             |
|                                  | p |                 |   |             |
|                                  | p |                 |   |             |
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|                                  | \ |                 |   |             |
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|                                  |   |                 |   |             |
|                                  | ] |                 |   |             |
|                                  | { |                 |   |             |
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|                                  | r |                 |   |             |
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|                                  | n |                 |   |             |
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|                                  | } |                 |   |             |
|                                  | \ |                 |   |             |
|                                  | $ |                 |   |             |
|                                  | 1 |                 |   |             |
|                                  | 5 |                 |   |             |
|                                  | . |                 |   |             |
|                                  | 0 |                 |   |             |
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|                                  |   |                 |   |             |
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|                                  | 6 |                 |   |             |
|                                  | 0 |                 |   |             |
|                                  | . |                 |   |             |
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|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | b |                 |   |             |
|                                  | r |                 |   |             |
|                                  | a |                 |   |             |
|                                  | n |                 |   |             |
|                                  | d |                 |   |             |
|                                  | > |                 |   |             |
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|                                  | n |                 |   |             |
|                                  | a |                 |   |             |
|                                  | m |                 |   |             |
|                                  | e |                 |   |             |
+----------------------------------+---+-----------------+---+-------------+
| Dental Care                      | > |                 | > |             |
|                                  |   |                 |   |             |
|                                  | N |                 | 3 |             |
|                                  | o |                 | 8 |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | b |                 |   |             |
|                                  | e |                 |   |             |
|                                  | n |                 |   |             |
|                                  | e |                 |   |             |
|                                  | f |                 |   |             |
|                                  | i |                 |   |             |
|                                  | t |                 |   |             |
|                                  | . |                 |   |             |
+----------------------------------+---+-----------------+---+-------------+
| Vision Care                      | > |                 | > |             |
|                                  |   |                 |   |             |
|                                  | \ |                 | 2 |             |
|                                  | $ |                 | 0 |             |
|                                  | 2 |                 |   |             |
|                                  | 5 |                 |   |             |
|                                  | > |                 |   |             |
|                                  |   |                 |   |             |
|                                  | p |                 |   |             |
|                                  | e |                 |   |             |
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|                                  | t |                 |   |             |
+----------------------------------+---+-----------------+---+-------------+
| > Special features: Flexible     |   |                 | > |             |
| > benefits option, Local Service |   |                 |   |             |
| > and Assistance, and Eyewear    |   |                 | 3 |             |
| > Discounts                      |   |                 | 7 |             |
+----------------------------------+---+-----------------+---+-------------+
| Protection against catastrophic  | N |                 | > |             |
| costs                            | o |                 |   |             |
|                                  | t |                 | 1 |             |
| (your out-of-pocket maximum)     | h |                 | 3 |             |
|                                  | i |                 |   |             |
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|                                  | a |                 |   |             |
|                                  | r |                 |   |             |
|                                  | d |                 |   |             |
|                                  | t |                 |   |             |
|                                  | h |                 |   |             |
|                                  | i |                 |   |             |
|                                  | s |                 |   |             |
|                                  | p |                 |   |             |
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|                                  | o |                 |   |             |
|                                  | t |                 |   |             |
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|                                  | c |                 |   |             |
|                                  | t |                 |   |             |
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|                                  | o |                 |   |             |
|                                  | n |                 |   |             |
|                                  | ) |                 |   |             |
+----------------------------------+---+-----------------+---+-------------+
| > Point of Service benefits \--  |   |                 | > |             |
|                                  |   |                 |   |             |
|                                  |   |                 | 3 |             |
|                                  |   |                 | 9 |             |
+----------------------------------+---+-----------------+---+-------------+
| > Protection against             |   | > 100% of       | > |             |
| > catastrophic costs             |   | > allowable     |   |             |
| >                                |   | > amount after  | 3 |             |
| > (your point-of-service out of  |   | > \$6,000/Self  | 9 |             |
| > pocket                         |   | > Only or       |   |             |
| > max                            |   | >               |   |             |
| imum)........................... |   | \$12,000/Family |   |             |
|                                  |   | > enrollment    |   |             |
|                                  |   | > per year      |   |             |
|                                  |   | > (Some costs   |   |             |
|                                  |   | > do not count  |   |             |
|                                  |   | > toward this   |   |             |
|                                  |   | > protection)   |   |             |
+----------------------------------+---+-----------------+---+-------------+

**2004 Rate Information for**

**PIEDMONT COMMUNITY HEALTHCARE (VIRGINIA)**

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

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

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

+------------+--------+-------------------------+---------------------+
| # Type of  | # Code | ##                      | ##                  |
|            |        |  **Non-Postal Premium** | **Postal Premium**  |
| **En       |        |                         |                     |
| rollment** |        | *                       | **[Biwe             |
|            |        | *[Biweekly]{.underline} | ekly]{.underline}** |
|            |        | [Monthly]{.underline}** |                     |
|            |        |                         | #  USPS Your        |
|            |        | **Gov\'t Your Gov\'t    |                     |
|            |        | Your**                  | **Share Share**     |
|            |        |                         |                     |
|            |        | #####                   |                     |
|            |        | Share Share Share Share |                     |
+------------+--------+-------------------------+---------------------+

+------------+--------+-------------------------+---------------------+
| **Self     | *      | **\$121.40 \$40.75      | **\$143.32          |
| Only**     | *2C1** | \$263.03 \$ 88.30**     | \$18.83**           |
|            |        |                         |                     |
| **Self &   | *      | **\$277.09 \$94.21      | **\$327.12 \$       |
| Family**   | *2C2** | \$600.36 \$204.12**     | 44.18**             |
+------------+--------+-------------------------+---------------------+

####