*{Keep this overview on 1 page.} {RV 6/30/}*

+-----------------------------------------------------------------------+
| **Section 5. Benefits \-- OVERVIEW**                                  |
|                                                                       |
| ***(See page xx for how our benefits changed this year and page xx    |
| 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. To obtain claims forms, claims filing advice, or more
information about our benefits, contact us at *{phone number}* or at our
website at www. *{insert web address}.* *{RV 5/12)*

(a) Medical services and supplies provided by physicians and other
    health care professionals xx-xx*{page #\'s of section}*

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

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

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

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

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

(d) Emergency services/accidents xx-xx

> •Medical emergency •Ambulance *{Note, if you STET Accidental injury in
> the text, add it back here}}*

(e) Mental health and substance abuse benefits xx-xx

(f) Prescription drug benefits xx

(g) Special features xx

• *{list your special features}*

(h) Dental benefits xx

(i) Point of service benefits *{If you don\'t have POS, remove t his and
    renumber j}* xx

(j) Non-FEHB benefits available to Plan members xx

Summary of benefits xx

*{insert page \# for summary at back of brochure}*

+---+---+-------------------------------------+----------------+---+----+
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+---+---+-------------------------------------+----------------+---+----+
|   | * | **Here are some important things to |                | * |    |
|   | * | keep in mind about these            |                | * |    |
|   | I | benefits:**                         |                | I |    |
|   | * |                                     |                | * |    |
|   | * | -   Please remember that all        |                | * |    |
|   |   |     benefits are subject to the     |                |   |    |
|   | * |     definitions, limitations, and   |                | * |    |
|   | * |     exclusions in this brochure and |                | * |    |
|   | M |     are payable only when we        |                | M |    |
|   | * |     determine they are medically    |                | * |    |
|   | * |     necessary.                      |                | * |    |
|   |   |                                     |                |   |    |
|   | * | -   Plan physicians must provide or |                | * |    |
|   | * |     arrange your care.              |                | * |    |
|   | P |                                     |                | P |    |
|   | * | -   The calendar year deductible    |                | * |    |
|   | * |     is: *{plan specific}* \$275 per |                | * |    |
|   |   |     person (\$550 per family). The  |                |   |    |
|   | * |     calendar year deductible        |                | * |    |
|   | * |     applies to almost all benefits  |                | * |    |
|   | O |     in this Section. We added "(No  |                | O |    |
|   | * |     deductible)" to show when the   |                | * |    |
|   | * |     calendar year deductible does   |                | * |    |
|   |   |     not apply. . *{If you want, you |                |   |    |
|   | * |     can say, "We added asterisks -  |                | * |    |
|   | * |     \* - to show when the calendar  |                | * |    |
|   | R |     year deductible does not        |                | R |    |
|   | * |     apply."}*. *{If HMO -- if you   |                | * |    |
|   | * |     don't have deductible, remove   |                | * |    |
|   |   |     this check mark or say "We have |                |   |    |
|   | * |     no calendar year deductible.}*  |                | * |    |
|   | * |                                     |                | * |    |
|   | T | ```{=html}                          |                | T |    |
|   | * | <!-- -->                            |                | * |    |
|   | * | ```                                 |                | * |    |
|   |   | -   Be sure to read Section 4,      |                |   |    |
|   | * |     *Your costs for covered         |                | * |    |
|   | * |     services* for valuable          |                | * |    |
|   | A |     information about how cost      |                | A |    |
|   | * |     sharing works. Also read        |                | * |    |
|   | * |     Section 9 about coordinating    |                | * |    |
|   |   |     benefits with other coverage,   |                |   |    |
|   | * |     including with Medicare.        |                | * |    |
|   | * |                                     |                | * |    |
|   | N |                                     |                | N |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | T |                                     |                | T |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | **You pay**    |   |    |
|   |   |                                     |                |   |    |
| * |   |                                     | **After the    |   |    |
| * |   |                                     | calendar year  |   |    |
| B |   |                                     | d              |   |    |
| e |   |                                     | eductible...** |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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| * |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$10 per     |   |    |
|   |   |                                     | > visit        |   |    |
| P |   |                                     | >              |   |    |
| r |   |                                     | > ***{Minimum  |   |    |
| o |   |                                     | > copay for    |   |    |
| f |   |                                     | > primary care |   |    |
| e |   |                                     | > office visit |   |    |
| s |   |                                     | > is \$10 per  |   |    |
| s |   |                                     | > 2000         |   |    |
| i |   |                                     | > neg          |   |    |
| o |   |                                     | otiations.}*** |   |    |
| n |   |                                     | >              |   |    |
| a |   |                                     | > *{{When you  |   |    |
| l |   |                                     | > have         |   |    |
| > |   |                                     | > different    |   |    |
|   |   |                                     | > copay for    |   |    |
| s |   |                                     | > primary care |   |    |
| e |   |                                     | > and          |   |    |
| r |   |                                     | > specialty    |   |    |
| v |   |                                     | > care, say:*  |   |    |
| i |   |                                     | >              |   |    |
| c |   |                                     | > \$10 per     |   |    |
| e |   |                                     | > visit to     |   |    |
| s |   |                                     | > your primary |   |    |
| > |   |                                     | > care         |   |    |
|   |   |                                     | > physician    |   |    |
| o |   |                                     | >              |   |    |
| f |   |                                     | > \$5 per      |   |    |
| > |   |                                     | > visit to a   |   |    |
|   |   |                                     | > specialist   |   |    |
| p |   |                                     | >              |   |    |
| h |   |                                     | > *{Change     |   |    |
| y |   |                                     | > copay        |   |    |
| s |   |                                     | > descriptions |   |    |
| i |   |                                     | > to fit your  |   |    |
| c |   |                                     | > cir          |   |    |
| i |   |                                     | cumstances}{RV |   |    |
| a |   |                                     | > 6-30}*       |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$10 per     |   |    |
|   |   |                                     | > visit        |   |    |
| P |   |                                     | >              |   |    |
| r |   |                                     | > *{Throughout |   |    |
| o |   |                                     | > this         |   |    |
| f |   |                                     | > brochure,    |   |    |
| e |   |                                     | > you may      |   |    |
| s |   |                                     | > reduce this  |   |    |
| s |   |                                     | > column, but  |   |    |
| i |   |                                     | > not less     |   |    |
| o |   |                                     | > than to 2\". |   |    |
| n |   |                                     | > Keep column  |   |    |
| a |   |                                     | > width        |   |    |
| l |   |                                     | > consistent   |   |    |
| > |   |                                     | > \-- e.g.,    |   |    |
|   |   |                                     | > don\'t have  |   |    |
| s |   |                                     | > a 2\" You    |   |    |
| e |   |                                     | > pay column   |   |    |
| r |   |                                     | > in one       |   |    |
| v |   |                                     | > section and  |   |    |
| i |   |                                     | > a 3\" You    |   |    |
| c |   |                                     | > pay column   |   |    |
| e |   |                                     | > in another   |   |    |
| s |   |                                     | > section.}{RV |   |    |
| > |   |                                     | > 5/11}*       |   |    |
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| * |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+

*Diagnostic and treatment services \-- Continued on next page*

+---------------------------------------------+------------------------+
| ### **Diagno                                | **You pay**            |
| stic and treatment services** *(Continued)* |                        |
+---------------------------------------------+------------------------+
| > *Not covered: { **remove this section if  | > *All charges.*       |
| > it does not apply}***                     |                        |
| >                                           |                        |
| > ***{You may [NOT]{.underline} exclude the |                        |
| > following, per HCFA\'s Office of Managed  |                        |
| > Care 12/4/84:***                          |                        |
| >                                           |                        |
| > ***{· Vaccines for pediatric and adult    |                        |
| > immunizations***                          |                        |
| >                                           |                        |
| > ***{· Nondental treatment of              |                        |
| > temporomandibular joint(TMJ) syndrome***  |                        |
| >                                           |                        |
| > ***{· Services for which a member has no  |                        |
| > responsibility to pay***                  |                        |
| >                                           |                        |
| > ***{· Services for intentionally          |                        |
| > inflicted injuries***                     |                        |
| >                                           |                        |
| > ***{· Services for injuries resulting     |                        |
| > from hazardous activities***              |                        |
| >                                           |                        |
| > {· *Injuries received in connection with  |                        |
| > the commission of a felony}*              |                        |
+---------------------------------------------+------------------------+
| # Lab, X-ray and other diagnostic tests     |                        |
+---------------------------------------------+------------------------+
| > Tests, such as: {RV 5/11}                 | > Nothing if you       |
|                                             | > receive these        |
| -   Blood tests                             | > services during your |
|                                             | > office visit;        |
| -   Urinalysis                              | > otherwise, \$10 per  |
|                                             | > visit                |
| -   Non-routine pap tests                   | >                      |
|                                             | > ***{ Normally there  |
| -   Pathology                               | > is not a copay for   |
|                                             | > these services when  |
| -   X-rays                                  | > received during an   |
|                                             | > office visit. Please |
| -   Non-routine Mammograms                  | > modify to show the   |
|                                             | > plan\'s benefit.}*** |
| -   Cat Scans/MRI                           |                        |
|                                             |                        |
| -   Ultrasound                              |                        |
|                                             |                        |
| -   Electrocardiogram and EEG               |                        |
+---------------------------------------------+------------------------+
| ##### Preventive care, adult                |                        |
+---------------------------------------------+------------------------+
| > Routine screenings, such as: *{---add     | > \$10 per visit       |
| > whatever benefits you want to add but     |                        |
| > keep these as a [minimum]{.underline};    |                        |
| > new boxes when the costs are different;   |                        |
| > same box if same cost.}*                  |                        |
|                                             |                        |
| -   Blood lead level -- One annually        |                        |
|                                             |                        |
| -   Total Blood Cholesterol -- once every   |                        |
|     three years, ages 19 through 64         |                        |
|                                             |                        |
| -   Colorectal Cancer Screening, including  |                        |
|                                             |                        |
| > ••Fecal occult blood test                 |                        |
+---------------------------------------------+------------------------+
|                                             |                        |
+---------------------------------------------+------------------------+
| > ••Sigmoidoscopy, screening -- every five  | > \$10 per visit       |
| > years starting at age 50                  |                        |
+---------------------------------------------+------------------------+
| > Prostate Specific Antigen (PSA test) --   | > \$10 per visit       |
| > one annually for men age 40 and older     |                        |
+---------------------------------------------+------------------------+
| > Routine pap test                          | > \$10 per visit       |
| >                                           |                        |
| > Note: The office visit is covered if pap  |                        |
| > test is received on the same day; see     |                        |
| > *Diagnosis and Treatment*, above.         |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ##### Preventive care, adult *(Continued)*  | > **You pay**          |
+---------------------------------------------+------------------------+
| > Routine mammogram --covered for women age | > \$10 per visit       |
| > 35 and older, as follows:                 |                        |
|                                             | ***{All FEHB plans     |
| -   From age 35 through 39, one during this | will follow the        |
|     five year period                        | recommendations of the |
|                                             | National Cancer        |
| -   From age 40 through 64, one every       | Advisory Board for the |
|     calendar year                           | provision of mammogram |
|                                             | at a minimum. Modify   |
| -   At age 65 and older, one every two      | to reflect plan        |
|     consecutive calendar years              | benefit.}***           |
+---------------------------------------------+------------------------+
| > *Not covered: Physical exams required for | > *All charges.*       |
| > obtaining or continuing employment or     |                        |
| > insurance, attending schools or camp, or  | ***{This exclusion is  |
| > travel.*                                  | not required under the |
|                                             | FEHB but we expect it  |
|                                             | applies to most plans  |
|                                             | and prefer this        |
|                                             | language. It is not    |
|                                             | intended to exclude    |
|                                             | periodic physical      |
|                                             | exams or check-ups; we |
|                                             | consider these to be   |
|                                             | preventive care.}***   |
+---------------------------------------------+------------------------+
| > Routine Immunizations, limited to:        | > \$10 per visit       |
|                                             |                        |
| -   Tetanus-diphtheria (Td) booster -- once | *{You may not charge   |
|     every 10 years, ages19 and over (except | coinsurance or copays  |
|     as provided for under Childhood         | for immunizations;     |
|     immunizations)                          | copays may apply to    |
|                                             | associated visits      |
| -   Influenza/Pneumococcal vaccines,        | however.}*             |
|     annually, age 65 and over               |                        |
+---------------------------------------------+------------------------+
| ##### Preventive care, children             | **You pay**            |
+---------------------------------------------+------------------------+
| -   Childhood immunizations recommended by  | > \$10 per visit       |
|     the American Academy of Pediatrics      |                        |
+---------------------------------------------+------------------------+
| -   Examinations, such as:                  | > \$10 per visit       |
|                                             | >                      |
| > ••Eye exams through age 17 to determine   | > ***{\"Eye and ear    |
| > the need for vision correction.           | > examinations for     |
| >                                           | > children through age |
| > ••Ear exams through age 17 to determine   | > 17, to determine the |
| > the need for hearing correction           | > need for vision and  |
| >                                           | > hearing correction\" |
| > ••Examinations done on the day of         | > are basic services   |
| > immunizations ( through age 22)           | > required of          |
|                                             | > Federally-qualified  |
| -   Well-child care charges for routine     | > plans.}***           |
|     examinations, immunizations and care    |                        |
|     (through age 22)                        |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Maternity care                     | **You pay**            |
+---------------------------------------------+------------------------+
| > Complete maternity (obstetrical) care,    | > \$10 per visit       |
| > such as:                                  |                        |
|                                             | ***{We encourage you   |
| -   Prenatal care                           | to provide incentives  |
|                                             | for prenatal care,     |
| -   Delivery                                | e.g., copay waivers.   |
|                                             | Some plans may apply a |
| -   Postnatal care                          | single copay for the   |
|                                             | entire pregnancy, if   |
| > Note: Here are some things to keep in     | you do, say that here. |
| > mind:                                     | The maternity stay     |
|                                             | requirement reflects   |
| -   You do not need to precertify your      | Title VI of Public Law |
|     normal delivery; see page xx for other  | 104-204, the           |
|     circumstances, such as extended stays   | Newborns\' and         |
|     for you or your baby.                   | Mothers\' Health       |
|                                             | Protection Act of      |
| -   You may remain in the hospital up to 48 | 1996\".}***            |
|     hours after a regular delivery and 96   |                        |
|     hours after a cesarean delivery. We     | ***{Definitive         |
|     will extend your inpatient stay if      | treatment for purposes |
|     medically necessary.                    | of your benefit:       |
|                                             | \"Treatment of a       |
| -   We cover routine nursery care of the    | disease or disorder    |
|     newborn child during the covered        | that includes          |
|     portion of the mother's maternity stay. | everything . . .       |
|     We will cover other care of an infant   | necessary to attain a  |
|     who requires non-routine treatment only | cure or the best       |
|     if we cover the infant under a Self and | results possible under |
|     Family enrollment. *{RV 6-16}*          | the                    |
|                                             | circumstances.\"}***   |
| -   We pay hospitalization and surgeon      |                        |
|     services (delivery) the same as for     |                        |
|     illness and injury. See Hospital        |                        |
|     benefits (Section 5c) and Surgery       |                        |
|     benefits (Section 5b)*.*                |                        |
+---------------------------------------------+------------------------+
| > *Not covered: Routine sonograms to        | > *All charges*        |
| > determine fetal age, size or sex*         |                        |
+---------------------------------------------+------------------------+
| ######## Family planning                    |                        |
+---------------------------------------------+------------------------+
| -   Voluntary sterilization                 | > \$10 per visit       |
|                                             |                        |
| -   Surgically implanted contraceptives     |                        |
|                                             |                        |
| -   Injectable contraceptive drugs          |                        |
|                                             |                        |
| -   Intrauterine devices (IUDs)             |                        |
|                                             |                        |
| ***{\"A broad range of voluntary family     |                        |
| planning services\" is one of the basic     |                        |
| health services mandated for                |                        |
| Federally-qualified plans. Modify benefit   |                        |
| description to describe Plan benefit.       |                        |
| Copays or coinsurance may apply. Voluntary  |                        |
| abortions may not be covered. Coinsurance   |                        |
| or copays may apply to surgical             |                        |
| procedures.}***                             |                        |
+---------------------------------------------+------------------------+
| > *Not covered: reversal of voluntary       | > *All charges.*       |
| > surgical sterilization, genetic           |                        |
| > counseling,*                              |                        |
+---------------------------------------------+------------------------+
| ######## Infertility services               | **You pay**            |
+---------------------------------------------+------------------------+
| > Diagnosis and treatment of infertility,   | > \$10 per visit       |
| > such as:                                  |                        |
|                                             |                        |
| -   Artificial insemination:                |                        |
|                                             |                        |
| > ••*intravaginal insemination (IVI)*       |                        |
| >                                           |                        |
| > ••*intra­cervical insemination (ICI)*      |                        |
| >                                           |                        |
| > ••*intrauterine insemina­tion (IUI)*       |                        |
|                                             |                        |
| -   Fertility drugs                         |                        |
|                                             |                        |
| Note: We cover injectable fertility drugs   |                        |
| under medical benefits and oral fertility   |                        |
| drugs under the prescription drug benefit.  |                        |
|                                             |                        |
| > ***{Services for the treatment of         |                        |
| > infertility, including at least one type  |                        |
| > of artificial insemination, are basic     |                        |
| > services required of Federally-qualified  |                        |
| > HMOs and may not be limited as to time    |                        |
| > and cost.. Coinsurance may apply and you  |                        |
| > may limit the number of procedures based  |                        |
| > on standards of accepted medical          |                        |
| > practice, per the fourth General          |                        |
| > Exclusion. You may cover the cost of      |                        |
| > donor sperm; we do not require that you   |                        |
| > exclude this benefit. Clarify the         |                        |
| > coverage of fertility drugs and, if       |                        |
| > covered, whether they are covered as      |                        |
| > prescription drugs. Expanded coverage,    |                        |
| > e.g., ART, is required in several states. |                        |
| > We expect you to cover state-mandated     |                        |
| > benefits whether or not they are          |                        |
| > specifically referenced in a plan\'s      |                        |
| > community package. In that case, modify   |                        |
| > the language to reflect Plan              |                        |
| > benefits.***}                             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Assisted reproductive technology (ART) |                        |
|     procedures, such as:*                   |                        |
|                                             |                        |
| > ••*in vitro fertilization*                |                        |
| >                                           |                        |
| > ••*embryo transfer and GIFT*              |                        |
|                                             |                        |
| -   *Services and supplies related to       |                        |
|     excluded ART procedures*                |                        |
|                                             |                        |
| -   *Cost of donor sperm*                   |                        |
+---------------------------------------------+------------------------+
| > **Allergy care**                          |                        |
+---------------------------------------------+------------------------+
| > Testing and treatment                     | > \$10 per visit       |
| >                                           |                        |
| > Allergy injection                         |                        |
| >                                           |                        |
| > ***{Allergy testing and treatment are     |                        |
| > required benefits for all                 |                        |
| > Federally-qualified HMOs, and therefore   |                        |
| > FEHB HMOs. You must cover allergy serum   |                        |
| > in full.}***                              |                        |
+---------------------------------------------+------------------------+
| > Allergy serum                             | > Nothing              |
+---------------------------------------------+------------------------+
| > *Not covered: provocative food testing    | > *All charges.*       |
| > and sublingual allergy desensitization*   |                        |
+---------------------------------------------+------------------------+
| ######## Treatment therapies                | **You pay**            |
+---------------------------------------------+------------------------+
| -   Chemotherapy and radiation therapy      | > \$10 per visit       |
|                                             |                        |
| > Note: High dose chemotherapy in           |                        |
| > association with autologous bone marrow   |                        |
| > transplants are limited to those          |                        |
| > transplants listed under Organ/Tissue     |                        |
| > Transplants on page xx.                   |                        |
|                                             |                        |
| -   Respiratory and inhalation therapy      |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Dialysis -- Hemodialysis and peritoneal |                        |
|     dialysis                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Intravenous (IV)/Infusion Therapy --    |                        |
|     Home IV and antibiotic therapy          |                        |
|                                             |                        |
| -   Growth hormone therapy (GHT)            |                        |
|                                             |                        |
| > Note: -- We will only cover GHT when we   |                        |
| > preauthorize the treatment. *{Plan        |                        |
| > specific\--IF YOU HAVE SUCH REQUIREMENT;  |                        |
| > summarize instructions on how to get      |                        |
| > authorization \-- here is one plan\'s     |                        |
| > example}* Call xxx for preauthorization.  |                        |
| > We will ask you to submit information     |                        |
| > that establishes that the GHT is          |                        |
| > medically necessary. Ask us to authorize  |                        |
| > GHT before you begin treatment;           |                        |
| > otherwise, we will only cover GHT         |                        |
| > services from the date you submit the     |                        |
| > information. If you do not ask or if we   |                        |
| > determine GHT is not medically necessary, |                        |
| > we will not cover the GHT or related      |                        |
| > services and supplies. See *Services      |                        |
| > requiring our prior approval* in Section  |                        |
| > 3.                                        |                        |
|                                             |                        |
| ***{Growth Hormone therapy is a required    |                        |
| benefit for all plans. Note whether it is   |                        |
| covered under the plan\'s prescription drug |                        |
| benefit or under medical..}***              |                        |
|                                             |                        |
| ***{Radiation therapy and inhalation        |                        |
| therapy are basic health services required  |                        |
| of federally-qualified plans and therefore  |                        |
| of FEHB plans, starting in 1990. For this   |                        |
| reason, they must be provided without       |                        |
| limitations as to time and cost. As         |                        |
| respiratory therapy includes inhalation     |                        |
| therapy, we will not permit respiratory     |                        |
| therapy to be subject to limitations of     |                        |
| time and cost.}***                          |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Rehabilitative therapies**              | **You pay**            |
+---------------------------------------------+------------------------+
| > Physical therapy, occupational therapy    | > \$10 per visit       |
| > and speech therapy \--                    |                        |
|                                             |                        |
| -   60 visits per condition for the         |                        |
|     services of each of the following:      |                        |
|                                             |                        |
| > ••qualified physical therapists;          |                        |
| >                                           |                        |
| > ••speech therapists; and                  |                        |
| >                                           |                        |
| > ••occupational therapists.                |                        |
| >                                           |                        |
| > Note: We only cover therapy to restore    |                        |
| > bodily function or speech when there has  |                        |
| > been a total or partial loss of bodily    |                        |
| > function or functional speech due to      |                        |
| > illness or injury.                        |                        |
| >                                           |                        |
| > ***{The required benefit level is up to   |                        |
| > two consecutive months per condition. A   |                        |
| > plan may provide a richer benefit, such   |                        |
| > as 60 visits per condition, if that is    |                        |
| > their community benefit. The word         |                        |
| > \"condition\" is part of the benefit      |                        |
| > description for Federally-qualified plans |                        |
| > and must be retained. Copays or           |                        |
| > coinsurance of up to 50% may apply}***    |                        |
|                                             |                        |
| -   Cardiac rehabilitation following a      |                        |
|     heart transplant, bypass surgery or a   |                        |
|     myocardial infarction, is provided for  |                        |
|     up to 00 sessions                       |                        |
|                                             |                        |
| > *{Cardiac rehabilitation is n**ot a       |                        |
| > required benefit but a desirable one      |                        |
| > covered by many plans. If not covered,    |                        |
| > list as an exclusion. Modify language to  |                        |
| > fit the Plan\'s benefit.}***              |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *long-term rehabilitative therapy*      |                        |
|                                             |                        |
| -   *exercise programs*                     |                        |
+---------------------------------------------+------------------------+
| > **Hearing services (testing, treatment,   |                        |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| -   First hearing aid and testing only when | > \$10 per visit       |
|     necessitated by accidental injury       |                        |
|                                             |                        |
| -   Hearing testing for children through    |                        |
|     age 17 (see *Preventive care,           |                        |
|     children*)                              |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *all other hearing testing*             |                        |
|                                             |                        |
| -   *hearing aids, testing and examinations |                        |
|     for them*                               |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Vision services (testing, treatment,    | **You pay**            |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| > *{insert any vision care benefit from     |                        |
| > 2000 brochure}*                           |                        |
+---------------------------------------------+------------------------+
| -   One pair of eyeglasses or contact       | > \$10 per visit       |
|     lenses to correct an impairment         |                        |
|     directly caused by accidental ocular    |                        |
|     injury or intraocular surgery (such as  |                        |
|     for cataracts)                          |                        |
+---------------------------------------------+------------------------+
| -   Eye exam to determine the need for      | > \$10 per visit       |
|     vision correction for children through  |                        |
|     age 17 (see preventive care)            |                        |
|                                             |                        |
| -   Annual eye refractions                  |                        |
|                                             |                        |
| > ***{Modify to reflect plan benefit. Like  |                        |
| > Dental care, we will accept proposals for |                        |
| > Vision care only when the benefit is an   |                        |
| > integral part of the community            |                        |
| > package.}***                              |                        |
| >                                           |                        |
| > ***{We encourage plans offering new       |                        |
| > vision or dental benefits that are        |                        |
| > [not]{.underline} part of the community   |                        |
| > package to describe them on the non-FEHB  |                        |
| > page of the brochure.}***                 |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Eyeglasses or contact lenses and,      |                        |
|     after age 17, examinations for them*    |                        |
|                                             |                        |
| -   *Eye exercises and orthoptics*          |                        |
|                                             |                        |
| -   *Radial keratotomy and other refractive |                        |
|     surgery*                                |                        |
+---------------------------------------------+------------------------+
| ######## Foot care                          |                        |
+---------------------------------------------+------------------------+
| > Routine foot care when you are under      | > \$10 per visit       |
| > active treatment for a metabolic or       |                        |
| > peripheral vascular disease, such as      |                        |
| > diabetes.                                 |                        |
| >                                           |                        |
| > See orthopedic and prosthetic devices for |                        |
| > information on podiatric shoe inserts.    |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Cutting, trimming or removal of corns, |                        |
|     calluses, or the free edge of toenails, |                        |
|     and similar routine treatment of        |                        |
|     conditions of the foot, except as       |                        |
|     stated above*                           |                        |
|                                             |                        |
| -   *Treatment of weak, strained or flat    |                        |
|     feet or bunions or spurs; and of any    |                        |
|     instability, imbalance or subluxation   |                        |
|     of the foot (unless the treatment is by |                        |
|     open cutting surgery)*                  |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Orthopedic and prosthetic devices**     | **You pay**            |
+---------------------------------------------+------------------------+
| > ***{Not a required benefit; However, all  | > \$10 per visit       |
| > plans must cover breast prostheses and    |                        |
| > surgical bras including necessary         |                        |
| > replacements following a mastectomy.}***  |                        |
| >                                           |                        |
| > ***{Modify language to describe Plan      |                        |
| > benefits and note any exclusions or       |                        |
| > specific type of coverage e.g. standard   |                        |
| > artificial limbs, or if plan will cover   |                        |
| > upgrades up to cost of standard           |                        |
| > device.}***                               |                        |
|                                             |                        |
| -   Artificial limbs and eyes; stump hose   |                        |
|                                             |                        |
| -   Externally worn breast prostheses and   |                        |
|     surgical bras, including necessary      |                        |
|     replacements, following a mastectomy    |                        |
|                                             |                        |
| > *{If you pay for devices in this section, |                        |
| > use the following language:}*             |                        |
|                                             |                        |
| -   Internal prosthetic devices, such as    |                        |
|     artificial joints, pacemakers, cochlear |                        |
|     implants, and surgically implanted      |                        |
|     breast implant following mastectomy.    |                        |
|     Note: See 5(b) for coverage of the      |                        |
|     surgery to insert the device.           |                        |
|                                             |                        |
| > *{If you pay for devices under hospital   |                        |
| > benefits, use the following language:}*   |                        |
|                                             |                        |
| -   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.                      |                        |
|                                             |                        |
| -   Corrective orthopedic appliances for    |                        |
|     non-dental treatment of                 |                        |
|     temporomandibular joint (TMJ) pain      |                        |
|     dysfunction syndrome.                   |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *orthopedic and corrective shoes*       |                        |
|                                             |                        |
| -   *arch supports*                         |                        |
|                                             |                        |
| -   *foot orthotics*                        |                        |
|                                             |                        |
| -   *heel pads and heel cups*               |                        |
|                                             |                        |
| -   *lumbosacral supports*                  |                        |
|                                             |                        |
| -   *corsets, trusses, elastic stockings,   |                        |
|     support hose, and other supportive      |                        |
|     devices*                                |                        |
|                                             |                        |
| -   *prosthetic replacements provided less  |                        |
|     than 3 years after the last one we      |                        |
|     covered*                                |                        |
+---------------------------------------------+------------------------+
| ######## Durable medical equipment (DME)    | **You pay**            |
+---------------------------------------------+------------------------+
| > ***{ Not a required benefit; If you       | > \$10 per visit       |
| > don\'t cover any, show \"No benefit\" in  |                        |
| > the benefit description and You Pay       |                        |
| > column.}***                               |                        |
| >                                           |                        |
| > ***{Modify language to describe Plan      |                        |
| > benefits and note any DME exclusions,     |                        |
| > e.g., motorized wheel chairs. If any are  |                        |
| > not covered, list under \"Not             |                        |
| > covered\".}***                            |                        |
| >                                           |                        |
| > Rental or purchase, at our option,        |                        |
| > including repair and adjustment, of       |                        |
| > durable medical equipment prescribed by   |                        |
| > your Plan physician, such as oxygen and   |                        |
| > dialysis equipment. Under this benefit,   |                        |
| > we also cover: *{List plan speciifc}*     |                        |
|                                             |                        |
| -   hospital beds;                          |                        |
|                                             |                        |
| -   wheelchairs; *{If you don't cover a     |                        |
|     certain kind of wheelchair, you need to |                        |
|     show what you do cover here, and what   |                        |
|     you don't, below}*                      |                        |
|                                             |                        |
| -   crutches;                               |                        |
|                                             |                        |
| -   walkers;                                |                        |
|                                             |                        |
| -   blood glucose monitors; and             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   insulin pumps.                          |                        |
|                                             |                        |
| > Note: Call us at xxx as soon as your Plan |                        |
| > physician prescribes this equipment. We   |                        |
| > will arrange with a health care provider  |                        |
| > to rent or sell you durable medical       |                        |
| > equipment at discounted rates and will    |                        |
| > tell you more about this service when you |                        |
| > call. *{add this kind of note if you      |                        |
| > offer this type of enhancement}*          |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Motorized wheel chairs*                |                        |
|                                             |                        |
| -                                           |                        |
+---------------------------------------------+------------------------+
| ######## Home health services               |                        |
+---------------------------------------------+------------------------+
| -   Home health care ordered by a Plan      | > \$10 per visit       |
|     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. *{You    |                        |
|     must cover home health aide for this.}* |                        |
|                                             |                        |
| -   Services include oxygen therapy,        |                        |
|     intravenous therapy and medications.    |                        |
|                                             |                        |
| > ***{Home health services are a required   |                        |
| > benefit. Federally-qualified HMOs are     |                        |
| > required to provide \"Home health         |                        |
| > services provided at a member\'s home by  |                        |
| > health care personnel, as prescribed or   |                        |
| > directed by the responsible physician or  |                        |
| > other authority designated by the HMO.\"  |                        |
| > Modify the language to describe the staff |                        |
| > used by the Plan to provide these         |                        |
| > services. These are basic benefits and    |                        |
| > may not be subject to dollar or day       |                        |
| > limitations. If a copay applies,          |                        |
| > reference under you pay or show Nothing.  |                        |
| > Outpatient benefits provided only in      |                        |
| > conjunction with home health care, e.g.,  |                        |
| > oxygen therapy, should be described here. |                        |
| > Coverage of intravenous therapy and       |                        |
| > medications was required for \'94 per the |                        |
| > \'93 Call Letter. This benefit was        |                        |
| > previously listed under Prescription Drug |                        |
| > Benefits.}***                             |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Home health services *(Continued)* | **You pay**            |
+---------------------------------------------+------------------------+
| > Not covered:                              | > *All charges.*       |
|                                             |                        |
| -   *nursing care requested by, or for the  |                        |
|     convenience of, the patient or the      |                        |
|     patient's family;*                      |                        |
|                                             |                        |
| -   *nursing care primarily for hygiene,    |                        |
|     feeding, exercising, moving the         |                        |
|     patient, homemaking, companionship or   |                        |
|     giving oral medication.*                |                        |
+---------------------------------------------+------------------------+
| ######## Alternative treatments             |                        |
+---------------------------------------------+------------------------+
| > Acupuncture -- by a doctor of medicine or | > \$10 per visit       |
| > osteopathy for: anesthesia, pain relief   |                        |
| > *{plan specific}*                         |                        |
+---------------------------------------------+------------------------+
| ## Not covered:                             | > *All charges.*       |
|                                             |                        |
| -   *chiropractic services*                 |                        |
|                                             |                        |
| ## naturopathic services                    |                        |
|                                             |                        |
| ## hypnotherapy                             |                        |
|                                             |                        |
| ## biofeedback                              |                        |
+---------------------------------------------+------------------------+
| #### **Educational classes and programs**   |                        |
+---------------------------------------------+------------------------+
| > Coverage is limited to:                   | > \$10 per visit       |
|                                             |                        |
| -   Smoking Cessation -- Up to \$100 for    |                        |
|     one smoking cessation program per       |                        |
|     member per lifetime, including all      |                        |
|     related expenses such as drugs.         |                        |
|                                             |                        |
| -   Diabetes self-management                |                        |
|                                             |                        |
| > ***{You may list classes or support       |                        |
| > sessions that promote self-care on this   |                        |
| > page with other preventive services IF    |                        |
| > they are included in the community        |                        |
| > package, and thus are paid for by our     |                        |
| > premium. Charges, if any, should be       |                        |
| > minimal. If not under community package,  |                        |
| > list on non-FEHB page.}***                |                        |
+---------------------------------------------+------------------------+

+---+---+-------------------------------------+----------------+---+---+
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| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
|   | * | > **Here are some important things  |                | * |   |
|   | * | > to keep in mind about these       |                | * |   |
|   | I | > benefits:**                       |                | I |   |
|   | * |                                     |                | * |   |
|   | * | -   Please remember that all        |                | * |   |
|   |   |     benefits are subject to the     |                |   |   |
|   | * |     definitions, limitations, and   |                | * |   |
|   | * |     exclusions in this brochure and |                | * |   |
|   | M |     are payable only when we        |                | M |   |
|   | * |     determine they are medically    |                | * |   |
|   | * |     necessary.                      |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Plan physicians must provide or |                | * |   |
|   | * |     arrange your care.              |                | * |   |
|   | P |                                     |                | P |   |
|   | * | -   The calendar year deductible    |                | * |   |
|   | * |     is: \$275 per person (\$550 per |                | * |   |
|   |   |     family). The calendar year      |                |   |   |
|   | * |     deductible applies to almost    |                | * |   |
|   | * |     all benefits in this Section.   |                | * |   |
|   | O |     We added "(No deductible)" to   |                | O |   |
|   | * |     show when the calendar year     |                | * |   |
|   | * |     deductible does not apply. *{If |                | * |   |
|   |   |     you want, you can say, "We      |                |   |   |
|   | * |     added asterisks - \* - to show  |                | * |   |
|   | * |     when the calendar year          |                | * |   |
|   | R |     deductible does not apply."}.*  |                | R |   |
|   | * |     *{If HMO -- if you don't have   |                | * |   |
|   | * |     deductible, remove this check   |                | * |   |
|   |   |     mark or say "We have no         |                |   |   |
|   | * |     calendar year deductible.}*     |                | * |   |
|   | * |                                     |                | * |   |
|   | T | -   Be sure to read Section 4,      |                | T |   |
|   | * |     *Your costs for covered         |                | * |   |
|   | * |     services* for valuable          |                | * |   |
|   |   |     information about how cost      |                |   |   |
|   | * |     sharing works. Also read        |                | * |   |
|   | * |     Section 9 about coordinating    |                | * |   |
|   | A |     benefits with other coverage,   |                | A |   |
|   | * |     including with Medicare.        |                | * |   |
|   | * |                                     |                | * |   |
|   |   | -   The amounts listed below are    |                |   |   |
|   | * |     for the charges billed by a     |                | * |   |
|   | * |     physician or other health care  |                | * |   |
|   | N |     professional for your surgical  |                | N |   |
|   | * |     care. Look in Section 5(c) for  |                | * |   |
|   | * |     charges associated with the     |                | * |   |
|   |   |     facility (i.e. hospital,        |                |   |   |
|   | * |     surgical center, etc.). *{RV    |                | * |   |
|   | * |     6-30}*                          |                | * |   |
|   | T |                                     |                | T |   |
|   | * | ```{=html}                          |                | * |   |
|   | * | <!-- -->                            |                | * |   |
|   |   | ```                                 |                |   |   |
|   |   | -   YOU MUST GET PRECERTIFICATION   |                |   |   |
|   |   |     OF SOME SURGICAL PROCEDURES.    |                |   |   |
|   |   |     Please refer to the             |                |   |   |
|   |   |     precertification information    |                |   |   |
|   |   |     shown in Section 3 to be sure   |                |   |   |
|   |   |     which services require          |                |   |   |
|   |   |     precertification and identify   |                |   |   |
|   |   |     which surgeries require         |                |   |   |
|   |   |     precertification. *{Plan        |                |   |   |
|   |   |     specific -- delete if not       |                |   |   |
|   |   |     applicable}*                    |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | **You pay**    |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     | **After the    |   |   |
| * |   |                                     | calendar year  |   |   |
| B |   |                                     | d              |   |   |
| e |   |                                     | eductible...** |   |   |
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+---+---+-------------------------------------+----------------+---+---+
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+---+---+-------------------------------------+----------------+---+---+
| - |   |                                     | > \$10 per     |   |   |
|   |   |                                     | > visit        |   |   |
|   |   |                                     | >              |   |   |
|   |   |                                     | > *{Change     |   |   |
| T |   |                                     | > copay        |   |   |
| r |   |                                     | > descriptions |   |   |
| e |   |                                     | > to fit your  |   |   |
| a |   |                                     | >              |   |   |
| t |   |                                     | circumstances. |   |   |
| m |   |                                     | > For many     |   |   |
| e |   |                                     | > plans, this  |   |   |
| n |   |                                     | > would be     |   |   |
| t |   |                                     | > \$10 per     |   |   |
|   |   |                                     | > office       |   |   |
|   |   |                                     | > visit;       |   |   |
|   |   |                                     | > nothing for  |   |   |
|   |   |                                     | > hospital     |   |   |
| o |   |                                     | > visits}{RV   |   |   |
| f |   |                                     | > 6-30}*       |   |   |
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+---+---+-------------------------------------+----------------+---+---+

*Surgical procedures continued on next page.*

+---------------------------------------------+------------------------+
| > **Surgical procedures** *(Continued)*     | > **You pay**          |
+---------------------------------------------+------------------------+
| > ***{Surgical treatment of morbid          |                        |
| > obesity*** ***is required of              |                        |
| > Federally-qualified plans, and therefore  |                        |
| > FEHB HMOs. In our view, surgery for       |                        |
| > morbid obesity should be performed only   |                        |
| > as a last resort, when the member\'s      |                        |
| > health is endangered and more             |                        |
| > conservative medical measures, including  |                        |
| > prescription drugs such as appetite       |                        |
| > suppressants, have not been               |                        |
| > successful.}***                           |                        |
| >                                           |                        |
| > ***{The internal prosthetic device must   |                        |
| > be medically necessary to restore bodily  |                        |
| > function and require a surgical incision  |                        |
| > (as opposed to an external prosthetic     |                        |
| > device). Examples: artificial knuckles    |                        |
| > and joints, pacemakers, defibrillator,    |                        |
| > penile implants. Medically necessary      |                        |
| > implants are required of                  |                        |
| > Federally-qualified HMOs, and therefore   |                        |
| > FEHB HMOs. The Plan may exclude the cost  |                        |
| > of the device if it is excluded from      |                        |
| > their community package but must cover    |                        |
| > the surgery. List non-covered devices     |                        |
| > under Not covered.}{RV 5/12}***           |                        |
+---------------------------------------------+------------------------+
| -   Voluntary sterilization                 | > \$10 per visit       |
|                                             |                        |
| -   Norplant (a surgically implanted        |                        |
|     contraceptive) and intrauterine devices |                        |
|     (IUDs) Note: Devices are covered under  |                        |
|     5(a).                                   |                        |
|                                             |                        |
| -   Treatment of burns                      |                        |
|                                             |                        |
| Note: Generally, we pay for internal        |                        |
| prostheses (devices) according to where the |                        |
| procedure is done. For example, we pay      |                        |
| Hospital benefits for a pacemaker and       |                        |
| Surgery benefits for insertion of the       |                        |
| pacemaker.                                  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Reversal of voluntary sterilization*   |                        |
|                                             |                        |
| -   *Routine treatment of conditions of the |                        |
|     foot; see Foot care.*                   |                        |
+---------------------------------------------+------------------------+
| > **Reconstructive surgery**                |                        |
+---------------------------------------------+------------------------+
| > ***{You may not limited this benefit as   | > \$10 per visit       |
| > to time or cost; nor apply a deductible,  |                        |
| > or coinsurance in excess of 50%. When     |                        |
| > this language was mandated in 1992 for    |                        |
| > all FEHB plans, in conjunction with the   |                        |
| > plastic surgery exclusion, it was our     |                        |
| > intent to avoid lists of specific         |                        |
| > procedures to be covered or excluded. We  |                        |
| > expect reconstructive surgery following a |                        |
| > mastectomy to approximate a normal        |                        |
| > appearance, including reconstruction of   |                        |
| > the nipple area; surgery would include    |                        |
| > distant tissue transfers and              |                        |
| > reconstruction of the healthy breast when |                        |
| > necessary to restore symmetry.}***        |                        |
|                                             |                        |
| -   Surgery to correct a functional defect  |                        |
|                                             |                        |
| -   Surgery to correct a condition caused   |                        |
|     by injury or illness if:                |                        |
|                                             |                        |
| > ••the condition produced a major effect   |                        |
| > on the member's appearance and            |                        |
| >                                           |                        |
| > ••the condition can reasonably be         |                        |
| > expected to be corrected by such surgery  |                        |
|                                             |                        |
| -   Surgery to correct a condition that     |                        |
|     existed at or from birth and is a       |                        |
|     significant deviation from the common   |                        |
|     form or norm. Examples of congenital    |                        |
|     anomalies are: protruding ear           |                        |
|     deformities; cleft lip; cleft palate;   |                        |
|     birth marks; webbed fingers; and webbed |                        |
|     toes.                                   |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Reconstructive surgery** *(Continued)*  | > **You pay**          |
+---------------------------------------------+------------------------+
| -   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. *{RV 6-22}*{***This            |                        |
| > requirement is effective 1/1/98, per the  |                        |
| > 3/31/97 Call Letter.}***                  |                        |
+---------------------------------------------+------------------------+
| > *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*                         |                        |
|                                             |                        |
| > ***{You may [not]{.underline} exclude     |                        |
| > sexual inadequacy and sexual dysfunction. |                        |
| > Coverage for both are required of         |                        |
| > federally qualified plans, and therefore  |                        |
| > required of HMOs in the FEHB.}***         |                        |
+---------------------------------------------+------------------------+
| > **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.                             |                        |
|                                             |                        |
| ***{Our intention is that this surgery is   |                        |
| performed only when medically necessary;    |                        |
| for example, orthognathic surgery would be  |                        |
| covered when the member\'s health is        |                        |
| affected but not when the doctor determines |                        |
| it is to improve the appearance of a        |                        |
| functioning structure.}***                  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Oral implants and transplants*         |                        |
|                                             |                        |
| -   *Procedures that involve the teeth or   |                        |
|     their supporting structures (such as    |                        |
|     the periodontal membrane, gingiva, and  |                        |
|     alveolar bone)*                         |                        |
|                                             |                        |
| ***{Treatment of TMJ, including surgical    |                        |
| and non-surgical intervention, corrective   |                        |
| orthopedic appliances and physical therapy, |                        |
| is required the same as for any other       |                        |
| skeletal joint and may not be excluded;     |                        |
| related dental work may be excluded or      |                        |
| limited.}***                                |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Organ/tissue transplants**              | > **You pay**          |
+---------------------------------------------+------------------------+
| > Limited to:                               | > \$10 per visit       |
|                                             |                        |
| -   Cornea                                  |                        |
|                                             |                        |
| -   Heart                                   |                        |
|                                             |                        |
| -   Heart/lung                              |                        |
|                                             |                        |
| -   Kidney                                  |                        |
|                                             |                        |
| -   Kidney/Pancreas                         |                        |
|                                             |                        |
| -   Liver                                   |                        |
|                                             |                        |
| -   Lung: Single --Double                   |                        |
|                                             |                        |
| -   Pancreas                                |                        |
|                                             |                        |
| -   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                                  |                        |
|                                             |                        |
| -   National Transplant Program (NTP) -     |                        |
|     *.............{plan specific here}*     |                        |
|                                             |                        |
| > 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. ***{You may require  |                        |
| > coinsurance for donor expenses of up to   |                        |
| > 20% of charges. The language \"when we    |                        |
| > cover the recipient \" is intended to     |                        |
| > prevent someone donating an organ to a    |                        |
| > non-Plan member from seeking coverage for |                        |
| > the operation.}***                        |                        |
| >                                           |                        |
| > ***{We require full coverage of cornea,   |                        |
| > heart, kidney and liver transplants. You  |                        |
| > may cover additional transplants, such as |                        |
| > lung (single/double), heart/lung,         |                        |
| > pancreas, pancreas/kidney. Leading the    |                        |
| > covered list with \"Limited to\" and the  |                        |
| > optional exclusion of \"Transplants not   |                        |
| > listed as covered\", under Not covered,   |                        |
| > clarifies that you do not cover other     |                        |
| > non-experimental transplants. You may     |                        |
| > limit coverage of autologous bone marrow  |                        |
| > transplants to non-random clinical        |                        |
| > trials, and propose limitations such as   |                        |
| > specific treatment location, requirement  |                        |
| > of medical director approval, etc.}***    |                        |
+---------------------------------------------+------------------------+
| > *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*     |                        |
|                                             |                        |
| > ***{You may not specify the type of       |                        |
| > breast cancer covered or not covered,     |                        |
| > e.g., stage 2. This does not mean that    |                        |
| > you must pay for a stage 4 case but       |                        |
| > rather that you must determine if stage 4 |                        |
| > is medically necessary treatment and      |                        |
| > communicate that reason to the            |                        |
| > patient.}***                              |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Anesthesia**                            | > **You pay**          |
+---------------------------------------------+------------------------+
| > Professional services provided in --      | > \$10 per visit       |
|                                             |                        |
| -   Hospital (inpatient)                    |                        |
+---------------------------------------------+------------------------+
| > Professional services provided in --      | > \$10 per visit       |
|                                             |                        |
| -   Hospital outpatient department          |                        |
|                                             |                        |
| -   Skilled nursing facility                |                        |
|                                             |                        |
| -   Ambulatory surgical center              |                        |
|                                             |                        |
| -   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.                |   |             | * |     |
|    | * |                                   |   |             | * |     |
|    |   | -   Unlike Sections (a) and (b),  |   |             |   |     |
|    | * |     in this section the calendar  |   |             | * |     |
|    | * |     year deductible applies to    |   |             | * |     |
|    | O |     only a few benefits. In that  |   |             | O |     |
|    | * |     case, we added "(calendar     |   |             | * |     |
|    | * |     year deductible applies)".    |   |             | * |     |
|    |   |     ***[{Be sure to notice this   |   |             |   |     |
|    | * |     is a different                |   |             | * |     |
|    | * |     bullet}]{.underline}***       |   |             | * |     |
|    | 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.      |   |             | * |     |
|    |   |                                   |   |             |   |     |
|    | * | -   The amounts listed below are  |   |             | * |     |
|    | * |     for the charges billed by the |   |             | * |     |
|    | A |     facility (i.e., hospital or   |   |             | A |     |
|    | * |     surgical center) or ambulance |   |             | * |     |
|    | * |     service for your surgery or   |   |             | * |     |
|    |   |     care. Any costs associated    |   |             |   |     |
|    | * |     with the professional charge  |   |             | * |     |
|    | * |     (i.e., physicians, etc.) are  |   |             | * |     |
|    | N |     covered in Section 5(a) or    |   |             | N |     |
|    | * |     (b).                          |   |             | * |     |
|    | * |                                   |   |             | * |     |
|    |   | ```{=html}                        |   |             |   |     |
|    | * | <!-- -->                          |   |             | * |     |
|    | * | ```                               |   |             | * |     |
|    | T | -   **YOU MUST GET                |   |             | T |     |
|    | * |     PRECERTIFICATION OF HOSPITAL  |   |             | * |     |
|    | * |     STAYS.** Please refer to      |   |             | * |     |
|    |   |     Section 3 to be sure which    |   |             |   |     |
|    |   |     services require              |   |             |   |     |
|    |   |     precertification. *{Don\'t    |   |             |   |     |
|    |   |     add this bullet unless you    |   |             |   |     |
|    |   |     have precertification.\--You  |   |             |   |     |
|    |   |     probably DON\'T have          |   |             |   |     |
|    |   |     precertification.}*           |   |             |   |     |
+----+---+-----------------------------------+---+-------------+---+-----+
| >  |   |                                   | * |             |   |     |
|  * |   |                                   | * |             |   |     |
| *B |   |                                   | Y |             |   |     |
| en |   |                                   | o |             |   |     |
| ef |   |                                   | u |             |   |     |
| it |   |                                   | p |             |   |     |
| >  |   |                                   | a |             |   |     |
|  D |   |                                   | y |             |   |     |
| es |   |                                   | * |             |   |     |
| cr |   |                                   | * |             |   |     |
| ip |   |                                   |   |             |   |     |
| ti |   |                                   |   |             |   |     |
| on |   |                                   |   |             |   |     |
| ** |   |                                   |   |             |   |     |
+----+---+-----------------------------------+---+-------------+---+-----+
| #  |   |                                   |   |             |   |     |
| ## |   |                                   |   |             |   |     |
|  * |   |                                   |   |             |   |     |
| *N |   |                                   |   |             |   |     |
| OT |   |                                   |   |             |   |     |
| E: |   |                                   |   |             |   |     |
|  T |   |                                   |   |             |   |     |
| he |   |                                   |   |             |   |     |
|  c |   |                                   |   |             |   |     |
| al |   |                                   |   |             |   |     |
| en |   |                                   |   |             |   |     |
| da |   |                                   |   |             |   |     |
| r  |   |                                   |   |             |   |     |
| ye |   |                                   |   |             |   |     |
| ar |   |                                   |   |             |   |     |
|  d |   |                                   |   |             |   |     |
| ed |   |                                   |   |             |   |     |
| uc |   |                                   |   |             |   |     |
| ti |   |                                   |   |             |   |     |
| bl |   |                                   |   |             |   |     |
| e  |   |                                   |   |             |   |     |
| ap |   |                                   |   |             |   |     |
| pl |   |                                   |   |             |   |     |
| ie |   |                                   |   |             |   |     |
| s  |   |                                   |   |             |   |     |
| on |   |                                   |   |             |   |     |
| ly |   |                                   |   |             |   |     |
|  w |   |                                   |   |             |   |     |
| he |   |                                   |   |             |   |     |
| n  |   |                                   |   |             |   |     |
| we |   |                                   |   |             |   |     |
|  s |   |                                   |   |             |   |     |
| ay |   |                                   |   |             |   |     |
|  b |   |                                   |   |             |   |     |
| el |   |                                   |   |             |   |     |
| ow |   |                                   |   |             |   |     |
| :  |   |                                   |   |             |   |     |
| "c |   |                                   |   |             |   |     |
| al |   |                                   |   |             |   |     |
| en |   |                                   |   |             |   |     |
| da |   |                                   |   |             |   |     |
| r  |   |                                   |   |             |   |     |
| ye |   |                                   |   |             |   |     |
| ar |   |                                   |   |             |   |     |
|  d |   |                                   |   |             |   |     |
| ed |   |                                   |   |             |   |     |
| uc |   |                                   |   |             |   |     |
| ti |   |                                   |   |             |   |     |
| bl |   |                                   |   |             |   |     |
| e  |   |                                   |   |             |   |     |
| ap |   |                                   |   |             |   |     |
| pl |   |                                   |   |             |   |     |
| ie |   |                                   |   |             |   |     |
| s" |   |                                   |   |             |   |     |
| .* |   |                                   |   |             |   |     |
| ** |   |                                   |   |             |   |     |
| {I |   |                                   |   |             |   |     |
| f  |   |                                   |   |             |   |     |
| yo |   |                                   |   |             |   |     |
| u  |   |                                   |   |             |   |     |
| do |   |                                   |   |             |   |     |
| n\ |   |                                   |   |             |   |     |
| 't |   |                                   |   |             |   |     |
|  h |   |                                   |   |             |   |     |
| av |   |                                   |   |             |   |     |
| e  |   |                                   |   |             |   |     |
| a  |   |                                   |   |             |   |     |
| ca |   |                                   |   |             |   |     |
| le |   |                                   |   |             |   |     |
| nd |   |                                   |   |             |   |     |
| ar |   |                                   |   |             |   |     |
|  y |   |                                   |   |             |   |     |
| ea |   |                                   |   |             |   |     |
| r  |   |                                   |   |             |   |     |
| de |   |                                   |   |             |   |     |
| du |   |                                   |   |             |   |     |
| ct |   |                                   |   |             |   |     |
| ib |   |                                   |   |             |   |     |
| le |   |                                   |   |             |   |     |
| ,  |   |                                   |   |             |   |     |
| de |   |                                   |   |             |   |     |
| le |   |                                   |   |             |   |     |
| te |   |                                   |   |             |   |     |
|  t |   |                                   |   |             |   |     |
| hi |   |                                   |   |             |   |     |
| s  |   |                                   |   |             |   |     |
| wh |   |                                   |   |             |   |     |
| ol |   |                                   |   |             |   |     |
| e  |   |                                   |   |             |   |     |
| ro |   |                                   |   |             |   |     |
| w. |   |                                   |   |             |   |     |
| }* |   |                                   |   |             |   |     |
+----+---+-----------------------------------+---+-------------+---+-----+
| #  |   |                                   |   | ########    |   |     |
| ## |   |                                   |   |             |   |     |
| ## |   |                                   |   |             |   |     |
| ## |   |                                   |   |             |   |     |
| #  |   |                                   |   |             |   |     |
| In |   |                                   |   |             |   |     |
| pa |   |                                   |   |             |   |     |
| ti |   |                                   |   |             |   |     |
| en |   |                                   |   |             |   |     |
| t  |   |                                   |   |             |   |     |
| ho |   |                                   |   |             |   |     |
| sp |   |                                   |   |             |   |     |
| it |   |                                   |   |             |   |     |
| al |   |                                   |   |             |   |     |
+----+---+-----------------------------------+---+-------------+---+-----+
| >  |   |                                   |   | > Nothing   |   |     |
| Ro |   |                                   |   | >           |   |     |
| om |   |                                   |   | > *{If you  |   |     |
| >  |   |                                   |   | > have an   |   |     |
|  a |   |                                   |   | > inpatient |   |     |
| nd |   |                                   |   | >           |   |     |
| >  |   |                                   |   |  copayment, |   |     |
| bo |   |                                   |   | > say:*     |   |     |
| ar |   |                                   |   | >           |   |     |
| d, |   |                                   |   | > \$100 per |   |     |
| >  |   |                                   |   | > admission |   |     |
| su |   |                                   |   | >           |   |     |
| ch |   |                                   |   | > *         |   |     |
| >  |   |                                   |   | {Throughout |   |     |
| as |   |                                   |   | > this      |   |     |
|    |   |                                   |   | > sample    |   |     |
| -  |   |                                   |   | > table,    |   |     |
|    |   |                                   |   | > we\'ve    |   |     |
|  w |   |                                   |   | > shown     |   |     |
| ar |   |                                   |   | > \"        |   |     |
| d, |   |                                   |   | Nothing\"}* |   |     |
|    |   |                                   |   |             |   |     |
|    |   |                                   |   | ***{We      |   |     |
| se |   |                                   |   | prefer Plan |   |     |
| mi |   |                                   |   | hospital    |   |     |
| pr |   |                                   |   | copays not  |   |     |
| iv |   |                                   |   | to exceed   |   |     |
| at |   |                                   |   | \$100 per   |   |     |
| e, |   |                                   |   | admission.  |   |     |
|    |   |                                   |   | As we view  |   |     |
|    |   |                                   |   | hospital    |   |     |
| or |   |                                   |   | care as a   |   |     |
|    |   |                                   |   | basic       |   |     |
|    |   |                                   |   | benefit,    |   |     |
|  i |   |                                   |   | coinsurance |   |     |
| nt |   |                                   |   | is not      |   |     |
| en |   |                                   |   | acceptable. |   |     |
| si |   |                                   |   | Copays      |   |     |
| ve |   |                                   |   | count       |   |     |
|    |   |                                   |   | toward      |   |     |
|    |   |                                   |   | annual      |   |     |
| ca |   |                                   |   | ou          |   |     |
| re |   |                                   |   | t-of-pocket |   |     |
|    |   |                                   |   | m           |   |     |
|    |   |                                   |   | aximum.}*** |   |     |
|  a |   |                                   |   |             |   |     |
| cc |   |                                   |   |             |   |     |
| om |   |                                   |   |             |   |     |
| mo |   |                                   |   |             |   |     |
| da |   |                                   |   |             |   |     |
| ti |   |                                   |   |             |   |     |
| on |   |                                   |   |             |   |     |
| s; |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
| -  |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|  g |   |                                   |   |             |   |     |
| en |   |                                   |   |             |   |     |
| er |   |                                   |   |             |   |     |
| al |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|  n |   |                                   |   |             |   |     |
| ur |   |                                   |   |             |   |     |
| si |   |                                   |   |             |   |     |
| ng |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|  c |   |                                   |   |             |   |     |
| ar |   |                                   |   |             |   |     |
| e; |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|  a |   |                                   |   |             |   |     |
| nd |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
| -  |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|  m |   |                                   |   |             |   |     |
| ea |   |                                   |   |             |   |     |
| ls |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|  a |   |                                   |   |             |   |     |
| nd |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|  s |   |                                   |   |             |   |     |
| pe |   |                                   |   |             |   |     |
| ci |   |                                   |   |             |   |     |
| al |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
| di |   |                                   |   |             |   |     |
| et |   |                                   |   |             |   |     |
| s. |   |                                   |   |             |   |     |
|    |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  N |   |                                   |   |             |   |     |
| OT |   |                                   |   |             |   |     |
| E: |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| If |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  y |   |                                   |   |             |   |     |
| ou |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| wa |   |                                   |   |             |   |     |
| nt |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  a |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  p |   |                                   |   |             |   |     |
| ri |   |                                   |   |             |   |     |
| va |   |                                   |   |             |   |     |
| te |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| ro |   |                                   |   |             |   |     |
| om |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| wh |   |                                   |   |             |   |     |
| en |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| it |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
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| Os |   |                                   |   |             |   |     |
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| ho |   |                                   |   |             |   |     |
| ut |   |                                   |   |             |   |     |
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| >  |   |                                   |   |             |   |     |
| co |   |                                   |   |             |   |     |
| st |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| li |   |                                   |   |             |   |     |
| mi |   |                                   |   |             |   |     |
| ta |   |                                   |   |             |   |     |
| ti |   |                                   |   |             |   |     |
| on |   |                                   |   |             |   |     |
| s, |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  a |   |                                   |   |             |   |     |
| nd |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| th |   |                                   |   |             |   |     |
| us |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
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| ir |   |                                   |   |             |   |     |
| ed |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| of |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| FE |   |                                   |   |             |   |     |
| HB |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  p |   |                                   |   |             |   |     |
| la |   |                                   |   |             |   |     |
| ns |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
| as |   |                                   |   |             |   |     |
| >  |   |                                   |   |             |   |     |
|  w |   |                                   |   |             |   |     |
| el |   |                                   |   |             |   |     |
| l. |   |                                   |   |             |   |     |
| }* |   |                                   |   |             |   |     |
| ** |   |                                   |   |             |   |     |
+----+---+-----------------------------------+---+-------------+---+-----+

Inpatient hospital continued on next page.

+---------------------------------------------+------------------------+
| ######## Inpatient hospital *(Continued)*   | ######## You pay       |
+---------------------------------------------+------------------------+
| #### Oth                                    | > Nothing              |
| er hospital services and supplies, such as: |                        |
|                                             |                        |
| -   Operating, recovery, maternity, and     |                        |
|     other treatment rooms                   |                        |
|                                             |                        |
| -   Prescribed drugs and medicines          |                        |
|                                             |                        |
| -   Diagnostic laboratory tests and X-rays  |                        |
|                                             |                        |
| -   Administration of blood and blood       |                        |
|     products                                |                        |
|                                             |                        |
| -   Blood or blood plasma, if not donated   |                        |
|     or replaced                             |                        |
|                                             |                        |
| -   Dressings, splints, casts, and sterile  |                        |
|     tray services                           |                        |
|                                             |                        |
| -   Medical supplies and equipment,         |                        |
|     including oxygen                        |                        |
|                                             |                        |
| -   Anesthetics, including nurse            |                        |
|     anesthetist services                    |                        |
|                                             |                        |
| -   Take-home items                         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Medical supplies, appliances, medical   |                        |
|     equipment, and any covered items billed |                        |
|     by a hospital for use at home (Note:    |                        |
|     calendar year deductible applies.)      |                        |
|                                             |                        |
| ***{In-hospital administration of blood and |                        |
| blood products (including \"blood           |                        |
| processing\") is required of                |                        |
| Federally-qualified plans and of FEHB HMOs. |                        |
| You may exclude the coverage of blood that  |                        |
| is not donated or replaced if this is a     |                        |
| community exclusion}.***                    |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Custodial care*                        |                        |
|                                             |                        |
| -   *Non-covered facilities, such as        |                        |
|     nursing homes, extended care            |                        |
|     facilities, schools*                    |                        |
|                                             |                        |
| -   *Personal comfort items, such as        |                        |
|     telephone, television, barber services, |                        |
|     guest meals and beds*                   |                        |
|                                             |                        |
| -   *Private nursing care*                  |                        |
+---------------------------------------------+------------------------+
| #### **Outpatie                             | ####                   |
| nt hospital or ambulatory surgical center** |                        |
+---------------------------------------------+------------------------+
| -   Operating, recovery, and other          | > 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                 | ######## You pay       |
| fits/skilled nursing care facility benefits |                        |
+---------------------------------------------+------------------------+
| > Extended care benefit: {Insert benefit;   | > Nothing              |
| > day limits, etc}                          |                        |
| >                                           | ***.***                |
| > {Extended care is to be used in addition  |                        |
| > to hospital care, not in place of         |                        |
| > hospital care. You must provide a minimum |                        |
| > of 30 days of extended care coverage per  |                        |
| > year when full-time skilled nursing care  |                        |
| > is necessary and confinement in a skilled |                        |
| > nursing facility is medically             |                        |
| > appropriate. As it is considered to be a  |                        |
| > basic benefit, coinsurance may not be     |                        |
| > applied. We prefer to state covered days  |                        |
| > \"per calendar year\", not \"per          |                        |
| > confinement\" or \"per condition.\" Any   |                        |
| > copays count toward annual out-of-pocket  |                        |
| > maximum}                                  |                        |
| >                                           |                        |
| > {If you cover care in a sub-acute         |                        |
| > facility you may describe it here.}       |                        |
+---------------------------------------------+------------------------+
| > Skilled nursing facility (SNF): {Insert   | > Nothing              |
| > benefit; day limits, etc. }               |                        |
+---------------------------------------------+------------------------+
| > (Plan \-- if extended care and skilled    |                        |
| > nursing are the same in your plan, only   |                        |
| > show one block and describe your          |                        |
| > benefit.}                                 |                        |
+---------------------------------------------+------------------------+
| > Not covered: custodial care               | > *All charges*        |
+---------------------------------------------+------------------------+
| #### **Hospice care**                       | ####                   |
+---------------------------------------------+------------------------+
| > *{Insert benefit}*                        | > Nothing              |
| >                                           |                        |
| > ***{Hospice care is an optional benefit   |                        |
| > we strongly encourage for FEHB HMOs.      |                        |
| > Adjust language to reflect Plan           |                        |
| > benefit.}***                              |                        |
+---------------------------------------------+------------------------+
| > *Not covered: Independent nursing,        | > *All charges*        |
| > homemaker services*                       |                        |
+---------------------------------------------+------------------------+
| ######## Ambulance                          | ########               |
+---------------------------------------------+------------------------+
| -   Local professional ambulance service    | > Nothing              |
|     when medically appropriate              |                        |
+---------------------------------------------+------------------------+

+---+---+------------------------------------------------------+---+---+
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
|   |   |                                                      |   |   |
| S |   |                                                      |   |   |
| e |   |                                                      |   |   |
| c |   |                                                      |   |   |
| t |   |                                                      |   |   |
| i |   |                                                      |   |   |
| o |   |                                                      |   |   |
| n |   |                                                      |   |   |
|   |   |                                                      |   |   |
| 5 |   |                                                      |   |   |
|   |   |                                                      |   |   |
| ( |   |                                                      |   |   |
| d |   |                                                      |   |   |
| ) |   |                                                      |   |   |
| . |   |                                                      |   |   |
|   |   |                                                      |   |   |
| E |   |                                                      |   |   |
| m |   |                                                      |   |   |
| e |   |                                                      |   |   |
| r |   |                                                      |   |   |
| g |   |                                                      |   |   |
| e |   |                                                      |   |   |
| n |   |                                                      |   |   |
| c |   |                                                      |   |   |
| y |   |                                                      |   |   |
|   |   |                                                      |   |   |
| s |   |                                                      |   |   |
| e |   |                                                      |   |   |
| r |   |                                                      |   |   |
| v |   |                                                      |   |   |
| i |   |                                                      |   |   |
| c |   |                                                      |   |   |
| e |   |                                                      |   |   |
| s |   |                                                      |   |   |
| / |   |                                                      |   |   |
| a |   |                                                      |   |   |
| c |   |                                                      |   |   |
| c |   |                                                      |   |   |
| i |   |                                                      |   |   |
| d |   |                                                      |   |   |
| e |   |                                                      |   |   |
| n |   |                                                      |   |   |
| t |   |                                                      |   |   |
| s |   |                                                      |   |   |
|   |   |                                                      |   |   |
+---+---+------------------------------------------------------+---+---+
|   | * | > Here are some important things to keep in mind     | * | # |
|   | * | > about these benefits:                              | * | # |
|   | I |                                                      | I | # |
|   | * | -   Please remember that all benefits are subject to | * | # |
|   | * |     the definitions, limitations, and exclusions in  | * | # |
|   |   |     this brochure.                                   |   |   |
|   | * |                                                      | * |   |
|   | * | -   The calendar year deductible is: *{Plan          | * |   |
|   | M |     specific}* \$275 per person (\$550 per family).  | M |   |
|   | * |     The calendar year deductible applies to almost   | * |   |
|   | * |     all benefits in this Section. We added "(No      | * |   |
|   |   |     deductible)" to show when the calendar year      |   |   |
|   | * |     deductible does not apply. *{{If you want, you   | * |   |
|   | * |     can say, "We added asterisks - \* - to show when | * |   |
|   | P |     the calendar year deductible does not            | P |   |
|   | * |     apply."}}*. *{{If HMO -- if you don't have       | * |   |
|   | * |     deductible, remove this check mark or say "We    | * |   |
|   |   |     have no calendar year deductible.}}*             |   |   |
|   | * |                                                      | * |   |
|   | * | -   Be sure to read Section 4, *Your costs for       | * |   |
|   | O |     covered services* for valuable information about | O |   |
|   | * |     how cost sharing works. Also read Section 9      | * |   |
|   | * |     about coordinating benefits with other coverage, | * |   |
|   |   |     including with Medicare.                         |   |   |
|   | * |                                                      | * |   |
|   | * | #####                                                | * |   |
|   | R |                                                      | R |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | T |                                                      | T |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | A |                                                      | A |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | N |                                                      | N |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | T |                                                      | T |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
+---+---+------------------------------------------------------+---+---+
| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| * |   |                                                      |   |   |
| * |   |                                                      |   |   |
| W |   |                                                      |   |   |
| h |   |                                                      |   |   |
| a |   |                                                      |   |   |
| t |   |                                                      |   |   |
| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| i |   |                                                      |   |   |
| s |   |                                                      |   |   |
| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| a |   |                                                      |   |   |
| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| m |   |                                                      |   |   |
| e |   |                                                      |   |   |
| d |   |                                                      |   |   |
| i |   |                                                      |   |   |
| c |   |                                                      |   |   |
| a |   |                                                      |   |   |
| l |   |                                                      |   |   |
| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| e |   |                                                      |   |   |
| m |   |                                                      |   |   |
| e |   |                                                      |   |   |
| r |   |                                                      |   |   |
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| * |   |                                                      |   |   |
+---+---+------------------------------------------------------+---+---+

+-------------------------------------------------+--------------------+---+
| **~~What is an accidental injury?~~** *{Stet    |                    |   |
| this IF you have a special benefit for          |                    |   |
| accidental injury}*                             |                    |   |
|                                                 |                    |   |
| ~~An accidental injury is a bodily injury       |                    |   |
| sustained solely through violent, external, and |                    |   |
| accidental means, such as broken bones, animal  |                    |   |
| bites, and poisonings. We do not cover dental   |                    |   |
| care for accidental injury*.*~~ *{{Plan         |                    |   |
| specific}}*                                     |                    |   |
+-------------------------------------------------+--------------------+---+
| > **Benefit Description**                       | **You pay**        |   |
+-------------------------------------------------+--------------------+---+
| > **Emergency within our service area**         |                    |   |
+-------------------------------------------------+--------------------+---+
| -   Emergency care at a doctor\'s office        | > \$xx per...      |   |
|                                                 |                    |   |
| -   Emergency care at an urgent care center     |                    |   |
|                                                 |                    |   |
| ```{=html}                                      |                    |   |
| <!-- -->                                        |                    |   |
| ```                                             |                    |   |
| -   Emergency care as an outpatient or          |                    |   |
|     inpatient at a hospital, including          |                    |   |
|     doctors\' services *{RV 6-16}*              |                    |   |
+-------------------------------------------------+--------------------+---+
| > *Not covered: Elective care or non-emergency  | > *All charges.*   |   |
| > care*                                         |                    |   |
+-------------------------------------------------+--------------------+---+
| ######## Emergency outside our service area     |                    |   |
+-------------------------------------------------+--------------------+---+
| -   Emergency care at a doctor\'s office        | > \$xx...          |   |
|                                                 |                    |   |
| -   Emergency care at an urgent care center     |                    |   |
|                                                 |                    |   |
| -   Emergency care as an outpatient or          |                    |   |
|     inpatient at a hospital, including          |                    |   |
|     doctors\' services                          |                    |   |
|                                                 |                    |   |
| ########                                        |                    |   |
+-------------------------------------------------+--------------------+---+
| > *Not covered:*                                | > *All charges.*   |   |
|                                                 |                    |   |
| -   *Elective care or non-emergency care*       |                    |   |
|                                                 |                    |   |
| -   *Emergency care provided outside the        |                    |   |
|     service area if the need for care could     |                    |   |
|     have been foreseen before leaving the       |                    |   |
|     service area*                               |                    |   |
|                                                 |                    |   |
| ```{=html}                                      |                    |   |
| <!-- -->                                        |                    |   |
| ```                                             |                    |   |
| -   *Medical and hospital costs resulting from  |                    |   |
|     a normal full-term delivery of a baby       |                    |   |
|     outside the service area {If you **cover    |                    |   |
|     full-term deliveries outside the service    |                    |   |
|     area delete this exclusion}***              |                    |   |
|                                                 |                    |   |
| ########                                        |                    |   |
+-------------------------------------------------+--------------------+---+
| ######## ~~Accidental injury~~ *{{th            |                    |   |
| is is primarily a FFS benefit -- if you don't h |                    |   |
| ave special benefit for accidents, don't add}}* |                    |   |
+-------------------------------------------------+--------------------+---+
|                                                 |                    |   |
+-------------------------------------------------+--------------------+---+
| > **Ambulance**                                 |                    |   |
+-------------------------------------------------+--------------------+---+
| > Professional ambulance service when medically | > \$xx per...      |   |
| > appropriate.                                  |                    |   |
| >                                               |                    |   |
| > See 5(c) for non-emergency service.           |                    |   |
+-------------------------------------------------+--------------------+---+
| > *Not covered: air ambulance {{If covered,     | > *All charges.*   |   |
| > show above}*                                  |                    |   |
+-------------------------------------------------+--------------------+---+

*{Plan - everything in 5(e) is standard \-- edit to fit your benefits,
only)*

+---+---+-----------------------------------------+----------------+---+---+
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| 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 |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+
|   | * | > **Parity**                            |                | * |   |
|   | * | >                                       |                | * |   |
|   | I | > Beginning in 2001, all FEHB plans\'   |                | I |   |
|   | * | > mental health and substance abuse     |                | * |   |
|   | * | > benefits will achieve \"parity\" with |                | * |   |
|   |   | > other benefits. This means that we    |                |   |   |
|   | * | > will provide mental health and        |                | * |   |
|   | * | > substance abuse benefits differently  |                | * |   |
|   | M | > than in the past.                     |                | M |   |
|   | * | >                                       |                | * |   |
|   | * | > When you get our approval for         |                | * |   |
|   |   | > services and follow a treatment plan  |                |   |   |
|   | * | > we approve, cost-sharing and          |                | * |   |
|   | * | > limitations for Plan mental health    |                | * |   |
|   | P | > and substance abuse benefits will be  |                | P |   |
|   | * | > no greater than for similar benefits  |                | * |   |
|   | * | > for other illnesses and conditions.   |                | * |   |
|   |   | >                                       |                |   |   |
|   | * | > **Here are some important things to   |                | * |   |
|   | * | > keep in mind about these benefits:**  |                | * |   |
|   | O | >                                       |                | O |   |
|   | * | > • All benefits are subject to the     |                | * |   |
|   | * | > definitions, limitations, and         |                | * |   |
|   |   | > exclusions in this brochure.          |                |   |   |
|   | * |                                         |                | * |   |
|   | * | -   The calendar year deductible or,    |                | * |   |
|   | R |     for facility care, the inpatient    |                | R |   |
|   | * |     deductible apply to almost all      |                | * |   |
|   | * |     benefits in this Section. We added  |                | * |   |
|   |   |     "(No deductible)" to show when a    |                |   |   |
|   | * |     deductible does not apply. *{If you |                | * |   |
|   | * |     don't have one or either            |                | * |   |
|   | T |     deductible, edit or remove this     |                | T |   |
|   | * |     check mark.}*                       |                | * |   |
|   | * |                                         |                | * |   |
|   |   | > • Be sure to read Section 4, *Your    |                |   |   |
|   | * | > costs for covered services* for       |                | * |   |
|   | * | > valuable information about how cost   |                | * |   |
|   | A | > sharing works. Also read Section 9    |                | A |   |
|   | * | > about coordinating benefits with      |                | * |   |
|   | * | > other coverage, including with        |                | * |   |
|   |   | > Medicare.                             |                |   |   |
|   | * | >                                       |                | * |   |
|   | * | > • **YOU MUST GET PREAUTHORIZATION OF  |                | * |   |
|   | N | > THESE SERVICES.** See the             |                | N |   |
|   | * | > instructions after the benefits       |                | * |   |
|   | * | > description below.                    |                | * |   |
|   |   |                                         |                |   |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   | T |                                         |                | T |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
+---+---+-----------------------------------------+----------------+---+---+
| > |   |                                         | **You pay**    |   |   |
|   |   |                                         |                |   |   |
| * |   |                                         | **After the    |   |   |
| * |   |                                         | calendar year  |   |   |
| B |   |                                         | d              |   |   |
| e |   |                                         | eductible...** |   |   |
| n |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| f |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| > |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| D |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| c |   |                                         |                |   |   |
| r |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| p |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| o |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
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| * |   |                                         |                |   |   |
| N |   |                                         |                |   |   |
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| : |   |                                         |                |   |   |
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+---+---+-----------------------------------------+----------------+---+---+
| > |   |                                         | > Your cost    |   |   |
|   |   |                                         | > sharing      |   |   |
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| a |   |                                         | > are no       |   |   |
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| n |   |                                         | > for other    |   |   |
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| s |   |                                         | > conditions.  |   |   |
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| . |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+
| - |   |                                         | > \$15 per     |   |   |
|   |   |                                         | > visit        |   |   |
|   |   |                                         | > *{amount can |   |   |
|   |   |                                         | > be no more   |   |   |
| P |   |                                         | > than copay   |   |   |
| r |   |                                         | > for Section  |   |   |
| o |   |                                         | > 5(a)         |   |   |
| f |   |                                         | >              |   |   |
| e |   |                                         |  specialist.}* |   |   |
| s |   |                                         | >              |   |   |
| s |   |                                         | > *{If you     |   |   |
| i |   |                                         | > have         |   |   |
| o |   |                                         | > different    |   |   |
| n |   |                                         | > copays for   |   |   |
| a |   |                                         | >              |   |   |
| l |   |                                         | psychiatrists/ |   |   |
|   |   |                                         | psychologists, |   |   |
|   |   |                                         | > counselors,  |   |   |
|   |   |                                         | > or           |   |   |
|   |   |                                         | > medication   |   |   |
| s |   |                                         | > management   |   |   |
| e |   |                                         | > visits, show |   |   |
| r |   |                                         | > that         |   |   |
| v |   |                                         | > here..}*     |   |   |
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|   |   |                                         |                |   |   |
| - |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| M |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| d |   |                                         |                |   |   |
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| c |   |                                         |                |   |   |
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|   |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| m |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| g |   |                                         |                |   |   |
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| t |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+

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

+----------------------------------------------+-----------------------+
| ### **Mental health a                        | ### **You pay**       |
| nd substance abuse benefits** *(Continued)*  |                       |
+----------------------------------------------+-----------------------+
| -   Diagnostic tests                         | > \$xx per (visit or  |
|                                              | > test)               |
|                                              | >                     |
|                                              | > (Nothing)           |
+----------------------------------------------+-----------------------+
| -   Services provided by a hospital or other | > Nothing             |
|     facility                                 | >                     |
|                                              | > *{or:* \$xx per     |
| -   Services in approved alternative care    | > admission*}*        |
|     settings such as partial                 | >                     |
|     hospitalization, half-way house,         | > *{If you have       |
|     residential treatment, full-day          | > different           |
|     hospitalization, facility based          | > cost-sharing for    |
|     intensive outpatient treatment           | > alternate care      |
|     *{plan-specific explanation of this      | > settings, show that |
|     information}*                            | > here.}*             |
+----------------------------------------------+-----------------------+
| ##                                           | > *All charges.*      |
|  Not covered: Services we have not approved. |                       |
|                                              |                       |
| ## Note: OP                                  |                       |
| M will base its review of disputes about tre |                       |
| atment plans on the treatment plan\'s clinic |                       |
| al appropriateness. OPM will generally not o |                       |
| rder us to pay or provide one clinically app |                       |
| ropriate treatment plan in favor of another. |                       |
+----------------------------------------------+-----------------------+
| **Preauthorization** To be eligible to       |                       |
| receive these benefits you must follow your  |                       |
| treatment plan and all the following         |                       |
| authorization processes:                     |                       |
|                                              |                       |
| *{insert phone numbers, referral procedures, |                       |
| provider entry procedures, how to identify   |                       |
| providers and obtain provider directories,   |                       |
| and all inpatient and outpatient service and |                       |
| treatment plan approval procedures}*         |                       |
+----------------------------------------------+-----------------------+
| *{About the special transitional benefit     |                       |
| below: Your contract specialist will work    |                       |
| with you to decide which bullets listed      |                       |
| below apply to your plan.)*                  |                       |
|                                              |                       |
| ## **Special transitional benefit** If a m   |                       |
| ental health or substance abuse professional |                       |
|  provider is treating you under our plan as  |                       |
| of January 1, 2001, you will be eligible for |                       |
|  continued coverage with your provider for u |                       |
| p to 90 days under the following conditions: |                       |
|                                              |                       |
| -   If your mental health or substance abuse |                       |
|     professional provider with whom you are  |                       |
|     currently in treatment leaves the plan   |                       |
|     at our request for other than cause, or  |                       |
|     *{{delete this if you did NOT have Plan  |                       |
|     mental health and substance abuse        |                       |
|     providers in 2000}*                      |                       |
|                                              |                       |
| -   If changes to this plan\'s benefit       |                       |
|     structure for 2001 cause your            |                       |
|     out-of-pocket costs for your             |                       |
|     out-of-network provider to be greater    |                       |
|     than they were in year 2000. *{delete    |                       |
|     this bullet UNLESS you are a POS and you |                       |
|     increased out-of-network member cost     |                       |
|     sharing}*                                |                       |
|                                              |                       |
| ##  If thes                                  |                       |
| e conditions apply to you, {or, If this cond |                       |
| ition applies to you,} we will allow you rea |                       |
| sonable time to transfer your care to a Plan |                       |
|  mental health or substance abuse profession |                       |
| al provider. During the transitional period, |                       |
|  you may continue to see your treating provi |                       |
| der and will not pay any more out-of-pocket  |                       |
| than you did in the year 2000 for services.  |                       |
| This transitional period will begin with our |                       |
|  notice to you of the change in coverage and |                       |
|  will end 90 days after you receive our noti |                       |
| ce. If we write to you before October 1, 200 |                       |
| 0, the 90-day period ends before January 1 a |                       |
| nd this transitional benefit does not apply. |                       |
+----------------------------------------------+-----------------------+

+-----------------------------------------------------------------------+
| ## **Limitation**                                                     |
|  We may limit your benefits if you do not follow your treatment plan. |
+-----------------------------------------------------------------------+

*{Re **POS** \-- if you offer mental health and substance abuse benefits
under a POS option, go ahead and describe those benefits where you
discuss the POS medical benefits.)*

*{RV \-- new section \-- 6/2/00}*

+-----+---+-------------------------------------------------+---+-------+
| **S |   |                                                 |   |       |
| ect |   |                                                 |   |       |
| ion |   |                                                 |   |       |
| 5   |   |                                                 |   |       |
| (   |   |                                                 |   |       |
| f). |   |                                                 |   |       |
| Pre |   |                                                 |   |       |
| scr |   |                                                 |   |       |
| ipt |   |                                                 |   |       |
| ion |   |                                                 |   |       |
| d   |   |                                                 |   |       |
| rug |   |                                                 |   |       |
| b   |   |                                                 |   |       |
| ene |   |                                                 |   |       |
| fit |   |                                                 |   |       |
| s** |   |                                                 |   |       |
+-----+---+-------------------------------------------------+---+-------+
|     | * | > *{This block and all headers are standard;    | * |       |
|     | * | > you add text}*                                | * |       |
|     | I |                                                 | I |       |
|     | * | **Here are some important things to keep in     | * |       |
|     | * | mind about these benefits:**                    | * |       |
|     |   |                                                 |   |       |
|     | * | -   We cover prescribed drugs and medications,  | * |       |
|     | * |     as described in the chart beginning on the  | * |       |
|     | M |     next page.                                  | M |       |
|     | * |                                                 | * |       |
|     | * | -   All benefits are subject to the             | * |       |
|     |   |     definitions, limitations and exclusions in  |   |       |
|     | * |     this brochure and are payable only when we  | * |       |
|     | * |     determine they are medically necessary.     | * |       |
|     | P |                                                 | P |       |
|     | * | ```{=html}                                      | * |       |
|     | * | <!-- -->                                        | * |       |
|     |   | ```                                             |   |       |
|     | * | -   The calendar year deductible is: \$275 per  | * |       |
|     | * |     person (\$550 per family). The calendar     | * |       |
|     | O |     year deductible applies to almost all       | O |       |
|     | * |     benefits in this Section. We added "No      | * |       |
|     | * |     deductible" to show when the calendar year  | * |       |
|     |   |     deductible does not apply. *{If you want,   |   |       |
|     | * |     you can say, "We added asterisks - \* - to  | * |       |
|     | * |     show when the calendar year deductible does | * |       |
|     | R |     not apply."}*                               | R |       |
|     | * |                                                 | * |       |
|     | * | ```{=html}                                      | * |       |
|     |   | <!-- -->                                        |   |       |
|     | * | ```                                             | * |       |
|     | * | -   *{{If you have a prescription deductible,   | * |       |
|     | T |     describe it here; also describe any prior   | T |       |
|     | * |     authorization requirements.}}*              | * |       |
|     | * |                                                 | * |       |
|     |   | ```{=html}                                      |   |       |
|     | * | <!-- -->                                        | * |       |
|     | * | ```                                             | * |       |
|     | A | -   Be sure to read Section 4, *Your costs for  | A |       |
|     | * |     covered services* for valuable information  | * |       |
|     | * |     about how cost sharing works. Also read     | * |       |
|     |   |     Section 9 about coordinating benefits with  |   |       |
|     | * |     other coverage, including with Medicare.    | * |       |
|     | * |                                                 | * |       |
|     | N |                                                 | N |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     |   |                                                 |   |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     | T |                                                 | T |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
+-----+---+-------------------------------------------------+---+-------+
|     | > |                                                 |   |       |
|     |   |                                                 |   |       |
|     | * |                                                 |   |       |
|     | * |                                                 |   |       |
|     | T |                                                 |   |       |
|     | h |                                                 |   |       |
|     | e |                                                 |   |       |
|     | r |                                                 |   |       |
|     | e |                                                 |   |       |
|     | > |                                                 |   |       |
|     |   |                                                 |   |       |
|     | a |                                                 |   |       |
|     | r |                                                 |   |       |
|     | e |                                                 |   |       |
|     | > |                                                 |   |       |
|     |   |                                                 |   |       |
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|     | * |                                                 |   |       |
+-----+---+-------------------------------------------------+---+-------+

*Prescription drug benefits begin on the next page.*

+---------------------------------------------+------------------------+
| > **Benefit Description**                   | **You pay**            |
|                                             |                        |
|                                             | **After the calendar   |
|                                             | year deductible...**   |
+---------------------------------------------+------------------------+
| ### **NOTE: The cale                        |                        |
| ndar year deductible applies to almost all  |                        |
| benefits in this Section. We say "No deduct |                        |
| ible" when it does not apply.** *{{Delete t |                        |
| he row if you don't' have a deductible.}}.* |                        |
+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      |                        |
+---------------------------------------------+------------------------+
| > We cover the following medications and    | > \$ per....           |
| > supplies prescribed by a Plan physician   | >                      |
| > and obtained from a Plan pharmacy or      | > \$ per...            |
| > through our mail order program:           | >                      |
|                                             | > Note: If there is no |
| -   *Plan specific -- based on what a plan  | > generic equivalent   |
|     lists in 2000 under "what is covered"*  | > available, you will  |
|                                             | > still have to pay    |
| ```{=html}                                  | > the brand name       |
| <!-- -->                                    | > copay. *{Insert this |
| ```                                         | > if this is the       |
| -   Drugs and medicines that by Federal law | > case}*               |
|     of the United States require a          |                        |
|     physician's prescription for their      | ***{Lifetime or annual |
|     purchase, except as excluded below.     | benefit maximums on    |
|     *{if state law, edit to show}*          | prescription drugs are |
|                                             | not permitted. Drug    |
| -   Insulin                                 | benefit deductibles    |
|                                             | may not exceed \$600   |
| -   Disposable needles and syringes for the | and member coinsurance |
|     administration of covered medications   | may not exceed         |
|                                             | 50%.}***               |
| -   Drugs for sexual dysfunction (see Prior |                        |
|     authorization below)                    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Contraceptive drugs and devices         |                        |
|                                             |                        |
| ***{Insulin is a required benefit.}***      |                        |
|                                             |                        |
| ***{Diabetic supplies other than needles    |                        |
| and syringes are not mandated under the     |                        |
| FEHB but their coverage is encouraged as    |                        |
| preventive services. Plan should include    |                        |
| only items it covers and add any not on our |                        |
| list. If Plan covers glucose monitors as    |                        |
| durable medical equipment, show under the   |                        |
| DME section.}***                            |                        |
|                                             |                        |
| > ***{Disposable needles and syringes       |                        |
| > needed to inject covered prescribed       |                        |
| > medication is a required benefit}***      |                        |
| >                                           |                        |
| > ***{You must cover the full range of FDA  |                        |
| > approved prescriptions and devices for    |                        |
| > birth control.}***                        |                        |
|                                             |                        |
| ***{Appetite suppressants may be excluded   |                        |
| under the cosmetic purposes exclusion or    |                        |
| covered as medically necessary in cases of  |                        |
| morbid obesity.}***                         |                        |
|                                             |                        |
| > ***{You must cover \"off-label\" use of   |                        |
| > covered medication if prescribed for such |                        |
| > use by a Plan doctor; you may             |                        |
| > [not]{.underline} exclude \"drugs used    |                        |
| > \'off-label\'\".}***                      |                        |
|                                             |                        |
| ***{Prescription benefits provided for      |                        |
| other than the usual copay(s) or that are   |                        |
| limited as to number of months\' supply     |                        |
| (e.g., nicotine patches) may be listed      |                        |
| here. Sexual dysfunction drug coverage.}*** |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      | > **You pay**          |
| > *(continued)*                             |                        |
+---------------------------------------------+------------------------+
| > Here are some things to keep in mind      |                        |
| > about our prescription drug program:      |                        |
|                                             |                        |
| -   A generic equivalent will be dispensed  |                        |
|     if it is available, unless your         |                        |
|     physician specifically requires a name  |                        |
|     brand. If you receive a name brand drug |                        |
|     when a Federally-approved generic drug  |                        |
|     is available, and your physician has    |                        |
|     not specified Dispense as Written for   |                        |
|     the name brand drug, you have to pay    |                        |
|     the difference in cost between the name |                        |
|     brand drug and the generic.             |                        |
|                                             |                        |
| -   We have an open formulary. If your      |                        |
|     physician believes a name brand product |                        |
|     is necessary or there is no generic     |                        |
|     available, your physician may prescribe |                        |
|     a name brand drug from a formulary      |                        |
|     list. This list of name brand drugs is  |                        |
|     a preferred list of drugs that we       |                        |
|     selected to meet patient needs at a     |                        |
|     lower cost. To order a prescription     |                        |
|     drug brochure, call xxxx. *{RV 6-16}*   |                        |
|                                             |                        |
| ***{Adjust text to reflect amounts provided |                        |
| per copay, differences in the Plan\'s copay |                        |
| structure, and/or the plan\'s policy        |                        |
| concerning generic vs. name brand           |                        |
| drugs.}***                                  |                        |
|                                             |                        |
| ***{No revisions will be accepted that      |                        |
| involve members in an authorization process |                        |
| or that impose financial consequences on    |                        |
| members when primary doctors fail to obtain |                        |
| authorizations}***                          |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All Charges*        |
|                                             |                        |
| -   *Drugs and supplies for cosmetic        |                        |
|     purposes*                               |                        |
|                                             |                        |
| -   *Vitamins, nutrients and food           |                        |
|     supplements even if a physician         |                        |
|     prescribes or administers them*         |                        |
|                                             |                        |
| -   *Nonprescription medicines*             |                        |
|                                             |                        |
| > ***{It is our policy not to list specific |                        |
| > substances (e.g., Rogaine) as excluded,   |                        |
| > but rather to exclude a class of such     |                        |
| > substances, e.g., drugs for cosmetic      |                        |
| > purposes. Among classes of drugs you may  |                        |
| > [not]{.underline} exclude are injectable  |                        |
| > drugs}***                                 |                        |
+---------------------------------------------+------------------------+

***{{Plan specific \-- put here items that aren\'t elsewhere \-- that
are nonetheless important features of your plan. All here are examples
only.}}***

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

+----------------------+-----------------------------------------------+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| > **Flexible         | > Under the flexible benefits option, we      |
| > benefits option**  | > determine the most effective way to provide |
|                      | > services.                                   |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
|                      |                                               |
|                      | > ***{This benefit description is             |
|                      | > standard}***                                |
+----------------------+-----------------------------------------------+
| > **24 hour nurse    | > For any of your health concerns, 24 hours a |
| > line**             | > day, 7 days a week, you may call            |
|                      | > 1-800-622-6252 and talk with a registered   |
|                      | > nurse who will discuss treatment options    |
|                      | > and answer your health questions.           |
+----------------------+-----------------------------------------------+
| > **Services for     |                                               |
| > deaf and hearing   |                                               |
| > impaired**         |                                               |
+----------------------+-----------------------------------------------+
| > **Reciprocity      |                                               |
| > benefit**          |                                               |
+----------------------+-----------------------------------------------+
| > **High risk        |                                               |
| > pregnancies**      |                                               |
+----------------------+-----------------------------------------------+
| > **Centers of       |                                               |
| > excellence for     |                                               |
| > transplants/heart  |                                               |
| > surgery/etc**      |                                               |
+----------------------+-----------------------------------------------+
| > **Travel benefit/  |                                               |
| > services           |                                               |
| > overseas**         |                                               |
+----------------------+-----------------------------------------------+

+---+---+---------------------------------------+----------+---+--------+
| > |   |                                       |          |   |        |
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+===+===+=======================================+==========+===+========+
|   | * | **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.                |          |   |        |
|   | * |                                       |          | * |        |
|   | * | -   The calendar year deductible is:  |          | * |        |
|   | P |     *{plan specific}* \$275 per       |          | P |        |
|   | * |     person (\$550 per family). The    |          | * |        |
|   | * |     calendar year deductible applies  |          | * |        |
|   |   |     to almost all benefits in this    |          |   |        |
|   | * |     Section. We added "(No            |          | * |        |
|   | * |     deductible)" to show when the     |          | * |        |
|   | O |     calendar year deductible does not |          | O |        |
|   | * |     apply. *{If you want, you can     |          | * |        |
|   | * |     say, "We added asterisks - \* -   |          | * |        |
|   |   |     to show when the calendar year    |          |   |        |
|   | * |     deductible does not apply."}*.    |          | * |        |
|   | * |     *{If HMO -- if you don't have     |          | * |        |
|   | R |     deductible, remove this check     |          | R |        |
|   | * |     mark or say "We have no calendar  |          | * |        |
|   | * |     year deductible.}*                |          | * |        |
|   |   |                                       |          |   |        |
|   | * | -   We cover hospitalization for      |          | * |        |
|   | * |     dental procedures only when a     |          | * |        |
|   | T |     nondental physical impairment     |          | T |        |
|   | * |     exists which makes                |          | * |        |
|   | * |     hospitalization necessary to      |          | * |        |
|   |   |     safeguard the health of the       |          |   |        |
|   | * |     patient; we do not cover the      |          | * |        |
|   | * |     dental procedure unless it is     |          | * |        |
|   | A |     described below.                  |          | A |        |
|   | * |     ***{Hospitalization for dental    |          | * |        |
|   | * |     procedures is optional, but       |          | * |        |
|   |   |     strongly recommended to reduce    |          |   |        |
|   | * |     risk of emergency                 |          | * |        |
|   | * |     hospitalizations.}***             |          | * |        |
|   | N |                                       |          | N |        |
|   | * | ```{=html}                            |          | * |        |
|   | * | <!-- -->                              |          | * |        |
|   |   | ```                                   |          |   |        |
|   | * | -   Be sure to read Section 4, *Your  |          | * |        |
|   | * |     costs for covered services* for   |          | * |        |
|   | T |     valuable information about how    |          | T |        |
|   | * |     cost sharing works. Also read     |          | * |        |
|   | * |     Section 9 about coordinating      |          | * |        |
|   |   |     benefits with other coverage,     |          |   |        |
|   |   |     including with Medicare.          |          |   |        |
+---+---+---------------------------------------+----------+---+--------+
| # |   |                                       | > **You  |   |        |
| # |   |                                       | > pay**  |   |        |
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+---+---+---------------------------------------+----------+---+--------+
| > |   |                                       | > *      |   |        |
|   |   |                                       | *\$...** |   |        |
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| x |   |                                       |          |   |        |
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|   |   |                                       |          |   |        |
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| v |   |                                       |          |   |        |
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| . |   |                                       |          |   |        |
| } |   |                                       |          |   |        |
| * |   |                                       |          |   |        |
| * |   |                                       |          |   |        |
| * |   |                                       |          |   |        |
+---+---+---------------------------------------+----------+---+--------+

***{{Or, if you have dental benefits and you have a fee scheduled use
this format/table:}}***

+-------------------------+--------------+--------------+--------------+
| **Dental Benefits**     |              |              |              |
+-------------------------+--------------+--------------+--------------+
| ### **Service**         | ### **We Pay |              | **You pay**  |
|                         |  (Scheduled  |              |              |
|                         | Allowance)** |              |              |
+-------------------------+--------------+--------------+--------------+
|                         | ### **H      | ### **Stand  |              |
|                         | igh Option** | ard Option** |              |
+-------------------------+--------------+--------------+--------------+
| *{List covered          | \$\_\_\_ per | \$\_\_\_ per | All charges  |
| services}*              |              |              | in excess of |
|                         |              |              | the          |
|                         |              |              | scheduled    |
|                         |              |              | amounts      |
|                         |              |              | listed to    |
|                         |              |              | the left     |
+-------------------------+--------------+--------------+--------------+

***{{If you have dental HMO benefits use this format/table:}}***

+-----------------------------------+----------------------------------+
| **Dental Benefits**               |                                  |
+-----------------------------------+----------------------------------+
| ### **Service**                   | **You pay**                      |
+-----------------------------------+----------------------------------+
| > {List services}                 | > \$xxx                          |
+-----------------------------------+----------------------------------+

  -----------------------------------------------------------------------
  **Section 5 (i). Point of service benefits**

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

*Plan \-- If none, remove this section and renumber next section.*

***If your plan offers a POS product place it here. Work with your
contract specialist to have text in plain language and to reflect plan
specific benefits. Be sure to add any bullets from Section 5 IMPORTANT
headers that apply.***

***Be sure to add any of the IMPORTANT bullets that apply to these
benefits.***

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

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

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

[What is covered]{.underline}

***List the medical services that are included in the POS benefit.***

***State which providers\' services are subject to POS payment levels
and which are subject to in-Plan payment levels. For example, once a
non-Plan doctor is engaged, are all charges related to that doctor\'s
services paid at POS levels? Or is the participating hospital this
doctor may use paid at in-Plan levels, while the assisting doctors at
the hospital paid POS? Or are all participating providers paid in-Plan
and only the out-of-network doctor paid at the POS level?***

***State whether services must be obtained within the service area to be
eligible for coverage under POS.***

***Define precertification. State the Plan\'s requirements for
precertification. Must the member obtain authorization for the service
from a Plan doctor and then seek a non-Plan doctor, or may the member go
to a non-Plan doctor to begin with? Also state the penalty for not
obtaining precertification. We do not accept a precertification penalty
of more than \$500.***

***Define deductible. State the Plan\'s deductible for POS benefits or
state that there is no deductible. Mention any family limit.***

***Define coinsurance. State the Plan\'s coinsurance for POS benefits.
OPM prefers 70%/30% but 80%/20% is acceptable. A Plan payment of less
than 70% is not acceptable. Plan may use a fee schedule but we prefer
the use of UCR. Both the fee schedule and the UCR should be at the 90th
percentile of HIAA UCR, or comparable, guidelines. State that the fee
schedule or the UCR allowance is set at the 90th percentile of the
standard UCR allowance. State that the member will be liable for the
member\'s coinsurance percentage plus any charges in excess of the UCR
allowance.***

***State here any limitation or cap on POS benefits, e.g., \$1,000,000
per member\'s lifetime. If applicable, state a catastrophic limit on
member\'s out-of-pocket POS expenses per calendar year. State whether
the member\'s out-of-pocket expenses under POS qualify for the Plan\'s
in-Plan out-of-pocket maximum.***

***State the benefit when a non-participating hospital is used. Clarify
whether the Plan will pay a participating hospital in full even though
the POS benefit (and non-Plan doctor) are being used. State that the
hospital charge, sometimes called facility charge, does not cover any
charges for doctors\' services.***

***State that true emergency care is always payable as an in-Plan
benefit.***

***List any other negotiated language for any other specified benefits
such as mental conditions and substance abuse; add a subhead for
each.***

***List here all medical services and procedures that are not covered
under the POS benefit.***

***Describe how to access POS benefits: what address to use and/or phone
number to call. State what information the Plan will need from the
member, such as CPT code, date of service, name of doctor or hospital,
and member\'s I.D. number.***

[Precertification]{.underline}

[Deductible]{.underline}

[Coinsurance]{.underline}

[Maximum benefit]{.underline}

[Hospital/extended care]{.underline}

[Emergency benefits]{.underline}

[Other benefits]{.underline}

[What is not covered]{.underline}

How to obtain benefits

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

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

***{Optional page, limited to one page only. On this page the Plan may
present health-related benefits that we do not buy but that the Plan
wishes to offer directly to enrollees, generally at an additional cost.
The following entire paragraph is mandatory for plans that use this
page.}***

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

{{Plan specific list }}

***{Benefits described on this page must be health-related. They may
include dental and vision benefits that we do not purchase and plan
wellness or preventive care not included in the community package that
the plan offers to its members at little or no charge, such as discounts
at fitness clubs, health assessments, maternity counseling and classes
in self care for diabetics.}***

***{Language may be included by plans offering Medicare prepaid plans
that wish to encourage Federal annuitants to enroll. Plans with Medicare
plans are encouraged but not required to advertise them here; in some
cases the Medicare plan offers lesser benefits than the Plan\'s FEHB
package.}***