**- Preferred Plus of Kansas**

[http://www.](http://www.planAddress.org/)[phsystems.com]{.underline}

**2004**

**A Health Maintenance Organization**

![](media/image2.png){width="1.5in" height="1.4874015748031495in"}

**Serving:** *Marion, Harvey, Kingman, Sedgwick, Butler, Sumner,
Cowley,*

*and Chautauqua Counties, in Kansas*

**Enrollment in this Plan is limited; see page** **7 for requirements.**

![](media/image3.png){width="2.0in" height="0.8993055555555556in"}

***This plan has [3 years]{.underline} accreditation from***

***[JCAHO]{.underline}***

**Enrollment codes for this Plan:**

**VA1 Self Only**

**VA2 Self and Family**

RI 73-604

RI 73-604

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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/image7.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 United States Office of Personnel Management (OPM), which
administers the Federal Employees Health Benefits (FEHB) Program, is
required to protect the privacy of your personal medical information.
OPM is also required to give you this notice to tell you how OPM may use
and give out ("disclose") your personal medical information held by OPM.

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

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 5

Preventing medical mistakes .6

Section 1. Facts about this HMO plan 7

How we pay providers 7

Who provides my health care? 7

Your Rights 7

Service Area 7

Section 2. How we change for 2004 8

Program-wide changes .8

Changes to this Plan 78

Section 3. How you ge are 9

Identification cards 9

Where you get covered care 9

Plan providers 9

Plan facilities 9

What you must do to get covered care 9

Primary care 9

Specialty care 9

Hospital care 10

Circumstances beyond our control 10

Services requiring our prior approval 11

Section 4. Your costs for covered services 12

Copayments 12

> Deductible 12

Coinsurance 12

Your Catastrophic protection out-of-pocket maximum 12

Section 5. Benefits 13

Overview 13

(a) Medical services and supplies provided by physicians and other
    health care professionals 14

(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 30

(e) Mental health and substance abuse benefits 32

(f) Prescription drug benefits 34

(g) Special features 37

-   Flexible benefit option

-   High risk pregnancies

-   Centers of excellence

(h) Dental benefits 38

Section 6. General exclusions \-- things we don\'t cover 39

Section 7. Filing a claim for covered services 40

Section 8. The disputed claims process 41

Section 9. Coordinating benefits with other coverage 43

When you have other health coverage 43

> What is Medicare 43

-   Primary payer chart 45

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-   Medicare + Choice plan 46

-   TRICARE and CHAMPVA .46

-   Workers\' Compensation 46

-   Medicaid 47

Other Government agencies 47

When others are responsible for injuries 47

Section 10. Definitions of terms we use in this brochure 48

Section 11. FEHB facts 49

Coverage information 49

No pre-existing condition limitation 49

Where you can get information about enrolling in the FEHB Program 49

Types of coverage available for you and your family 49

Children's Equity Act 50

When benefits and premiums start 50

When you retire 50

When you lose benefits 50

When FEHB coverage ends 50

Spouse equity coverage 51

Temporary Continuation of Coverage (TCC) 51

Converting to individual coverage 51

Getting a Certificate of Group Health Plan Coverage 51

Two new Federal Programs complement FEHB benefits 53

The Federal Flexible Spending Account Program -- *FSAFEDS* 53

The Federal Long Term Care 56

Index 57

Summary of benefits 58

Rates Back cover

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  Introduction

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This brochure describes the benefits of Preferred Plus of Kansas, under
our contract (CS 2667) with the Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. The address for
Preferred Plus of Kansas*'* administrative offices is:

Preferred Plus of Kansas

8535 E. 21^st^ North

Wichita, KS 67206

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 for 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 are summarized on page 6.
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
    Preferred Plus of Kansas*.*

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

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

If you have comments or suggestions about how to improve the structure
of this brochure, let us know. Visit OPM\'s \"Rate Us\" feedback area at
[www.opm.gov/insure](http://www.opm.gov/reitre) or e-mail us at
<fehbwebcomments@opm.gov>. You may also write to OPM at the Office of
Personnel Management, 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 employees 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.

-   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.

-   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 your 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 (316)
    609-2390 or 1-800- 660-8114 and explain the situation.

-   If we do not resolve the issue:

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

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

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

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

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

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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.**

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.

**Who provides my health care?**

Preferred Plus of Kansas is an individual practice prepayment (IPP)
model HMO. As a member of Preferred Plus of Kansas, you will select a
primary care doctor for yourself and each member of your family. Each
member may designate his or her own primary care doctor. You will be
able to choose from a list of doctors located throughout the service
area. Preferred Plus of Kansas has more than 300 primary care doctors in
its Kansas service area and more than 1,100 referral specialists.

**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.

-   Preferred Plus of Kansas is licensed under the laws of Kansas, as a
    Health Maintenance Organization.

-   Preferred Plus of Kansas was incorporated in 1991.

-   Preferred Plus of Kansas is a for-profit company.

If you want more information about us, call (316) 609-2390 or (800)
990-0345, or write to Preferred Health Systems, 8535 E. 21^st^ North,
Wichita, KS 67206. You may also contact us by fax at (316) 609-2483, or
visit our website at www.phsystems.com.

**Service Area**

To enroll in this plan, you must live or work in our Service Area. This
is where our providers practice. Our service area is the following
counties in Kansas*:* Marion, Harvey, Kingman, Sedgwick, Butler, Sumner,
Cowley, Chautauqua, and Greenwood.

You may also enroll with us if you live or work in the following places:

The Kansas counties of Saline, Dickenson, Morris, McPherson, Chase,
Reno, Harper, and Elk.

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

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

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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**

-   
-   
-   
-   

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-   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

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

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-   We added information regarding enrolling in Medicare. See page 43

-   We revised the Medicare Primary Payer Chart. See page 45.

**Changes to this Plan**

-   Your share of the non-Postal premium will increase by 146.5% for
    Self Only or 106.6% for Self and Family.

-   We added coverage for physician's office visits and laboratory
    services in conjunction with those office visits for medically
    necessary weight loss programs that are approved by the Plan.
    (Section 5(a) ) See page 23

-   We added coverage for certain care to covered children who are
    out-of-area. (Section 5(a) ) See page 23

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

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
(316) 609-2390 or write to us at Preferred Health Systems, 8535 E.
21^st^ Street, Wichita, Kansas 67206.

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

**Plan providers** Plan providers are physicians and other health care
professionals in our service area that we contract with to provide
covered services to our members. We credential Plan providers according
to national standards.

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.

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. A list of primary care providers can be reviewed in our
provider directory for Preferred Plus of Kansas. You must complete a
physician selection form or you may call our Customer Services
Department at (316) 609-2390, or (800) 660-8114.

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

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

**Specialty care** Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your
primary care physician, you must return to the primary care physician
after the consultation, unless your primary care physician authorized a
certain number of visits without additional referrals. The primary care
physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives
you a referral. However, you may see a contracting OB/Gyn for an annual
well-woman exam once a year or a contracting eye care provider for an
annual diabetic retinal eye examination without a referral, however, any
follow-up care as a result of this visit does require primary care
physician authorization.

Here are other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician will
develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals. Your primary care
physician will use our criteria when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist,
ask if you can see your current specialist. If your current specialist
does not participate with us, you must receive treatment from a
specialist who does. Generally, we will not pay for you to see a
specialist who does not participate with our Plan.

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

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

-   terminate our contract with your specialist for other than cause; or

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-   drop out of the Federal Employees Health Benefits (FEHB) Program and
    you enroll in another FEHB Plan; or

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-   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 (316) 609-2390 or (800)
660-8114. If you are new to the FEHB Program, we will arrange for you to
receive care.

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

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

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

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

    These provisions apply only to the benefits of the hospitalized
    person. If your plan terminates participation in the FEHB Program in
    whole or in part, or if OPM orders an enrollment change, this
    continuation of coverage provision does not apply. In such case, the
    hospitalized family member's benefits under the new plan begin on
    the effective date of enrollment.

**Circumstances 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, pre-certification. Your
physician must obtain pre-certification for the following services:

-   cardiac catheterization;

-   durable medical equipment;

-   home IV services;

-   hospice;

-   inpatient hospitalizations;

-   

-   OB care & delivery;

-   outpatient IV services/injectables;

-   out of the service area referrals;

-   outpatient surgical procedures;

-   pain management programs;

-   prosthetics;

-   request for use of non-contracting provider;

```{=html}
<!-- -->
```
-   Weight loss program

> It is the responsibility of the provider to receive precertification
> from us for the primary care physician authorized services. If the
> provider fails to pre-certify the services, he/she will be held
> responsible for the services. If you choose to seek any services
> without coordinating them with your primary care physician, you will
> be responsible for the costs of the services.

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

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

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

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

Example: When you see your primary care physician you pay a copayment of
\$10 per office visit and when you go in the hospital you pay \$50 per
day.

**Deductible** We do not have a deductible

**Coinsurance** We do not have coinsurance

**Your catastrophic protection**

**out-of-pocket maximum** We do not have an out of pocket maximum

+-----------------------------------------------------------------------+
| **Section 5. Benefits -- OVERVIEW**                                   |
|                                                                       |
| ***(See page*** ***8 for how our benefits changed this year and page  |
| 57 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 (316) 609-2390 or (800) 660-8114 or at our website at
www.phsystems.com*.*

(a) Medical services and supplies provided by physicians and other
    health care professionals 14-23

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

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

+---------------------------------+------------------------------------+
| Surgical procedures             | Oral and maxillofacial surgery     |
|                                 |                                    |
| Reconstructive surgery          | Temporal Mandibular Joint (TMJ)    |
|                                 | Syndrome                           |
|                                 |                                    |
|                                 | Organ/tissue transplants           |
|                                 |                                    |
|                                 | Anesthesia                         |
+---------------------------------+------------------------------------+

(c) Services provided by a hospital or other facility, and ambulance
    services 28-29

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

(d) Emergency services/accidents 30-31

> Medical emergency Ambulance

(e) Mental health and substance abuse benefits 32-33

(f) Prescription drug benefits 34-36

(g) Special features 37

(h) Dental benefits 38

Summary of
benefits.................................................................................................................58

+---+---+-------------------------------------+----------------+---+----+
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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 |    |
|   | * | -   We have no calendar year        |                | * |    |
|   | * |     deductible.                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * | ```{=html}                          |                | * |    |
|   | * | <!-- -->                            |                | * |    |
|   | O | ```                                 |                | O |    |
|   | * | -   Be sure to read Section 4,      |                | * |    |
|   | * |     *Your costs for covered*        |                | * |    |
|   |   |     *services,* for valuable        |                |   |    |
|   | * |     information about how cost      |                | * |    |
|   | * |     sharing works. Also read        |                | * |    |
|   | R |     Section 9 about coordinating    |                | R |    |
|   | * |     benefits with other coverage,   |                | * |    |
|   | * |     including with Medicare.        |                | * |    |
|   |   |                                     |                |   |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | T |                                     |                | T |    |
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|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | **You pay**    |   |    |
|   |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| # |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$10 per     |   |    |
|   |   |                                     | > office visit |   |    |
| P |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$10 per     |   |    |
|   |   |                                     | > office visit |   |    |
| P |   |                                     |                |   |    |
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| > |   |                                     | > Nothing if   |   |    |
|   |   |                                     | > you receive  |   |    |
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| t |   |                                     | > office       |   |    |
| s |   |                                     | > visit;       |   |    |
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|   |   |                                     | > visit.       |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| # |   |                                     | > **You Pay**  |   |    |
| # |   |                                     |                |   |    |
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| l |   |                                     |                |   |    |
| t |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$10 per     |   |    |
|   |   |                                     | > office visit |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$10 per     |   |    |
|   |   |                                     | > office visit |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$10 per     |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$10 per     |   |    |
|   |   |                                     | > office visit |   |    |
| R |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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+---+---+-------------------------------------+----------------+---+----+
| - |   |                                     | 50% of the     |   |    |
|   |   |                                     | charges up to  |   |    |
|   |   |                                     | a maximum Plan |   |    |
|   |   |                                     | benefit of     |   |    |
| W |   |                                     | \$30. You must |   |    |
| e |   |                                     | submit proof   |   |    |
|   |   |                                     | of payment and |   |    |
|   |   |                                     | class          |   |    |
|   |   |                                     | completion to  |   |    |
|   |   |                                     | our Member     |   |    |
| c |   |                                     | Services       |   |    |
| o |   |                                     | Department.    |   |    |
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|   |   |                                     | > office visit |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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| # |   |                                     | **You pay**    |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| x |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| r |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| p |   |                                     |                |   |    |
| r |   |                                     |                |   |    |
| o |   |                                     |                |   |    |
| g |   |                                     |                |   |    |
| r |   |                                     |                |   |    |
| a |   |                                     |                |   |    |
| m |   |                                     |                |   |    |
| s |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+

+---------------------------------------------+------------------------+
| > **Speech therapy**                        |                        |
+---------------------------------------------+------------------------+
| -   Coverage for speech therapy will be     | \$10 per visit         |
|     provided up to a maximum of \$1,500 per |                        |
|     member, per calendar year.              |                        |
+---------------------------------------------+------------------------+
| > **Hearing services (testing, treatment,   |                        |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| -   First hearing aid and testing only when | > \$10 per office      |
|     necessitated by accidental injury       | > visit                |
|                                             |                        |
| -   Hearing testing for children through    |                        |
|     age 17 (see *Preventive care,           |                        |
|     children*)                              |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *all other hearing testing*             |                        |
|                                             |                        |
| -   *hearing aids, testing and examinations |                        |
|     for them*                               |                        |
+---------------------------------------------+------------------------+
| > **Vision services (testing, treatment,    |                        |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| -   Lenses and Frames immediately following | > All charges above    |
|     cataract surgery or cornea transplant   | > \$150                |
|     surgery will be paid up to a maximum    |                        |
|     benefit of \$150.                       |                        |
+---------------------------------------------+------------------------+
| -   Eye exam to determine the need for      | > \$10 per office      |
|     vision correction for children through  | > visit                |
|     age 17 (see preventive care)            | >                      |
|                                             | > \$10 per office      |
| -   Members may self-refer to a Contracting | > visit                |
|     Provider for an annual diabetic retinal |                        |
|     eye examination.                        |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Eyeglasses or contact lenses. Eye      |                        |
|     examinations for persons over age 17*   |                        |
|                                             |                        |
| -   *Eye exercises and orthoptics*          |                        |
|                                             |                        |
| -   *Radial keratotomy and other refractive |                        |
|     surgery*                                |                        |
+---------------------------------------------+------------------------+
| ######## Foot care                          |                        |
+---------------------------------------------+------------------------+
| > Routine foot care when you are under      | > \$10 per office      |
| > active treatment for a metabolic or       | > visit                |
| > peripheral vascular disease, such as      |                        |
| > diabetes.                                 |                        |
| >                                           |                        |
| > See orthopedic and prosthetic devices for |                        |
| > information on podiatric shoe inserts.    |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Cutting, trimming or removal of corns, |                        |
|     calluses, or the free edge of toenails, |                        |
|     and similar routine treatment of        |                        |
|     conditions of the foot, except as       |                        |
|     stated above*                           |                        |
|                                             |                        |
| -   *Treatment of weak, strained or flat    |                        |
|     feet or bunions or spurs; and of any    |                        |
|     instability, imbalance or subluxation   |                        |
|     of the foot (unless the treatment is by |                        |
|     open cutting surgery)*                  |                        |
|                                             |                        |
| -                                           |                        |
|                                             |                        |
| -                                           |                        |
+---------------------------------------------+------------------------+
| > **Orthopedic and prosthetic devices**     | ###### You pay         |
+---------------------------------------------+------------------------+
| -   Artificial limbs and eyes; stump hose   | > Nothing              |
|                                             |                        |
| -   Externally worn breast prostheses and   |                        |
|     surgical bras, including necessary      |                        |
|     replacements, following a mastectomy    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Internal prosthetic devices, such as    |                        |
|     artificial joints, pacemakers, cochlear |                        |
|     implants, and surgically implanted      |                        |
|     breast implant following mastectomy.    |                        |
|     Note: We pay internal prosthetic        |                        |
|     devices as hospital benefits; see       |                        |
|     Section 5 (c) for payment information.  |                        |
|     See 5(b) for coverage of the surgery to |                        |
|     insert the device.                      |                        |
|                                             |                        |
| -   Orthopedic braces                       |                        |
|                                             |                        |
| -   Shoes which are a part of a brace and   |                        |
|     custom fabricated shoe inserts          |                        |
|                                             |                        |
| -   One pair of orthopedic shoes per        |                        |
|     diabetic member, per calendar year, for |                        |
|     members who have documented peripheral  |                        |
|     vascular disease and/or a peripheral    |                        |
|     neuropathy                              |                        |
|                                             |                        |
| > Note: We will cover one standard          |                        |
| > appliance device per lifetime, unless     |                        |
| > repair/replacement is medically necessary |                        |
| > as a result of normal usage or changes in |                        |
| > condition.                                |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *arch supports*                         |                        |
|                                             |                        |
| -   *foot orthotics*                        |                        |
|                                             |                        |
| -   *heel pads and heel cups*               |                        |
|                                             |                        |
| -   *lumbosacral supports*                  |                        |
|                                             |                        |
| -   *corsets, trusses, elastic stockings,   |                        |
|     support hose, and other supportive      |                        |
|     devices*                                |                        |
+---------------------------------------------+------------------------+
| > **Medical supplies**                      |                        |
+---------------------------------------------+------------------------+
| > Two pair compression stockings per        | > Nothing              |
| > member, per calendar year                 |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *over-the-counter bandages, gauze, and  |                        |
|     skin preparations*                      |                        |
+---------------------------------------------+------------------------+
| ######## Durable medical equipment (DME)    | ###### You pay         |
+---------------------------------------------+------------------------+
| > Rental or purchase, at our option,        | > All charges over the |
| > including repair and adjustment, of       | > \$1,000 yearly       |
| > durable medical equipment prescribed by   | > benefit maximum.     |
| > your Plan physician, such as oxygen and   |                        |
| > dialysis equipment. Under this benefit,   |                        |
| > we also cover:                            |                        |
|                                             |                        |
| -   hospital beds;                          |                        |
|                                             |                        |
| -   wheelchairs;                            |                        |
|                                             |                        |
| -   crutches;                               |                        |
|                                             |                        |
| -   walkers;                                |                        |
|                                             |                        |
| -   blood pressure monitors;                |                        |
|                                             |                        |
| -   blood glucose monitors; and             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   insulin pumps                           |                        |
|                                             |                        |
| -   enteral nutrition (tube feeding)        |                        |
|     covered under the following conditions  |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   The medical record indicates the        |                        |
|     Member's medical condition has existed  |                        |
|     longer than three months; and           |                        |
|                                             |                        |
| -   The members mdeical condition prevents  |                        |
|     food from reaching the intestines or    |                        |
|     prevents absorption of food in the      |                        |
|     intestines; and                         |                        |
|                                             |                        |
| -   The condition requires tube feedings to |                        |
|     provide sufficient nutrients to         |                        |
|     maintain weight and strength. Adequate  |                        |
|     nutrients must not be possible by       |                        |
|     dietary adjustment and/or oral          |                        |
|     supplements                             |                        |
|                                             |                        |
| > Limitations                               |                        |
|                                             |                        |
| -   Enteral pumps and supplies will be      |                        |
|     covered only when the above criteria    |                        |
|     are met                                 |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Motorized wheel chairs*                |                        |
|                                             |                        |
| -   *Enteral Products that can be           |                        |
|     administered orally*                    |                        |
|                                             |                        |
| -   *Products that can be purchased         |                        |
|     over-the-counter including, but not     |                        |
|     limited to, formula, Ensure, and        |                        |
|     Pedisure*                               |                        |
+---------------------------------------------+------------------------+
| ######## Disposable Medical Supplies        | **You pay**            |
+---------------------------------------------+------------------------+
| > Members may be reimbursed up to \$500 per | All charges above      |
| > person per calendar year with proof of    | \$500 per person per   |
| > purchase for specific disposable supplies | calendar year          |
| > when prescribed by the primary care       |                        |
| > physician. Covered disposable supplies    |                        |
| > are limited to supplies relating to the   |                        |
| > care of:                                  |                        |
|                                             |                        |
| -   An ostomy (appliance pouches, skin care |                        |
|     agents, support belts                   |                        |
|                                             |                        |
| -   An open wound (gauze pads, wound        |                        |
|     packing strips, ABD pads);              |                        |
|                                             |                        |
| -   A venous access catheter (alcohol pads, |                        |
|     benzoin, OP site);                      |                        |
|                                             |                        |
| -   Supplies used in conjunction with       |                        |
|     covered Durable Medical Equipment;      |                        |
|                                             |                        |
| -   Urinary supplies limited to catheters,  |                        |
|     bags and related supplies; and          |                        |
|                                             |                        |
| -   Tracheostomy supplies.                  |                        |
|                                             |                        |
| -   Inhaler supplies, (aero chamber masks,  |                        |
|     spacers, and peak flow meters)          |                        |
+---------------------------------------------+------------------------+
| ######## Home health services               | **You pay**            |
+---------------------------------------------+------------------------+
| -   Home health care ordered by a Plan      | > Nothing              |
|     physician and provided by a registered  |                        |
|     nurse (R.N.), licensed practical nurse  |                        |
|     (L.P.N.), licensed vocational nurse     |                        |
|     (L.V.N.), or home health aide.          |                        |
|                                             |                        |
| -   Services include oxygen therapy,        |                        |
|     intravenous therapy and                 |                        |
|                                             |                        |
| -   Covered drugs and medications approved  |                        |
|     by the FDA, which have a National Drug  |                        |
|     Code and provided by a home health      |                        |
|     professional, and not covered under a   |                        |
|     drug plan.                              |                        |
+---------------------------------------------+------------------------+
| > Not covered:                              | > *All charges.*       |
|                                             |                        |
| -   *nursing care requested by, or for the  |                        |
|     convenience of, the patient or the      |                        |
|     patient's family;*                      |                        |
|                                             |                        |
| -   *home care primarily for personal       |                        |
|     assistance that does not include a      |                        |
|     medical component and is not            |                        |
|     diagnostic, therapeutic, or             |                        |
|     rehabilitative.*                        |                        |
+---------------------------------------------+------------------------+
| ######## Chiropractic                       | **You pay**            |
+---------------------------------------------+------------------------+
| -   Manipulation of the spine and           | > \$10 per office      |
|     extremities                             | > visit                |
|                                             |                        |
| -   Adjunctive procedures such as           |                        |
|     ultrasound, electrical muscle           |                        |
|     stimulation, vibratory therapy, and     |                        |
|     cold pack application                   |                        |
|                                             |                        |
| > Note: These services require primary care |                        |
| > physician authorization.                  |                        |
+---------------------------------------------+------------------------+
| #### **Alternative treatments**             |                        |
+---------------------------------------------+------------------------+
| #### *Not co                                | *All Charges*          |
| vered: any alternative treatment not shown  |                        |
| as covered, including, but not limited to:* |                        |
|                                             |                        |
| -   *Naturopathic services*                 |                        |
|                                             |                        |
| -   *Hypnotherapy*                          |                        |
|                                             |                        |
| -   *Biofeedback*                           |                        |
|                                             |                        |
| -   *music therapy*                         |                        |
|                                             |                        |
| -   *guided imagery*                        |                        |
|                                             |                        |
| -   *therapeutic touch*                     |                        |
|                                             |                        |
| -   *aroma therapy*                         |                        |
|                                             |                        |
| -   *acupressure*                           |                        |
|                                             |                        |
| -   *reflexology*                           |                        |
|                                             |                        |
| -   *cranio-sacral* *therapy*               |                        |
|                                             |                        |
| -   *acupuncture*                           |                        |
+---------------------------------------------+------------------------+
| #### **Educational classes and programs**   |                        |
+---------------------------------------------+------------------------+
| > Coverage is limited to:                   | > Nothing              |
|                                             |                        |
| -   Smoking cessation when prescribed as    |                        |
|     part of a mental health treatment plan  |                        |
|                                             |                        |
| -   Diabetes self-management                |                        |
|                                             |                        |
| > Outpatient self management training, and  |                        |
| > education for diabetics is covered if     |                        |
| > treated in an approved program, and such  |                        |
| > treatment is rendered by a person         |                        |
| > certified by the National Certification   |                        |
| > Board of Diabetic Educators.              |                        |
+---------------------------------------------+------------------------+
| > **Weight Loss Services**                  |                        |
+---------------------------------------------+------------------------+
| > We provide benefits for the following     | > \$10                 |
| > services for medically necessary weight   | >                      |
| > loss programs that are approved by the    | > *All Charges*        |
| > Plan.                                     |                        |
|                                             |                        |
| -   Physicians office visits                |                        |
|                                             |                        |
| -   Laboratory services in conjunction with |                        |
|     physician's office visits               |                        |
|                                             |                        |
| > *Not covered*                             |                        |
|                                             |                        |
| -   *Behavioral* *modification classes;*    |                        |
|                                             |                        |
| -   *Nutritional supplements*               |                        |
|                                             |                        |
| -   *All medical services rendered in       |                        |
|     conjunction with prescription drug      |                        |
|     therapy for weight control. Such        |                        |
|     services include prescriptions,         |                        |
|     hospitalizations, laboratory and x-ray  |                        |
|     services, and Physician (including PCP) |                        |
|     office visits*                          |                        |
|                                             |                        |
| -   *Surgical treatment and all services    |                        |
|     related to such treatment of obesity    |                        |
|     and weight reduction, unless the member |                        |
|     weighs 100 pounds or 100% over his or   |                        |
|     her normal weight according to the      |                        |
|     current underwriting standards and is   |                        |
|     over the age of 18; and*                |                        |
|                                             |                        |
| -   *Membership costs or fees with health   |                        |
|     clubs, exercise programs, weight loss   |                        |
|     programs (unless otherwise specified in |                        |
|     the brochure)*                          |                        |
+---------------------------------------------+------------------------+
| > **Care for Dependent Children Out of      |                        |
| > Area**                                    |                        |
+---------------------------------------------+------------------------+
| > For covered dependent children who live   | > \$10                 |
| > outside of the service area, coverage     |                        |
| > will be limited to:                       |                        |
|                                             |                        |
| -   Physician office visits (including      |                        |
|     medically necessary lab and x-ray       |                        |
|     services);                              |                        |
|                                             |                        |
| -   Allergy shots;                          |                        |
|                                             |                        |
| -   Allergy treatment; and                  |                        |
|                                             |                        |
| -   Physical therapy                        |                        |
|                                             |                        |
| > *Note: Above services must be received    |                        |
| > from contracting providers and referred   |                        |
| > by the Dependent's PCP and authorized by  |                        |
| > the Health Plan*                          |                        |
+---------------------------------------------+------------------------+

+---+---+-------------------------------------+----------------+---+---+
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| 5 |   |                                     |                |   |   |
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| b |   |                                     |                |   |   |
| ) |   |                                     |                |   |   |
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| r |   |                                     |                |   |   |
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| n |   |                                     |                |   |   |
| d |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| h |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| h |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| l |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| h |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| f |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| l |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
|   | * | > **Here are some important things  |                | * |   |
|   | * | > 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 |   |
|   | * | -   We have no calendar year        |                | * |   |
|   | * |     deductible.                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Be sure to read Section 4,      |                | * |   |
|   | * |     *Your costs for covered         |                | * |   |
|   | O |     services* for valuable          |                | O |   |
|   | * |     information about how cost      |                | * |   |
|   | * |     sharing works. Also read        |                | * |   |
|   |   |     Section 9 about coordinating    |                |   |   |
|   | * |     benefits with other coverage,   |                | * |   |
|   | * |     including with Medicare.        |                | * |   |
|   | R |                                     |                | R |   |
|   | * | -   The amounts listed below are    |                | * |   |
|   | * |     for the charges billed by a     |                | * |   |
|   |   |     physician or other health care  |                |   |   |
|   | * |     professional for your surgical  |                | * |   |
|   | * |     care. Look in Section 5(c) for  |                | * |   |
|   | T |     charges associated with the     |                | T |   |
|   | * |     facility (i.e. hospital,        |                | * |   |
|   | * |     surgical center, etc.).         |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   YOUR PHYSICIAN MUST GET         |                | * |   |
|   | * |     PRECERTIFICATION OF SOME        |                | * |   |
|   | A |     SURGICAL PROCEDURES. Please     |                | A |   |
|   | * |     refer to the pre-certification  |                | * |   |
|   | * |     information shown in Section 3  |                | * |   |
|   |   |     to be sure which services       |                |   |   |
|   | * |     require pre-certification and   |                | * |   |
|   | * |     identify which surgeries        |                | * |   |
|   | N |     require pre-certification.      |                | N |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | T |                                     |                | T |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | **You pay**    |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| B |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| f |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| D |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
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+---+---+-------------------------------------+----------------+---+---+
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+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | > \$10 per     |   |   |
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| r |   |                                     |                |   |   |
| . |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| - |   |                                     | > \$10 per     |   |   |
|   |   |                                     | > office visit |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| V |   |                                     |                |   |   |
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| n |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
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| r |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
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| n |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
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| f |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
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| h |   |                                     |                |   |   |
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| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
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| r |   |                                     |                |   |   |
| . |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+

*Surgical procedures-*Continued on next page*.*

+---------------------------------------------+------------------------+
| > **Surgical procedures** *(Continued)*     | > **You pay**          |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Reversal of voluntary sterilization*   |                        |
|                                             |                        |
| -   *Routine treatment of conditions of the |                        |
|     foot; see Foot care.*                   |                        |
+---------------------------------------------+------------------------+
| > **Reconstructive surgery**                |                        |
+---------------------------------------------+------------------------+
| -   Surgery to correct a functional defect  | > \$10 per office      |
|                                             | > visit                |
| -   Surgery to correct a condition caused   |                        |
|     by injury or illness if:                |                        |
|                                             |                        |
| > the condition produced a major effect on  |                        |
| > the member's appearance and               |                        |
| >                                           |                        |
| > the condition can reasonably be expected  |                        |
| > to be corrected by such surgery           |                        |
|                                             |                        |
| -   Surgery to correct a condition that     |                        |
|     existed at or from birth and is a       |                        |
|     significant deviation from the common   |                        |
|     form or norm. Examples of congenital    |                        |
|     anomalies are: protruding ear           |                        |
|     deformities; cleft lip; cleft palate;   |                        |
|     birth marks; webbed fingers; and webbed |                        |
|     toes.                                   |                        |
+---------------------------------------------+------------------------+
| -   All stages of breast reconstruction     | > See above.           |
|     surgery following a mastectomy, such    |                        |
|     as:                                     |                        |
|                                             |                        |
| > surgery to produce a symmetrical          |                        |
| > appearance on the other breast;           |                        |
| >                                           |                        |
| > treatment of any physical complications,  |                        |
| > such as lymphedemas;                      |                        |
| >                                           |                        |
| > breast prostheses and surgical bras and   |                        |
| > replacements (see Prosthetic devices)     |                        |
| >                                           |                        |
| > Note: If you need a mastectomy, you may   |                        |
| > choose to have the procedure performed on |                        |
| > an inpatient basis and remain in the      |                        |
| > hospital up to 48 hours after the         |                        |
| > procedure.                                |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -                                           |                        |
|                                             |                        |
| -   *Cosmetic surgery -- any surgical       |                        |
|     procedure (or any portion of a          |                        |
|     procedure) performed primarily to       |                        |
|     improve physical appearance through     |                        |
|     change in bodily form, except repair of |                        |
|     accidental injury*                      |                        |
|                                             |                        |
| > *Surgeries related to sex transformation* |                        |
+---------------------------------------------+------------------------+
| > **Oral and maxillofacial surgery**        |                        |
+---------------------------------------------+------------------------+
| > Oral surgical procedures, limited to:     | > \$10 per visit       |
|                                             |                        |
| -   *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:*                            |                        |
|                                             |                        |
| -   *Oral implants and transplants*         |                        |
|                                             |                        |
| -   *Procedures that involve the teeth or   |                        |
|     their supporting structures (such as    |                        |
|     the periodontal membrane,* *gingival,   |                        |
|     and alveolar bone)*                     |                        |
|                                             |                        |
| -   *Services performed by a dentist unless |                        |
|     specified in section 5g*                |                        |
+---------------------------------------------+------------------------+
| > **Temporal Mandibular Joint** **Syndrome  | > **You Pay**          |
| > (TMJ)**                                   |                        |
+---------------------------------------------+------------------------+
| > Coverage for TMJ is provided for          | > \$10 per office      |
| > examinations, diagnostic x-rays and       | > visit                |
| > testing to diagnose the condition. If the |                        |
| > diagnosis is organic in nature (fracture, |                        |
| > tumor, arthritis) then treatment of the   |                        |
| > condition will be covered including       |                        |
| > appliances; as the condition is           |                        |
| > non-dental in origin.                     |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All Charges*        |
| >                                           |                        |
| > *Non-organic conditions*                  |                        |
+---------------------------------------------+------------------------+
| > **Organ/tissue transplants**              |                        |
+---------------------------------------------+------------------------+
| > Limited to:                               | > \$10 per office      |
|                                             | > visit                |
| -   Cornea                                  |                        |
|                                             |                        |
| -   Heart                                   |                        |
|                                             |                        |
| -   Heart/lung                              |                        |
|                                             |                        |
| -   Kidney                                  |                        |
|                                             |                        |
| -   Kidney/Pancreas                         |                        |
|                                             |                        |
| -   Liver                                   |                        |
|                                             |                        |
| -   Lung: Single --Double                   |                        |
|                                             |                        |
| -   Pancreas                                |                        |
|                                             |                        |
| -   Allogenic (donor) bone marrow           |                        |
|     transplants                             |                        |
|                                             |                        |
| -   Autologous bone marrow transplants      |                        |
|     (autologous stem cell and peripheral    |                        |
|     stem cell support) for the following    |                        |
|     conditions: acute lymphocytic or        |                        |
|     non-lymphocytic leukemia; advanced      |                        |
|     Hodgkin\'s lymphoma; advanced           |                        |
|     non-Hodgkin\'s lymphoma; advanced       |                        |
|     neuroblastoma; breast cancer; multiple  |                        |
|     myeloma; epithelial ovarian cancer; and |                        |
|     testicular, mediastinal,                |                        |
|     retroperitoneal and ovarian germ cell   |                        |
|     tumors []{.mark}                        |                        |
|                                             |                        |
| -   Intestinal transplants (small           |                        |
|     intestine) and the small intestine with |                        |
|     the liver or small intestine with       |                        |
|     multiple organs such as the liver,      |                        |
|     stomach, and pancreas.                  |                        |
|                                             |                        |
| -   National Transplant Program (NTP) -     |                        |
|     United Resource Network                 |                        |
|                                             |                        |
| > 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. We also cover        |                        |
| > transportation costs for the member and a |                        |
| > companion when the member resides more    |                        |
| > than 50 miles from the transplant site    |                        |
| > and if the transplant is performed        |                        |
| > outside our service area. We define       |                        |
| > transportation costs as commercial        |                        |
| > transportation for the member receiving   |                        |
| > the transplant, and a companion, to and   |                        |
| > from the site of the transplant. We also  |                        |
| > cover reasonable and necessary lodging    |                        |
| > and meal costs of the member and          |                        |
| > companion beginning 24 hours prior to the |                        |
| > hospitalization and 48 hours after        |                        |
| > discharge. We cover transportation,       |                        |
| > lodging and meals up to \$125 per day up  |                        |
| > to a maximum benefit of \$2,000.          |                        |
+---------------------------------------------+------------------------+
| > ***Organ/tissue transplants --***         |                        |
| > continued on next page                    |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Organ/tissue transplant** *(Continued)* | > **You Pay**          |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Donor screening tests and donor search |                        |
|     expenses, except those performed for    |                        |
|     the actual donor*                       |                        |
|                                             |                        |
| -   *Implants of artificial organs*         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Transplants not listed as covered*     |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Anesthesia**                            |                        |
+---------------------------------------------+------------------------+
| > Professional services provided in --      | > Nothing              |
|                                             |                        |
| -   Hospital (inpatient)                    |                        |
+---------------------------------------------+------------------------+
| > Professional services provided in --      | > \$10 per visit       |
|                                             |                        |
| -   Hospital outpatient department          |                        |
|                                             |                        |
| -   Skilled nursing facility                |                        |
|                                             |                        |
| -   Ambulatory center                       |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Office                                  |                        |
+---------------------------------------------+------------------------+

+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   |             |   |     |
|  * |   |                                   |             |   |     |
| *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.                |             | * |     |
|    | * |                                   |             | * |     |
|    |   | -   Be sure to read Section 4,    |             |   |     |
|    | * |     *Your costs for covered       |             | * |     |
|    | * |     services* for valuable        |             | * |     |
|    | O |     information about how cost    |             | O |     |
|    | * |     sharing works. Also read      |             | * |     |
|    | * |     Section 9 about coordinating  |             | * |     |
|    |   |     benefits with other coverage, |             |   |     |
|    | * |     including with Medicare.      |             | * |     |
|    | * |                                   |             | * |     |
|    | R | -   The amounts listed below are  |             | R |     |
|    | * |     for the charges billed by the |             | * |     |
|    | * |     facility (i.e., hospital or   |             | * |     |
|    |   |     surgical center) or ambulance |             |   |     |
|    | * |     service for your surgery or   |             | * |     |
|    | * |     care. Any costs associated    |             | * |     |
|    | T |     with the professional charge  |             | T |     |
|    | * |     (i.e., physicians, etc.) are  |             | * |     |
|    | * |     covered in Section 5(a) or    |             | * |     |
|    |   |     (b).                          |             |   |     |
|    | * |                                   |             | * |     |
|    | * | ```{=html}                        |             | * |     |
|    | A | <!-- -->                          |             | A |     |
|    | * | ```                               |             | * |     |
|    | * | -   **YOUR PHYSICIAN MUST GET     |             | * |     |
|    |   |     PRECERTIFICATION OF HOSPITAL  |             |   |     |
|    | * |     STAYS.** Please refer to      |             | * |     |
|    | * |     Section 3 to be sure which    |             | * |     |
|    | N |     services require              |             | N |     |
|    | * |     pre-certification.            |             | * |     |
|    | * |                                   |             | * |     |
|    |   |                                   |             |   |     |
|    | * |                                   |             | * |     |
|    | * |                                   |             | * |     |
|    | T |                                   |             | T |     |
|    | * |                                   |             | * |     |
|    | * |                                   |             | * |     |
+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   | **You pay** |   |     |
|  * |   |                                   |             |   |     |
| *B |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| ef |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  D |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| cr |   |                                   |             |   |     |
| ip |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| ** |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| #  |   |                                   | ########    |   |     |
| ## |   |                                   |             |   |     |
| ## |   |                                   |             |   |     |
| ## |   |                                   |             |   |     |
| #  |   |                                   |             |   |     |
| In |   |                                   |             |   |     |
| pa |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| t  |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| sp |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   | > \$50 per  |   |     |
| Ro |   |                                   | > day up to |   |     |
| om |   |                                   | > a \$500   |   |     |
| >  |   |                                   | > maximum   |   |     |
|  a |   |                                   | > per       |   |     |
| nd |   |                                   | > person    |   |     |
| >  |   |                                   | > per       |   |     |
| bo |   |                                   | > calendar  |   |     |
| ar |   |                                   | > year and  |   |     |
| d, |   |                                   | > a \$1,000 |   |     |
| >  |   |                                   | > maximum   |   |     |
| su |   |                                   | > per       |   |     |
| ch |   |                                   | > family    |   |     |
| >  |   |                                   | > per       |   |     |
| as |   |                                   | > calendar  |   |     |
|    |   |                                   | > year      |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  w |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| d, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| mi |   |                                   |             |   |     |
| pr |   |                                   |             |   |     |
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| at |   |                                   |             |   |     |
| e, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| or |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  i |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  m |   |                                   |             |   |     |
| ea |   |                                   |             |   |     |
| ls |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| pe |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| di |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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| ge |   |                                   |             |   |     |
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|  t |   |                                   |             |   |     |
| he |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
| em |   |                                   |             |   |     |
| ip |   |                                   |             |   |     |
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| va |   |                                   |             |   |     |
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| >  |   |                                   |             |   |     |
|  r |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| e. |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| #  |   |                                   | > Nothing   |   |     |
| ## |   |                                   |             |   |     |
| #  |   |                                   |             |   |     |
| Ot |   |                                   |             |   |     |
| he |   |                                   |             |   |     |
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| ,  |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| g, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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| nt |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| ms |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| cr |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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| ts |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| ra |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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| mi |   |                                   |             |   |     |
| ni |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| sm |   |                                   |             |   |     |
| a, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  d |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
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| es |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| sp |   |                                   |             |   |     |
| li |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| tr |   |                                   |             |   |     |
| ay |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| rv |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  M |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| eq |   |                                   |             |   |     |
| ui |   |                                   |             |   |     |
| pm |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| t, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  i |   |                                   |             |   |     |
| nc |   |                                   |             |   |     |
| lu |   |                                   |             |   |     |
| di |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| ox |   |                                   |             |   |     |
| yg |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| An |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| th |   |                                   |             |   |     |
| et |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  i |   |                                   |             |   |     |
| nc |   |                                   |             |   |     |
| lu |   |                                   |             |   |     |
| di |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  n |   |                                   |             |   |     |
| ur |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| ne |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
| he |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| rv |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  T |   |                                   |             |   |     |
| ak |   |                                   |             |   |     |
| e- |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| me |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  i |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| ms |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  M |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
| up |   |                                   |             |   |     |
| pl |   |                                   |             |   |     |
| ie |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| pp |   |                                   |             |   |     |
| li |   |                                   |             |   |     |
| an |   |                                   |             |   |     |
| ce |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  m |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| eq |   |                                   |             |   |     |
| ui |   |                                   |             |   |     |
| pm |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| t, |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| ny |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| ov |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  i |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| ms |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| bi |   |                                   |             |   |     |
| ll |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| by |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| sp |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  f |   |                                   |             |   |     |
| or |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  u |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| me |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   | #######     |   |     |
| *N |   |                                   | All charges |   |     |
| ot |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| ov |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| :* |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| *C |   |                                   |             |   |     |
| us |   |                                   |             |   |     |
| to |   |                                   |             |   |     |
| di |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| e* |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| *N |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| -c |   |                                   |             |   |     |
| ov |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  f |   |                                   |             |   |     |
| ac |   |                                   |             |   |     |
| il |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| ie |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| su |   |                                   |             |   |     |
| ch |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| as |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  n |   |                                   |             |   |     |
| ur |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| me |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| sc |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| ol |   |                                   |             |   |     |
| s* |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  * |   |                                   |             |   |     |
| Pe |   |                                   |             |   |     |
| rs |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| om |   |                                   |             |   |     |
| fo |   |                                   |             |   |     |
| rt |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| em |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| su |   |                                   |             |   |     |
| ch |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| as |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| le |   |                                   |             |   |     |
| ph |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| e, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| el |   |                                   |             |   |     |
| ev |   |                                   |             |   |     |
| is |   |                                   |             |   |     |
| io |   |                                   |             |   |     |
| n, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| ba |   |                                   |             |   |     |
| rb |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| vi |   |                                   |             |   |     |
| ce |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  g |   |                                   |             |   |     |
| ue |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  m |   |                                   |             |   |     |
| ea |   |                                   |             |   |     |
| ls |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| s* |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| *P |   |                                   |             |   |     |
| ri |   |                                   |             |   |     |
| va |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  n |   |                                   |             |   |     |
| ur |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| e* |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+

+---------------------------------------------+------------------------+
| #### **Outpatie                             | #### **You Pay**       |
| nt hospital or ambulatory surgical center** |                        |
+---------------------------------------------+------------------------+
| -   Operating, recovery, and other          | > Nothing              |
|     treatment rooms                         |                        |
|                                             |                        |
| #### Prescribed drugs and medicines         |                        |
|                                             |                        |
| -   Diagnostic laboratory tests, X-rays,    |                        |
|     and pathology services                  |                        |
|                                             |                        |
| -   Administration of blood, blood plasma,  |                        |
|     and other biologicals                   |                        |
|                                             |                        |
| -   Blood and blood plasma, if not donated  |                        |
|     or replaced                             |                        |
|                                             |                        |
| -   Pre-surgical testing                    |                        |
|                                             |                        |
| -   Dressings, casts, and sterile tray      |                        |
|     services                                |                        |
|                                             |                        |
| -   Medical supplies, including oxygen      |                        |
|                                             |                        |
| -   Anesthetics and anesthesia service      |                        |
|                                             |                        |
| > NOTE: -- We cover hospital services and   |                        |
| > supplies related to dental procedures     |                        |
| > when necessitated by a non-dental         |                        |
| > physical impairment. We do not cover the  |                        |
| > dental procedures.                        |                        |
+---------------------------------------------+------------------------+
| # *Not covered: blood and bl                | > *All charges*        |
| ood derivatives not replaced by the member* |                        |
+---------------------------------------------+------------------------+
| ######## Extended care bene                 | ########               |
| fits/skilled nursing care facility benefits |                        |
+---------------------------------------------+------------------------+
| > We cover all necessary services with no   | > Nothing              |
| > dollar or day limit, including:           |                        |
|                                             |                        |
| -   Bed, board and general nursing care.    |                        |
|                                             |                        |
| -   Drugs, biologicals, supplies, and       |                        |
|     equipment ordinarily provided or        |                        |
|     arranged by the skilled nursing         |                        |
|     facility when prescribed by a Plan      |                        |
|     doctor.                                 |                        |
+---------------------------------------------+------------------------+
| > Not covered: custodial care               | > *All charges*        |
+---------------------------------------------+------------------------+
| #### **Hospice care**                       | ####                   |
+---------------------------------------------+------------------------+
| > We cover supportive and palliative care   | > Nothing              |
| > for a terminally ill member in the home   |                        |
| > or 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, and    | > *All charges*        |
| > homemaker services*                       |                        |
+---------------------------------------------+------------------------+
| ######## Ambulance                          | ########               |
+---------------------------------------------+------------------------+
| -   Ambulance service when medically        | > Nothing              |
|     appropriate                             |                        |
+---------------------------------------------+------------------------+

+---+---+-------------------------------------------------+---+---------+
| # |   |                                                 |   |         |
| # |   |                                                 |   |         |
| # |   |                                                 |   |         |
| # |   |                                                 |   |         |
| # |   |                                                 |   |         |
|   |   |                                                 |   |         |
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| m |   |                                                 |   |         |
| e |   |                                                 |   |         |
| r |   |                                                 |   |         |
| g |   |                                                 |   |         |
| e |   |                                                 |   |         |
| n |   |                                                 |   |         |
| c |   |                                                 |   |         |
| y |   |                                                 |   |         |
|   |   |                                                 |   |         |
| s |   |                                                 |   |         |
| e |   |                                                 |   |         |
| r |   |                                                 |   |         |
| v |   |                                                 |   |         |
| i |   |                                                 |   |         |
| c |   |                                                 |   |         |
| e |   |                                                 |   |         |
| s |   |                                                 |   |         |
| / |   |                                                 |   |         |
| a |   |                                                 |   |         |
| c |   |                                                 |   |         |
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| 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.            |   |         |
|   | * |                                                 | * |         |
|   | * | -   We have no deductible.                      | * |         |
|   | M |                                                 | M |         |
|   | * | -   Be sure to read Section 4, *Your costs for  | * |         |
|   | * |     covered services* for valuable information  | * |         |
|   |   |     about how cost sharing works. Also read     |   |         |
|   | * |     Section 9 about coordinating benefits with  | * |         |
|   | * |     other coverage, including with Medicare.    | * |         |
|   | P |                                                 | P |         |
|   | * | #####                                           | * |         |
|   | * |                                                 | * |         |
|   |   |                                                 |   |         |
|   | * |                                                 | * |         |
|   | * |                                                 | * |         |
|   | O |                                                 | O |         |
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|   | * |                                                 | * |         |
|   |   |                                                 |   |         |
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|   | R |                                                 | R |         |
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|   |   |                                                 |   |         |
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|   | A |                                                 | A |         |
|   | * |                                                 | * |         |
|   | * |                                                 | * |         |
|   |   |                                                 |   |         |
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|   | * |                                                 | * |         |
|   | N |                                                 | N |         |
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|   | * |                                                 | * |         |
+---+---+-------------------------------------------------+---+---------+
| > |   |                                                 |   |         |
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| m |   |                                                 |   |         |
| b |   |                                                 |   |         |
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| l |   |                                                 |   |         |
| a |   |                                                 |   |         |
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| c |   |                                                 |   |         |
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| c |   |                                                 |   |         |
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| d |   |                                                 |   |         |
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| l |   |                                                 |   |         |
| . |   |                                                 |   |         |
+---+---+-------------------------------------------------+---+---------+

+---------------------------------------------+------------------------+
| > **Benefit Description**                   | **You pay**            |
+---------------------------------------------+------------------------+
| > **Emergency within our service area**     |                        |
+---------------------------------------------+------------------------+
| -   Emergency care at a doctor\'s office    | \$10 per visit         |
|                                             |                        |
| -   Emergency care at an urgent care center |                        |
+---------------------------------------------+------------------------+
| -   Emergency care as an outpatient or      | \$50 per visit         |
|     inpatient at a hospital, including      |                        |
|     doctors' services                       | (copay is waived if    |
|                                             | admitted)              |
+---------------------------------------------+------------------------+
| > *Not covered: Elective care or            | > *All charges.*       |
| > non-emergency care*                       |                        |
+---------------------------------------------+------------------------+
| ######## Emergency outside our service area |                        |
+---------------------------------------------+------------------------+
| -   Emergency care at a doctor\'s office    | > \$10 per visit       |
|                                             |                        |
| -   Emergency care at an urgent care center |                        |
+---------------------------------------------+------------------------+
| -   Emergency care as an outpatient or      | > \$50 per visit       |
|     inpatient at a hospital, including      | >                      |
|     doctors' services                       | > (copay is waived if  |
|                                             | > admitted)            |
+---------------------------------------------+------------------------+
| > *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*                               |                        |
|                                             |                        |
| -   *Medical and hospital costs resulting   |                        |
|     from a normal full-term delivery of a   |                        |
|     baby outside the service area*          |                        |
|                                             |                        |
| ########                                    |                        |
+---------------------------------------------+------------------------+
| > **Ambulance**                             |                        |
+---------------------------------------------+------------------------+
| > Ambulance service when medically          | > Nothing              |
| > appropriate including, air ambulance      |                        |
| >                                           |                        |
| > See 5(c) for non-emergency service.       |                        |
+---------------------------------------------+------------------------+

+---+---+----------------------------------------+---------------+---+---+
| * |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
| S |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| c |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| 5 |   |                                        |               |   |   |
| ( |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| ) |   |                                        |               |   |   |
| . |   |                                        |               |   |   |
| M |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| d |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| u |   |                                        |               |   |   |
| b |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| c |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| b |   |                                        |               |   |   |
| u |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| b |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| f |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+
|   | * | > When you get our approval for        |               | * |   |
|   | * | > services and follow a treatment 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 |   |
|   | * | > 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     |               | * |   |
|   | O | > other coverage, including with       |               | O |   |
|   | * | > Medicare.                            |               | * |   |
|   | * | >                                      |               | * |   |
|   |   | > **YOU MUST GET PREAUTHORIZATION OF   |               |   |   |
|   | * | > THESE SERVICES.** See the            |               | * |   |
|   | * | > instructions after the benefits      |               | * |   |
|   | R | > description below.                   |               | R |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   |   |                                        |               |   |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | T |                                        |               | T |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   |   |                                        |               |   |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | A |                                        |               | A |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   |   |                                        |               |   |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | N |                                        |               | N |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   |   |                                        |               |   |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | * |   |
|   | T |                                        |               | T |   |
|   | * |                                        |               | * |   |
|   | * |                                        |               | * |   |
+---+---+----------------------------------------+---------------+---+---+
| > |   |                                        | **You pay**   |   |   |
|   |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
| B |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| f |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| D |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| c |   |                                        |               |   |   |
| r |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| p |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+
| # |   |                                        | ###           |   |   |
| # |   |                                        |               |   |   |
| # |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
| M |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| l |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| h |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| d |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| u |   |                                        |               |   |   |
| b |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| c |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| b |   |                                        |               |   |   |
| u |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| b |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
| f |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
| * |   |                                        |               |   |   |
+---+---+----------------------------------------+---------------+---+---+
| > |   |                                        | > Your cost   |   |   |
|   |   |                                        | > sharing     |   |   |
| A |   |                                        | > res         |   |   |
| l |   |                                        | ponsibilities |   |   |
| l |   |                                        | > are no      |   |   |
| > |   |                                        | > greater     |   |   |
|   |   |                                        | > than for    |   |   |
| d |   |                                        | > other       |   |   |
| i |   |                                        | > illness or  |   |   |
| a |   |                                        | > conditions. |   |   |
| g |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| o |   |                                        |               |   |   |
| s |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| i |   |                                        |               |   |   |
| c |   |                                        |               |   |   |
| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| a |   |                                        |               |   |   |
| n |   |                                        |               |   |   |
| d |   |                                        |               |   |   |
| > |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
| t |   |                                        |               |   |   |
| r |   |                                        |               |   |   |
| e |   |                                        |               |   |   |
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| - |   |                                        | > \$10 per    |   |   |
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+---+---+----------------------------------------+---------------+---+---+
| - |   |                                        | > \$50 per    |   |   |
|   |   |                                        | > day up to   |   |   |
|   |   |                                        | > \$500 per   |   |   |
|   |   |                                        | > person per  |   |   |
| S |   |                                        | > calendar    |   |   |
| e |   |                                        | > year and    |   |   |
| r |   |                                        | > \$1,000 per |   |   |
| v |   |                                        | > family per  |   |   |
| i |   |                                        | > calendar    |   |   |
| c |   |                                        | > year        |   |   |
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|   |   |                                        |               |   |   |
|   |   |                                        |               |   |   |
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| a |   |                                        |               |   |   |
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+---+---+----------------------------------------+---------------+---+---+

+----------------------------------------------+-----------------------+
| ### **Mental health a                        | ### **You pay**       |
| nd substance abuse benefits** *(Continued)*  |                       |
+----------------------------------------------+-----------------------+
| ## Not covered: Services not app             | > *All charges.*      |
| roved in advance by Preferred Health Systems |                       |
|                                              |                       |
| ## 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. |                       |
+----------------------------------------------+-----------------------+
| **Pre-authorization**                        |                       |
|                                              |                       |
| To be eligible to receive these benefits you |                       |
| must obtain a treatment plan and follow all  |                       |
| of the following authorization processes:    |                       |
|                                              |                       |
| All services for mental conditions/substance |                       |
| abuse benefits must be coordinated by        |                       |
| Preferred Health Systems prior to receiving  |                       |
| services. Please contact Preferred Health    |                       |
| Systems at 316/609-2541 in Wichita or        |                       |
| 1/866/338-4281 outside of Wichita.           |                       |
|                                              |                       |
| **Limitation**                               |                       |
|                                              |                       |
| We may limit your benefits if you do not     |                       |
| obtain a treatment plan.                     |                       |
+----------------------------------------------+-----------------------+

+-----+---+-------------------------------------------------+---+-------+
| **S |   |                                                 |   |       |
| ect |   |                                                 |   |       |
| ion |   |                                                 |   |       |
| 5   |   |                                                 |   |       |
| (   |   |                                                 |   |       |
| f). |   |                                                 |   |       |
| Pre |   |                                                 |   |       |
| scr |   |                                                 |   |       |
| ipt |   |                                                 |   |       |
| ion |   |                                                 |   |       |
| d   |   |                                                 |   |       |
| rug |   |                                                 |   |       |
| b   |   |                                                 |   |       |
| ene |   |                                                 |   |       |
| fit |   |                                                 |   |       |
| s** |   |                                                 |   |       |
+-----+---+-------------------------------------------------+---+-------+
|     | * | **Here are some important things to keep in     | * |       |
|     | * | mind about these benefits:**                    | * |       |
|     | I |                                                 | I |       |
|     | * | -   We cover prescribed drugs and medications,  | * |       |
|     | * |     as described in the chart beginning on the  | * |       |
|     |   |     next page.                                  |   |       |
|     | * |                                                 | * |       |
|     | * | -   All benefits are subject to the             | * |       |
|     | 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 with Medicare.    | * |       |
|     | O |                                                 | O |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     |   |                                                 |   |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     | R |                                                 | R |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     |   |                                                 |   |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     | T |                                                 | T |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     |   |                                                 |   |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     | A |                                                 | A |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
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+-----+---+-------------------------------------------------+---+-------+

+---------------------------------------------+---+-----------------------+
| ### **                                      |   | ### **You pay**       |
| Prescription Drug Benefits** *(Continued)*  |   |                       |
+---------------------------------------------+---+-----------------------+
| > **Covered medications and supplies**      |   |                       |
+---------------------------------------------+---+-----------------------+
| > We cover the following medications and    |   | > \$5 copay per       |
| > supplies prescribed by a Plan physician   |   | > generic             |
| > and obtained from a Plan pharmacy or      |   | > prescription --     |
| > through our mail order program:           |   | > retail.             |
| >                                           |   | >                     |
| > Drugs and medicines that by Federal law   |   | > \$15 copay per      |
| > of the United States require a            |   | > brand name          |
| > physician's prescription for their        |   | > prescription --     |
| > purchase, except those listed as *Not     |   | > retail              |
| > covered*                                  |   | >                     |
| >                                           |   | > \$12 copay per      |
| > Insulin, with a copay charge applied to   |   | > generic mail-order  |
| > each vial                                 |   | > prescription and    |
| >                                           |   | > \$40 copay per      |
| > Disposable needles and syringes for the   |   | > brand name mail     |
| > administration of covered medications     |   | > order prescription  |
|                                             |   | >                     |
| Contraceptive drugs and devices             |   | > When generic        |
|                                             |   | > substitution is     |
| > Oral contraceptive drugs - up to a        |   | > permissible (i.e.,  |
| > three-cycle supply may be obtained at one |   | > a generic drug is   |
| > time with a copay charge applied to each  |   | > available and the   |
| > cycle.                                    |   | > prescribing doctor  |
|                                             |   | > does not require    |
| -   Contraceptive devices, such as          |   | > the use of a brand  |
|     diaphragms and IUD's                    |   | > name drug), but you |
|                                             |   | > request the brand   |
| > Diabetic supplies, including syringes,    |   | > name drug, you pay  |
| > diagnostic strips, alcohol swabs and      |   | > the difference      |
| > lancets. Diagnostic strips will be        |   | > between the generic |
| > subject to the name brand copayment. All  |   | > and brand name drug |
| > other diabetic supplies will be subject   |   | > as well as the \$15 |
| > to the generic copayment.                 |   | > copay               |
|                                             |   | >                     |
| Intravenous fluids and medication for home  |   | > Note: If there is   |
| use, implantable drugs, such as Norplant    |   | > no generic          |
| and some injectable drugs, such as Depo     |   | > equivalent          |
| Provera are covered under Medical and       |   | > available, you will |
| Surgical Benefits.                          |   | > still have to pay   |
|                                             |   | > the brand name      |
| -   Drugs to treat sexual dysfunction are   |   | > copay.              |
|     limited to an 8 unit dose per 34-day    |   |                       |
|     supply and a 24 unit dose per 90-day    |   |                       |
|     supply                                  |   |                       |
+---------------------------------------------+---+-----------------------+
| > Here are some things to keep in mind      |   |                       |
| > about our prescription drug program:      |   |                       |
|                                             |   |                       |
| -   Medications requiring pre-authorization |   |                       |
|     include: Adderal, Dexedrine and         |   |                       |
|     Desoxyn; Oral Anabolic Steroids;        |   |                       |
|     Medications to treat acne for persons   |   |                       |
|     over the age of 30 including, but not   |   |                       |
|     limited to, Retin-A, Accutane, and      |   |                       |
|     Differin; Hormone suppositories and     |   |                       |
|     powders; Anti-fungal medication         |   |                       |
|     including, but not limited to, Lamisil  |   |                       |
|     or Sporanox; and Wellbutrin SR/150 mg.  |   |                       |
+---------------------------------------------+---+-----------------------+
| > *Not covered:*                            | > |                       |
|                                             |   |                       |
| -   *Drugs and supplies for cosmetic        | * |                       |
|     purposes*                               | A |                       |
|                                             | l |                       |
| -   *Vitamins, nutrients and food           | l |                       |
|     supplements even if a physician         | > |                       |
|     prescribes or administers them*         |   |                       |
|                                             | C |                       |
| ```{=html}                                  | h |                       |
| <!-- -->                                    | a |                       |
| ```                                         | r |                       |
| -   *Drugs available without a prescription | g |                       |
|     or for which there is a nonprescription | e |                       |
|     equivalent available.*                  | s |                       |
|                                             | * |                       |
| ```{=html}                                  |   |                       |
| <!-- -->                                    |   |                       |
| ```                                         |   |                       |
| -   *Drugs obtained at a non-Plan pharmacy  |   |                       |
|     except for out-of-area emergencies.*    |   |                       |
|                                             |   |                       |
|     *Medical supplies such as dressings and |   |                       |
|     antiseptic.*                            |   |                       |
|                                             |   |                       |
| ```{=html}                                  |   |                       |
| <!-- -->                                    |   |                       |
| ```                                         |   |                       |
| -   *Drugs to enhance athletic              |   |                       |
|     performance.*                           |   |                       |
|                                             |   |                       |
| ```{=html}                                  |   |                       |
| <!-- -->                                    |   |                       |
| ```                                         |   |                       |
| -   *Drugs to aid in smoking cessation,     |   |                       |
|     including nicotine patches.*            |   |                       |
|                                             |   |                       |
| ```{=html}                                  |   |                       |
| <!-- -->                                    |   |                       |
| ```                                         |   |                       |
| -   *Fertility drugs.*                      |   |                       |
|                                             |   |                       |
| ```{=html}                                  |   |                       |
| <!-- -->                                    |   |                       |
| ```                                         |   |                       |
| -   *Appetite suppressants, except for      |   |                       |
|     treatment of morbid obesity.*           |   |                       |
+---------------------------------------------+---+-----------------------+

+--------------------------+-------------------------------------------+
| > Section 5 (g). Special |                                           |
| > features               |                                           |
+==========================+===========================================+
| ###### Feature           | > **Description**                         |
+--------------------------+-------------------------------------------+
| ######                   | > Under the flexible benefits option, we  |
|                          | > determine the most effective way to     |
| ######                   | > provide services.                       |
| Flexible benefits option |                                           |
|                          | -   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.                       |
+--------------------------+-------------------------------------------+
| ####                     | > A case manager is available to answer   |
| ## High risk pregnancies | > any question regarding the pregnancy.   |
|                          | > We also send educational materials to   |
|                          | > assist with any questions or concerns   |
|                          | > the member might have. For assistance   |
|                          | > please call (316) 609-2457 or           |
|                          | > 1-800-990-0345 ext. 457                 |
+--------------------------+-------------------------------------------+
| ####                     | > We have a case manager that follows our |
| ## Centers of excellence | > transplant cases and will assist with   |
|                          | > determining which facility within the   |
|                          | > Centers of Excellence (United Resource  |
|                          | > Network "URN") will work best for the   |
|                          | > member and his or her transplant need.  |
+--------------------------+-------------------------------------------+

+---+---+---------------------------------------+----------+---+--------+
| > |   |                                       |          |   |        |
|   |   |                                       |          |   |        |
| 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 |        |
|   | * | -   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   |          | * |        |
|   | M |     medically necessary.              |          | M |        |
|   | * |                                       |          | * |        |
|   | * | -   Plan dentists must provide or     |          | * |        |
|   |   |     arrange your care.                |          |   |        |
|   | * |                                       |          | * |        |
|   | * | -   We cover hospitalization for      |          | * |        |
|   | P |     dental procedures only when a     |          | P |        |
|   | * |     nondental physical impairment     |          | * |        |
|   | * |     exists which makes                |          | * |        |
|   |   |     hospitalization necessary to      |          |   |        |
|   | * |     safeguard the health of the       |          | * |        |
|   | * |     patient; [See Section 5 (c) for   |          | * |        |
|   | O |     inpatient hospital                |          | O |        |
|   | * |     benefits.]{.underline} We do not  |          | * |        |
|   | * |     cover the dental procedure unless |          | * |        |
|   |   |     it is described below.            |          |   |        |
|   | * |                                       |          | * |        |
|   | * | ```{=html}                            |          | * |        |
|   | R | <!-- -->                              |          | R |        |
|   | * | ```                                   |          | * |        |
|   | * | -   Be sure to read Section 4, *Your  |          | * |        |
|   |   |     costs for covered services*, for  |          |   |        |
|   | * |     valuable information about how    |          | * |        |
|   | * |     cost sharing works. Also read     |          | * |        |
|   | T |     Section 9 about coordinating      |          | T |        |
|   | * |     benefits with other coverage,     |          | * |        |
|   | * |     including with Medicare.          |          | * |        |
|   |   |                                       |          |   |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
|   | A |                                       |          | A |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
|   |   |                                       |          |   |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
|   | N |                                       |          | N |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
|   |   |                                       |          |   |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
|   | T |                                       |          | T |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
+---+---+---------------------------------------+----------+---+--------+
| # |   |                                       | > **You  |   |        |
| # |   |                                       | > pay**  |   |        |
| # |   |                                       |          |   |        |
|   |   |                                       |          |   |        |
| * |   |                                       |          |   |        |
| * |   |                                       |          |   |        |
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| j |   |                                       |          |   |        |
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| t |   |                                       |          |   |        |
| * |   |                                       |          |   |        |
| * |   |                                       |          |   |        |
+---+---+---------------------------------------+----------+---+--------+
| > |   |                                       | > \$10   |   |        |
|   |   |                                       | > copay  |   |        |
| W |   |                                       | > per    |   |        |
| e |   |                                       | > office |   |        |
| > |   |                                       | > visit  |   |        |
|   |   |                                       |          |   |        |
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+---+---+---------------------------------------+----------+---+--------+
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+---+---+---------------------------------------+----------+---+--------+
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| > |   |                                       | plicable |   |        |
|   |   |                                       | > P      |   |        |
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| o |   |                                       | > Office |   |        |
| v |   |                                       | > Visit  |   |        |
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| . |   |                                       |          |   |        |
+---+---+---------------------------------------+----------+---+--------+
| > |   |                                       |          |   |        |
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|   |   |                                       |          |   |        |
| b |   |                                       |          |   |        |
| e |   |                                       |          |   |        |
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| e |   |                                       |          |   |        |
| f |   |                                       |          |   |        |
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| t |   |                                       |          |   |        |
| s |   |                                       |          |   |        |
| . |   |                                       |          |   |        |
+---+---+---------------------------------------+----------+---+--------+

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

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

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

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

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

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

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

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

-   Services, drugs, or supplies related to sex transformations

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

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

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

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

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

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, hospital, drug benefits** In most cases, providers and
facilities file claims for you. Physicians must file on the form
HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at
1-(800)-660-8114 or 316-(609)-2390.

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: Preferred Health Systems, 8535 E. 21^st^
> North, Wichita, Kansas 67206**

**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: 8535 E. 21^st^ Street North,     |
|   |     Wichita, Kansas 67206; and                                   |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or, if applicable, arrange for the health     |
| * |     care provider to give you the care); or                      |
| * |                                                                  |
|   | (b) Write to you and maintain our denial \-- go to step 4; or    |
|   |                                                                  |
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request---go   |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us \-- if we did not       |
|   |     answer that request in some way within 30 days; or           |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: Office of Personnel Management, Insurance       |
|   | Services Programs, Health Insurance Group 3, 1900 E Street, NW,  |
|   | Washington, DC 20415-3630.                                       |
+---+------------------------------------------------------------------+

+---+------------------------------------------------------------------+
|   | **The Disputed Claims Process** ***(Continued)***                |
|   |                                                                  |
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+

+---+------------------------------------------------------------------+
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| c |                                                                  |
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| s |                                                                  |
| e |                                                                  |
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| f |                                                                  |
| r |                                                                  |
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| a |                                                                  |
| s |                                                                  |
| o |                                                                  |
| n |                                                                  |
| s |                                                                  |
| b |                                                                  |
| e |                                                                  |
| y |                                                                  |
| o |                                                                  |
| n |                                                                  |
| d |                                                                  |
| y |                                                                  |
| o |                                                                  |
| u |                                                                  |
| r |                                                                  |
| c |                                                                  |
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| . |                                                                  |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | If you do not agree with OPM's decision, your only recourse is   |
|   | to sue. If you decide to sue, you must file the suit against OPM |
|   | in Federal court by December 31 of the third year after the year |
|   | in which you received the disputed services, drugs, or supplies  |
|   | or from the year in which you were denied precertification or    |
|   | prior approval. This is the only deadline that may not be        |
|   | extended.                                                        |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support their disputed claim decision. This           |
|   | information will become part of the court record.                |
|   |                                                                  |
|   | You may not sue until you have completed the disputed claims     |
|   | process. Further, Federal law governs your lawsuit, benefits,    |
|   | and payment of benefits. The Federal court will base its review  |
|   | on the record that was before OPM when OPM decided to uphold or  |
|   | overturn our decision. You may recover only the amount of        |
|   | benefits in dispute.                                             |
+---+------------------------------------------------------------------+

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

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at 1-(800)-424-0345 or
    (316)-609-2359; and we will expedite our review; or

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

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

-   You may call OPM's Health Insurance Group 3 at 202/606-0737 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 or a family member have coverage under another group health plan
or have automobile insurance that pays health care expenses without
regard to fault. This is called "double coverage."

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

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

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

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

People 65 years of age and older.

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 + Choice plan you have.

**The Original Medicare Plan** 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 primary care
physician, or precertified as required.

**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 claims will be coordinated
    automatically and we will then provide secondary benefits for
    covered charges. You will not need to do anything. To find out if
    you need to do something to file your claims, call us at (316)
    609-2390 or 1-(800)-660-8114 or locate us at
    [www.phsystems.com](http://www.phsystems.com/).

> We do not waive any costs if the Original Medicare is your primary
> payer.
>
> ***(Primary payer chart begins on next page.)***
>
> 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.

+------------------------------------------------+------------+--------+
|                                                |            |        |
+------------------------------------------------+------------+--------+
|                                                |            |        |
+------------------------------------------------+------------+--------+
|                                                |            |        |
+------------------------------------------------+------------+--------+
| 1)                                             |            |        |
+------------------------------------------------+------------+--------+
| 2)                                             |            |        |
+------------------------------------------------+------------+--------+
| 3)                                             |            |        |
|                                                |            |        |
| ```{=html}                                     |            |        |
| <!-- -->                                       |            |        |
| ```                                            |            |        |
| a)                                             |            |        |
+------------------------------------------------+------------+--------+
| b)                                             |            |        |
+------------------------------------------------+------------+--------+
| 4)                                             | ######     |        |
+------------------------------------------------+------------+--------+
| 5)                                             |            |        |
+------------------------------------------------+------------+--------+
| 6)                                             |            |        |
+------------------------------------------------+------------+--------+
|                                                |            |        |
+------------------------------------------------+------------+--------+
| ######                                         |            |        |
+------------------------------------------------+------------+--------+
| 1)                                             |            |        |
+------------------------------------------------+------------+--------+
| 2)                                             |            |        |
+------------------------------------------------+------------+--------+
|                                                |            |        |
+------------------------------------------------+------------+--------+
| 1)                                             |            |        |
|                                                |            |        |
| ```{=html}                                     |            |        |
| <!-- -->                                       |            |        |
| ```                                            |            |        |
| a)                                             |            |        |
+------------------------------------------------+------------+--------+
| b)                                             |            |        |
+------------------------------------------------+------------+--------+
| c)                                             |            | []{    |
|                                                |            | .mark} |
+------------------------------------------------+------------+--------+
| d)                                             |            |        |
+------------------------------------------------+------------+--------+

> *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 |   | for      |
|     your employment status                         | P   |   | other    |
|                                                    | art |   | services |
|                                                    | 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 sol                           |     |   |          |
| ely 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 |     | f |          |
|     already a Medicare beneficiary and**...**      |     | o |          |
|                                                    |     | r |          |
| -   This Plan was the primary payer before         |     | 3 |          |
|     eligibility due to ESRD                        |     | 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 plan** If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from a Medicare +
Choice plan. These are health care choices (like HMOs) in some areas of
the country. In most Medicare + Choice plans, you can only go to
doctors, specialists, or hospitals that are part of the plan. Medicare +
Choice plans provide all the benefits that Original Medicare covers.
Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare + Choice plan, contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at
[www.medicare.gov](http://www.medicare.gov/).

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

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

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

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

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

**Suspended FEHB coverage to enroll in TRICARE or CHAMPVA:** If you are
an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in 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,

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

**When others are responsible**

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

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

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

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

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

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 9

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

**Experimental or** If a service has not been approved by the Federal
Drug Administration

**investigational services** (FDA) or is labeled experimental or
investigational on the protocol, the Plan considers the service
experimental or investigational*.*

**Medical necessity** Means a service or item (intervention) that is
delivered or undertaken primarily to prevent, diagnose, treat or
palliate a disease, illness or injury, genetic or congenital defect,
pregnancy, or psychological condition that lies outside the range of
normal, age appropriate human variation.

> Interventions must be:

-   Effective for the patient's medical condition and indications, which
    is determined by scientific evidence consisting primarily of
    controlled clinical trails that demonstrate the effect of the
    intervention on health outcomes. If clinical trails have not been
    conducted, effectiveness is evaluated on the basis of professional
    standards of care or expert opinion.

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-   Expected to produce the intended results and have expected outcomes
    that outweigh potential harmful effects.

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```
-   Measurable by positive changes in the patient's health status as
    determined by length or quality of life.

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```
-   Appropriate for the patient's medical condition and indications. The
    expected outcome relative to cost must represent an economically
    efficient use of resources.

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-   Performed in the proper setting, at the proper time, in the proper
    amounts, and by the proper provider of care relative to the
    patient's condition.

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```
-   Recommended by the PCP and treating physician and determined by the
    Health Plan medical director to meet the above criteria.

**Allowed Amounts** Means the amount the Health Plan determines to be
the maximum amount for service(s) provided. The allowed amount(s) are
negotiated amounts agreed upon with Contracting Providers as payment in
full for services received by a Member.

**Us/We** Us and we refer to Preferred Plus of Kansas

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

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

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

**Coverage information**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   If you have no FEHB coverage, your employing office will enroll you
    for self and family coverage in the Blue Cross and Blue Shield
    Service Benefits Plan's Basic Option;

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

-   

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

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

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

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

> **Group Health Plan Coverage** The Health Insurance Portability and
> Accountability Act of 1996 (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 questions. These highlight HIPAA
rules, such as the requirement that Federal employees must exhaust any
TCC eligibility as one condition for guaranteed access to individual
health coverage under HIPAA, and has 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

> may help you decide whether to participate in FSAFEDS.

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

> the HCFSA at any time during the year for expenses up to the annual
> amount you\'ve
>
> elected to contribute.
>
> Only health care expenses exceeding 7.5% of your adjusted gross income
> are eligible to be deducted on your Federal income tax return. Using
> the example listed in the above chart, only health care expenses
> exceeding \$3,750 (7.5% of \$50,000) would be eligible to be deducted
> on your Federal income tax return. In addition, money set aside
> through a HCFSA is also exempt from FICA taxes. This exemption 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/).

-   
-   
-   
-   

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```
-   
-   

  -----------------------------------------------------------------------
  **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 38

Allergy tests 17

Allogenetic (donor) bone marrow transplant 26

Alternative treatment 22

Ambulance 29

Anesthesia 27

Autologous bone marrow transplant 26

Biopsy 24

Blood and blood plasma 28

Casts 28

Centers of Excellence 37

Changes for 2004, 8

Chemotherapy 18

Childbirth 16

Chiropractic 22

Cholesterol tests 15

Claims 40

Cognitive Therapy 32

Colorectal cancer screening 15

Compression Stockings 20

Congenital anomalies 24

Contraceptive devices and drugs 16,35

Coordination of benefits 43

Covered providers 9

Crutches 21

Definitions 48

Dental care 38

Diagnostic services 14

Disposable medical supplies 21

Disputed claims review 41

Donor expenses (transplants 27

Dressings 29

Durable medical equipment (DME) 21

Educational classes and programs 22

Effective date of enrollment 48

Emergency 30

Experimental or

investigational 39

Eyeglasses 19

**F**amily planning 16

Fecal occult blood test 15

Flexible benefits option 37

Fraud 6

**G**eneral Exclusions 39

**H**earing services 19

High risk pregnancies 37

Home health services 21

Hospice care 29

Home nursing care 22

Hospital 28

**I**mmunizations 15

Infertility 17

In-hospital physician care 28

Inpatient Hospital Benefits 28

Insulin 35

**L**aboratory and pathological services 14

**M**achine diagnostic tests 14

Magnetic Resonance Imagings (MRIs) 14

Mail Order Prescription Drugs 34

Mammograms 15

Maternity Benefits 16

Medicaid 47

Medicare 43

Mental Conditions/Substance Abuse Benefits 32

Newborn care 16

**O**bstetrical care 16

Occupational therapy 18

Office visits 14

Oral and maxillofacial surgery 25

Orthopedic devices 20

Ostomy and catheter supplies 21

Out-of-pocket expenses 12

Outpatient facility care 29

Oxygen 21

Pap test 15

Physical examination 15

Physical therapy 18

Precertification 11

Preventive care, adult 15

Preventive care, children 15

Prescription drugs 34

Preventive services 15

Prior approval 11

Prostate cancer screening 15

Prosthetic devices 20

Radiation therapy 18

Renal dialysis 18

Room and board 28

**S**econd surgical opinion 14

Skilled nursing facility care 29

Smoking cessation 32, 36

Speech therapy 19

Sterilization procedures 16

Substance abuse 32

Surgery 24

-   Anesthesia 27

```{=html}
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```
-   Oral 25

-   Outpatient 29

-   Reconstructive 25

    Syringes 35

    Temporary continuation of coverage 51

    Transplants 26

Treatment therapies 18

**V**ision services 19

**W**ell child care 15

Wheelchairs 21

Workers' compensation 46

**X**-rays 14

  -----------------------------------------------------------------------
  **Summary of benefits for the Preferred Plus of Kansas -** **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**                           | **You Pay**        | **P   |
|                                        |                    | age** |
+----------------------------------------+--------------------+-------+
| Medical services provided by           | Office visit       | > 14  |
| physicians:                            | copay: \$10        |       |
|                                        | primary care; \$10 |       |
| -   Diagnostic and treatment services  | specialist         |       |
|     provided in the office             |                    |       |
+----------------------------------------+--------------------+-------+
| Services provided by a hospital:       | > \$50 copay per   | > 28  |
|                                        | > day up to \$500  | >     |
| -   Inpatient                          | > maximum per      | > 29  |
|                                        | > person per       |       |
| -   Outpatient                         | > calendar         |       |
|                                        | > year/\$1,000     |       |
|                                        | > maximum per      |       |
|                                        | > family           |       |
|                                        | >                  |       |
|                                        | > Nothing          |       |
+----------------------------------------+--------------------+-------+
| Emergency benefits:                    | > \$50 per visit   | > 30  |
|                                        | >                  | >     |
| -   In-area                            | > \$50 per visit   | > 31  |
|                                        |                    |       |
| -   Out-of-area                        |                    |       |
+----------------------------------------+--------------------+-------+
| Mental health and substance abuse      | > Regular cost     | > 32  |
| treatment                              | > sharing          |       |
+----------------------------------------+--------------------+-------+
| Prescription drugs                     | > \$5 generic      | > 34  |
|                                        | > copay; \$15 name |       |
|                                        | > brand copay;     |       |
|                                        | > \$12 generic     |       |
|                                        | > mail-order       |       |
|                                        | > copay; \$40 name |       |
|                                        | > brand mail order |       |
|                                        | > copay            |       |
+----------------------------------------+--------------------+-------+
| Dental Care                            | > Accidental       | > 38  |
|                                        | > injury benefit;  |       |
|                                        | > \$10 copay per   |       |
|                                        | > visit            |       |
+----------------------------------------+--------------------+-------+
| Vision Care                            | > No benefit.      | > 19  |
+----------------------------------------+--------------------+-------+

**2004** **Rate Information for**

**Preferred Plus of Kansas**

**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 special
FEHB guide is published for Postal Service Inspectors and Office of
Inspector General (OIG) employees (see RI 70-2IN).

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

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

# Location Information: Marion, Harvey, Kingman, Sedgwick, Butler, Sumner, Cowley and Chautauqua counties in Kansas. 

  --------------- --------- -------------- -------------- -------------- -------------- -------------- --------------
  **Self Only**   **VA1**   **\$121.40**   **\$90.87**    **\$263.03**   **\$196.89**   **\$143.32**   **\$68.95**

  **Self and      **VA2**   **\$277.09**   **\$287.55**   **\$600.36**   **\$623.03**   **\$327.12**   **\$237.52**
  Family**                                                                                             
  --------------- --------- -------------- -------------- -------------- -------------- -------------- --------------

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

                                                                      

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

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

                                                                      
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