Humana CoverageFirst

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**A Consumer Driven Individual Practice Plan**

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| Enrollment codes for Phoenix,   | Enrollment codes for **Memphis,    |
| AZ:                             | TN**:                              |
|                                 |                                    |
| > DB1 Self Only                 | > **L61** Self Only                |
| >                               | >                                  |
| > **DB2** Self and Family       | > **L62** Self and Family          |
|                                 |                                    |
| Enrollment codes for            | Enrollment codes for **Austin,     |
| **Jacksonville, FL**:           | TX**:                              |
|                                 |                                    |
| > **MQ1** Self Only             | > **TV1** Self Only                |
| >                               | >                                  |
| > **MQ2** Self and Family       | > **TV2** Self and Family          |
|                                 |                                    |
| Enrollment codes for **Tampa,   | Enrollment codes for **Corpus      |
| FL**:                           | Christi, TX**:                     |
|                                 |                                    |
| > **MJ1** Self Only             | > **TP1** Self Only                |
| >                               | >                                  |
| > **MJ2** Self and Family       | > **TP2** Self and Family          |
|                                 |                                    |
| Enrollment codes for South      | Enrollment codes for **Dallas/Ft.  |
| Florida:                        | Worth, TX**:                       |
|                                 |                                    |
| > **QP1** Self Only             | > **T81** Self Only                |
| >                               | >                                  |
| > **QP2** Self and Family       | > **T82** Self and Family          |
|                                 |                                    |
| Enrollment codes for **Chicago, | Enrollment codes for **Houston,    |
| IL**:                           | TX**:                              |
|                                 |                                    |
| > **MW1** Self Only             | > **T21** Self Only                |
| >                               | >                                  |
| > **MW2** Self and Family       | > **T22** Self and Family          |
|                                 |                                    |
| Enrollment codes for Kansas     | Enrollment codes for **San         |
| City, KS/MO:                    | Antonio, TX**:                     |
|                                 |                                    |
| > **PH1** Self Only             | > **TU1** Self Only                |
| >                               | >                                  |
| > **PH2** Self and Family       | > **TU2** Self and Family          |
|                                 |                                    |
| Enrollment codes for            | Enrollment codes for **Milwaukee,  |
| Louisville, KY:                 | WI**:                              |
|                                 |                                    |
| > BM1 Self Only                 | > **FB1** Self Only                |
| >                               | >                                  |
| > BM2 Self and Family           | > **FB2** Self and Family          |
|                                 |                                    |
| Enrollment codes for            |                                    |
| Cincinnati/Dayton, OH:          |                                    |
|                                 |                                    |
| > **L81** Self Only             |                                    |
| >                               |                                    |
| > **L82** Self and Family       |                                    |
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  **Special notice:** This Plan is offered for the first time under the
  Federal Employees Health Benefits Program during the 2003 Open Season.

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![](media/image5.png){width="0.75in" height="0.75in"}**UNITED STATES**

**OFFICE OF PERSONNEL MANAGEMENT**

**WASHINGTON, DC 20415-0001**

**OFFICE OF THE DIRECTOR**

> Dear Federal Employees Health Benefits Program Participant:
>
> I am pleased to present this 2004 Federal Employees Health Benefits
> (FEHB) Program plan brochure. The brochure describes the benefits this
> plan offers you for 2004. Because benefits vary from year to year, you
> should review your plan's brochure every Open Season - especially
> Section 2, which explains how the plan changed.
>
> It takes a lot of information to help a consumer make wise healthcare
> decisions. The information in this brochure, our FEHB Guide, and our
> web-based resources, make it easier than ever to get information about
> plans, to compare benefits and to read customer service satisfaction
> ratings for the national and local plans that may be of interest. Just
> click on www.opm.gov/insure!
>
> The FEHB Program continues to be an enviable national model that
> offers exceptional choice, and uses private-sector competition to keep
> costs reasonable, ensure high-quality care, and spur innovation. The
> Program, which began in 1960, is sound and has stood the test of time.
> It enjoys one of the highest levels of customer satisfaction of any
> healthcare program in the country.
>
> I continue to take aggressive steps to keep the FEHB Program on the
> cutting edge of employer-sponsored health benefits. We demand
> cost-effective quality care from our FEHB carriers and we have
> encouraged Federal agencies and departments to pay the full FEHB
> health benefit premium for their employees called to active duty in
> the Reserve and National Guard so they can continue FEHB coverage for
> themselves and their families. Our carriers have also responded to my
> request to help our members to be prepared by making additional
> supplies of medications available for emergencies as well as call-up
> situations and you can help by getting an Emergency Preparedness Guide
> at www.opm.gov. OPM's *HealthierFeds* campaign is another way the
> carriers are working with us to ensure Federal employees and retirees
> are informed on healthy living and best-treatment strategies. You can
> help to contain healthcare costs and keep premiums down by living a
> healthy life style.
>
> Open Season is your opportunity to review your choices and to become
> an educated consumer to meet your healthcare needs. Use this brochure,
> the FEHB Guide, and the web resources to make your choice an informed
> one. Finally, if you know someone interested in Federal employment,
> refer them to www.usajobs.opm.gov.

![](media/image6.png){width="2.46875in" height="0.8229166666666666in"}
Sincerely,

> Kay Cole James
>
> Director

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# Notice of the Office of Personnel Management's

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

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  Table of Contents
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Introduction 4

Plain Language 4

Stop Health Care Fraud! 4-5

Preventing medical mistakes 5-6

Section 1. Facts about this plan 7-8

How we pay providers 7

Your Rights 7-8

Service Area 8

Section 2. We are a new plan 9

Section 3. How you get care 10-12

Identification cards 10

Where you get covered care 10

-   Plan providers 10

-   Plan facilities 10

What you must do to get covered care 10-11

-   Specialty care 10

-   Hospital care 11

Circumstances beyond our control 11

Services requiring our prior approval 11

Section 4. Your costs for covered services 12-14

-   Copayments 13

-   Deductible 13

-   Coinsurance 13

Your catastrophic protection out-of-pocket maximum 14

Section 5. Benefits 15-40

Overview 15

(a) Medical services and supplies provided by physicians and other
    health care professionals 16-24

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 25-28

(c) Services provided by a hospital or other facility, and ambulance
    services 29-31

(d) Emergency services/accidents 32-33

(e) Mental health and substance abuse benefits 34-35

(f) Prescription drug benefits 36-37

(g) Special features 38

-   Flexible benefits option 38

-   24-hour nurse line 38

-   Services for deaf and hearing impaired 38

-   High risk pregnancies 38

-   Centers of excellence 38

(h) Dental benefits 39

(i) Non-FEHB benefits available to Plan members 40

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

Section 7. Filing a claim for covered services 42

Section 8. The disputed claims process 43-44

Section 9. Coordinating benefits with other coverage 45-49

When you have other health coverage 45

-   What is Medicare? 45

-   Should I enroll in Medicare? 45-46

-   Medicare + Choice 48

-   TRICARE and CHAMPVA 48

-   Workers\' Compensation 49

-   Medicaid 49

-   Other Government agencies 49

-   When others are responsible for injuries 49

Section 10. Definitions of terms we use in this brochure 50-51

Section 11. FEHB facts 52-55

Coverage information 52-53

-   No pre-existing condition limitation 52

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-   Where you can get information about enrolling in the FEHB Program 52

-   Types of coverage available for you and your family 52

-   Children's Equity Act 52-53

-   When benefits and premiums start 53

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-   When you retire 53

    When you lose benefits 54-55

-   When FEHB coverage ends 54

-   Spouse equity coverage 54

-   Temporary Continuation of Coverage (TCC) 54

-   Converting to individual coverage 54

-   Getting a Certificate of Group Health Plan Coverage 55

Two new Federal Programs complement FEHB benefits 56-59

> The Federal Flexible Spending Account Program -- *FSAFEDS* 56-59
>
> The Federal Long Term Care Insurance Program 59

Index 60

Summary of benefits 62

Rates 63-65

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  Introduction

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This brochure describes the benefits of Humana CoverageFirst, under our
contract (CS 2887) with the Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. This plan is
underwritten by Humana Health Plan Inc., Humana Health Insurance Company
of Florida, Inc., and Humana Insurance Company. The address for
CoverageFirst administrative offices is:

Humana Inc.

500 West Main

Louisville, KY 40201

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

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

OPM negotiates benefits and rates with each plan annually. Rates are
shown at the end of this brochure.

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

-   Except for necessary technical terms, we use common words. For
    instance, "you" means the enrollee or family member; "we" means
    Humana CoverageFirst.

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

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

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

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

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

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

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

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at
    1-800/4HUMANA and explain the situation.

-   If we do not resolve the issue:

> **CALL -- THE HEALTH CARE FRAUD HOTLINE**
>
> **202-418-3300**
>
> **OR WRITE TO:**
>
> United States Office of Personnel Management\
> Office of the Inspector General Fraud Hotline\
> 1900 E Street, NW, Room 6400\
> Washington, DC 20415-1100

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

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

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

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

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

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

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

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

Want more information on patient safety?

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

-   www.nnpsf.org. The National Patient Safety Foundation has
    information on how to ensure safer healthcare for you and your
    family.

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

-   www.leapfroggroup.org. The Leapfrog Group is active in promoting
    safe practices in hospital care.

-   www.ahqa.org. The American Health Quality Association represents
    organizations and healthcare professionals working to improve
    patient safety.

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

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  **Section 1. Facts about this plan**

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This Plan is a Consumer Driven Individual Practice Plan. This Plan
allows you to choose your own physicians, hospitals and other health
care providers. Members can use Participating Providers or Non
Participating Providers and no referrals are necessary.

**When you use Participating Providers**

When you use participating providers, you receive the highest level of
benefits, with less out of pocket expenses. You will not have to submit
claim forms. You pay only the copayments, coinsurance, and deductibles
described in this brochure.

The Plan pays the first \$500 of covered medical services for each
person enrolled. We call this your benefit allowance. While using the
\$500 benefit allowance you are only responsible for the applicable
copayments. You do not have to submit receipts for reimbursement. The
benefit allowance can only be used to pay for covered medical services
from participating providers. Any benefit allowance that remains at the
end of the Plan year cannot be "rolled over" or "cashed out."

The following services do not reduce your \$500 benefit allowance:

**Preventive Care** services are separate and do not apply toward the
benefit allowance. Your copayments are the only out of pocket costs for
these covered benefits. The costs of the services are not subject to the
deductible.

**Prescription Drug** copayments do not apply toward your benefit
allowance. You are responsible only for any applicable copayments or
coinsurance when you use a participating provider. You do not have to
satisfy a deductible.

Once your expenses reach the \$500 benefit allowance, you pay for
medical services until you meet the deductible. After you meet the
deductible, the Plan pays for most or all of the covered services that
you receive. Your payments and the Plan's payments are based on Humana
CoverageFirst's contracted rates.

**Routine physician office visit benefits are excluded from the
deductible. You will only be responsible for the applicable copayment
throughout the plan year, even if your benefit allowance has been
depleted. The copayment covers services billed as an office visit or
consultation. Other services provided in the physician's office, such as
lab work, X-rays and surgery, are still subject to the deductible.**

**When you use Non-Participating Providers**

When you use a non-participating provider, we will pay benefits at a
lower level and you will pay a larger share of the costs. Since
non-participating providers have not agreed to accept discounted or
negotiated fees as payment in full, they may balance bill you for
charges in excess of the allowable amount. You will be responsible for
charges in excess of the allowable amount in addition to any applicable
deductible or coinsurance. Any amount that you pay to a
non-participating provider in excess of your coinsurance (percentage of
the allowable fee) will not apply to your out of pocket limit or
deductible. There is no benefit allowance when you use non-participating
providers.

**How we pay providers**

**Participating Providers:** We contract with physicians, health care
facilities, or other health care professionals to provide the benefits
in this brochure. These plan providers accept a negotiated payment from
us based on a maximum allowable fee schedule. They will not bill you and
you will not have to file claim forms. You will only be responsible for
your copayments, coinsurance and deductibles.

**Non-Participating Providers:** Humana uses the maximum allowable fee
schedule agreed to by us and network physicians. The schedules are based
on a percentage of the Health Insurance Association of America (HIAA)
fee schedule.

You will be responsible for any difference between the amount
non-participating providers charge and our allowance, in addition to the
applicable coinsurance and copayment amounts. Any amount that you pay to
the provider in excess of the allowed amount will not apply to your out
of pocket maximum deductible.

**Your Rights**

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

-   Medical case management is a special Humana program that coordinates
    the provision of care and the management of benefits in cases of
    catastrophic illness or injury, transplant management and disease
    management. The program strives to ensure that patients receive the
    most appropriate, cost-effective care and also derive maximum
    advantage from plan benefits.

-   Humana subscribes to preventive care guidelines based on the United
    States Preventive Health Task Force and subscribes to their Healthy
    People 2010 goals. Our Patterns of Preventive Care (POPC) program
    monitors the delivery of well care and uses an automated reminder
    system to help assure that our members schedule routine preventative
    services.

-   Humana provides comprehensive disease management programs to plan
    members. Key to each program is ongoing education, communication and
    coordination. Each contracted vendor offers plan members access to a
    staff of highly specialized nurses and doctors, experienced in the
    respective disease field. The programs focus on linking the plan
    member with a specialized nurse or interdisciplinary team to ensure
    an individualized care development approach. These nurses work
    closely with the plan member, member's family, member's primary care
    physician (PCP) and other involved providers to provide information,
    education and assistance when needed.

-   Nationally, Humana has been in the health care business since 1961.

-   Humana is a for profit corporation which is publicly traded on the
    New York Stock Exchange (NYSE).

If you want more information about us, call 1-800/448-6262. You may also
contact us by visiting our website at feds.humana.com.

**Service Area**

To enroll in this plan you must live or work in our service areas. This
is where our providers practice.

**[Arizona, Phoenix]{.underline}** -- Enrollment code **DB** - Maricopa
County

**[Florida, Jacksonville]{.underline}** -- Enrollment code **MQ** -
Nassau, Duval, Clay, St. John's, Alachua, Bradford, Union, Baker,
Columbia, and Putnam counties.

**[Florida, Tampa]{.underline}** -- Enrollment code **MJ** - Pinellas,
Hillsborough, Polk, Manatee, Sarasota, Pasco, Hernando, and Citrus
counties.

**[Florida, South Florida]{.underline}** -- Enrollment code **QP** -
Dade, Broward, Palm Beach, Martin, St. Lucie, Indian River, and
Okeechobee counties.

**[Illinois, Chicago]{.underline}** -- Enrollment code **MW** - The
Illinois counties of McHenry, Lake, Kane, DuPage, Cook, Will, Kendall
and Kankakee. The Indiana counties of Lake, Porter, and LaPorte.

**[Kansas/Missouri, Kansas City]{.underline}** -- Enrollment code
**PH** - The Missouri counties of Carroll, Lafayette, Johnson, Henry,
Ray, Bates, Cass, Jackson, Clay and Platte. The Kansas counties of
Miami, Johnson, Leavenworth and Wyandotte.

**[Kentucky, Louisville]{.underline}** -- Enrollment code **BM** - The
Kentucky counties of Jefferson, Oldham, Henry, Trimble, Carroll, Shelby,
Spencer, Bullitt, Nelson, Washington, Marion, Green, Taylor, Hart,
Larue, Hardin, Meade, Breckinridge, Grayson, Barren, Metcalfe, Monroe,
Allen, Warren, Simpson, Edmonson, Butler, Logan, Daviess, and Hancock.
The Indiana counties of Harrison, Floyd, Clark, Washington, Scott, and
Jefferson.

**[Ohio, Cincinnati]{.underline}** -- Enrollment code **L8** - The Ohio
counties of Hamilton, Clermont, Brown, Adams, Butler, Warren, Clinton,
Greene, Montgomery, Preble, Miami, Clark, and Champaign. The Kentucky
counties of Boone, Kenton, Campbell, Pendleton, Grant, and Gallatin.

**[Tennessee, Memphis]{.underline}** -- Enrollment code **L6** - Dyer,
Fayette, Gibson, Haywood, Lauderdale, Shelby, and Tipton counties.

**[Texas, Austin]{.underline}** -- Enrollment code **TV** - Bosque,
Hamilton, Coryell, Lampasas, McLennan, Limestone, Robertson, Bell,
Falls, Milam, Burleson, Lee, Bastrop, Caldwell, Hays, Travis,
Williamson, and Burnet counties.

**[Texas, Corpus Christi]{.underline}** -- Ennrollment code **TP** -
DeWitt, Victoria, Goliad, Bee, Live Oak, Refugio, San Patricio, Nueces,
Jim Wells, Duval, Kleberg, Brooks, Kenedy, Jim Hogg, Zapata, Starr,
Hidalgo, Willacy, and Cameron counties.

**[Texas, Dallas]{.underline}** -- Enrollment code **T8** - Collin,
Dallas, Denton, Ellis, Hood, Hunt, Johnson, Kaufman, Parker, Rockwall,
Tarrant, Grayson, Navarro, Hill, Somervell, Wise, and Cooke counties

**[Texas, Houston]{.underline}** -- Enrollment code **T2** - Madison,
Grimes, Washington, Austin, Montgomery, Harris, Liberty, Hardin,
Chambers, Jefferson, Orange, Galveston, Brazoria, Fort Bend, Wharton,
Colorado, Waller, and Fayette counties.

**[Texas, San Antonio]{.underline}** -- Enrollment code **TU** - Blanco,
Kendall, Comal, Guadalupe, Gonzales, Wilson, Karnes, Atascosa, Frio,
Medina, Uvalde, Bandera, Webb, and Bexar counties.

***[Wisconsin, Milwaukee]{.underline}** -- Enrollment code **FB** -
Dodge, Green, Jefferson, Kenosha, Milwaukee, Ozaukee, Racine, Rock,
Walworth, Washington, Waukesha, Fond du Lac, Manitowoc, and Sheboygan
counties.*

  -----------------------------------------------------------------------
  **Section 2. We are a new plan**

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

This Plan is new to the FEHB Program. We are being offered for the first
time during the 2003 open season.

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program -- FSAFEDS, and the Federal Long Term Care Insurance
    Program. See pages 56-59.

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

-   We added information regarding enrolling in Medicare. See pages
    45-46.

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

  -----------------------------------------------------------------------
  Section 3. How you get care
  -----------------------------------------------------------------------

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

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

If you do not receive your ID card within 30 days after the effective\
date of your enrollment, or if you need replacement cards, call us at\
1-800/4HUMANA or 1-800/448-6262. You may also request replacement cards
through our website at feds.humana.com.

**Where you get covered care** You can get care from any "Plan provider"
or "Plan facility." You will only pay copayments, deductibles, and/or
coinsurance, and you will not have to file claims. You can also get care
from non-Plan providers, but it will cost you more.

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

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

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

**What you must do**

**to get covered care** You do not have to select a primary care
physician and may self refer. To obtain the highest level of coverage,
however, a member must seek care from a participating provider. Some
care requires you or your provider to obtain prior authorization.

**• Specialty care** Here are things you should know about specialty
care:

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

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

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

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

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

**• Hospital care** If you are in the hospital when your enrollment in
our Plan begins, call our customer service department immediately at
1-800/4 HUMANA or 1-800/448-6262. If you are new to the FEHB Program, we
will arrange for you to receive care.

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

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

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

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

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

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

**Services requiring our** Your physician must obtain approval from us
for certain services.

**prior approval** We consider if the service is covered, medically
necessary, and we follow generally accepted medical practice before we
approve it.

You must obtain preauthorization for the following services and
supplies:

-   Non-emergent hospital, rehabilitation, skilled nursing and hospice
    facility admissions;

-   Non-emergent admissions for mental health services and chemical
    dependency services;

-   Hospice care programs;

-   Transplant services;

-   Durable medical equipment, prosthetics, and orthotics and diabetes
    equipment with a purchase price in excess of \$750 per item.

> You are responsible for alerting your health care provider to the
> preauthorization requirements. You or your provider must contact us by
> telephone, electronic mail, or in writing. If preauthorization is
> required but not obtained, benefits will be reduced by \$500. This
> pre-authorization penalty will apply if you receive services from a
> non-participating provider.

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

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

Each covered member under Humana CoverageFirst has a \$500 benefit
allowance to use for participating provider services. This allowance can
be used for medical and mental health benefits before a deductible must
be reached. For expenses applied to the \$500 benefit allowance, your
only out-of-pocket costs are copayments.

Once your \$500 benefit allowance is depleted, you pay 100% of your
medical expenses until you satisfy your deductible. Your payments are
based on Humana's contracted rates. The following services do not apply
to the deductible:

-   P**rescription drugs and preventive care services** -- You pay only
    the copayments.

-   R**outine physician office visits** -- You pay only the copayments,
    even if your benefit allowance has been depleted. The copayment
    covers services billed as an office visit or consultation. Other
    services provided in the physician's office, such as lab work or
    X-rays, are subject to the deductible.

CoverageFirst pays most or all other covered expenses after you meet
your deductible.

**Here are some examples of how Humana CoverageFirst works:**

**Example 1**

In January, member sees her primary care physician for a preventive care
exam. Her physician orders a prescription drug which she receives from a
participating pharmacy. Preventive care services and prescription drug
costs do not reduce her \$500 benefit allowance. In May, she becomes ill
and sees her primary care physician. Her physician sends her to the
hospital for lab work and x-rays.

  --------- ---------------------------- --------- ----------- --------------- -------
  Date\     Services -- Provided by\     Cost of   Member      Amount applied  Plan
  of\       Participating Providers      Service   Copayment   to              pays
  Service                                                      CoverageFirst   
                                                               Benefit         
                                                               Allowance       

  January   Preventive Care Exam --      \$250     \$20        \$0             \$230
            Office Visit                                                       

  January   Prescription Drug (Level 1)  \$75      \$10        \$0             \$65

  May       Routine Care Exam - Office   \$100     \$20        \$80            \$0
            Visit                                                              

  May       Routine Care - Outpatient    \$350     \$0         \$350           \$0
            Lab & X-ray                                                        

            Totals                       \$775     \$50        \$430           \$295
  --------- ---------------------------- --------- ----------- --------------- -------

In this example, benefit charges were \$775. CoverageFirst paid \$430,
the member paid \$50 and plan benefits paid \$295. The member has a
CoverageFirst benefit allowance of \$70 remaining before the \$1,500
individual deductible applies.

**Example 2**

In June, member has an accident, visits the emergency room and receives
X-rays. He has outpatient surgery at a local hospital and five
rehabilitation sessions. In August, member has a ruptured appendix,
visits the emergency room and has surgery at a local hospital where he
spends one night.

  --------- ---------------------- --------- ----------- --------------- ------------ ---------
  Date\     Services -- Provided   Cost of   Member      Amount applied  Member       Plan pays
  of\       by\                    Service   Copayment   to              payment      
  Service   Participating                                CoverageFirst   toward       
            Providers                                    Benefit         deductible   
                                                         Allowance                    

  June      Emergency Room Visit & \$450     \$100       \$350           \$0          \$0
            X-ray                                                                     

  June      Outpatient Surgery     \$1,600   \$50        \$150           \$1,400      \$0

  June      5 Outpatient Physical  \$250     \$0         \$0             \$100        \$150
            Therapy Visits                                                            
            (Rehabilitation                                                           
            Sessions)                                                                 

  August    Emergency Room Visit\  \$350     waived      \$0             \$0          \$350
            (Admitted as                                                              
            Inpatient)                                                                

  August    Inpatient Surgery and  \$5,500   \$100       \$0             \$0          \$5,400
            1 day hospital stay                                                       

            Totals                 \$8,150   \$250       \$500           \$1,500      \$5,900
  --------- ---------------------- --------- ----------- --------------- ------------ ---------

In this example, the CoverageFirst allowance was used. The member was
responsible for \$250 in copayments and the \$1,500 individual
deductible. Services received in August were paid by the plan. The
member was only responsible for the copayment.

**Copayments**

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

Example: When you see a participating Family Practice physician you will
pay a \$20 copayment. When you have outpatient surgery at a
participating facility, you will pay a \$50 copayment. Copayments do not
reduce your \$500 benefit allowance or count towards the deductible.

**Deductible**

A deductible is a fixed expense you must incur for certain covered
services and supplies before we start paying benefits for them.

Participating providers -- If you use participating providers, you do
not have to meet a deductible until your \$500 benefit allowance is
depleted. The calendar year individual deductible is \$1,500. Under a
family enrollment, the deductible is \$3,000.

Non-participating providers -- If you use non-participating providers,
the \$500 benefit allowance does not apply. Before benefits are payable,
the calendar year deductible of \$3,000 per person must be met. The
deductible for family coverage is \$6,000. Deductible and out-of-pocket
limits for participating and non-participating benefits are calculated
separately.

**Coinsurance**

Coinsurance is the percentage of the Plan allowance that you must pay
for your care. Coinsurance begins after you meet your deductible.

Participating providers -- The infertility benefit has a 50%
coinsurance. All other benefits on this Plan are covered services or the
member responsibility is a copayment.

Non-participating providers -- You pay a 30% coinsurance for an office
visit with a physician.

**Differences between our allowance and the bill**

Participating providers -- have agreed to accept a negotiated payment
from us; you are only responsible for your copayments. You never have to
pay the difference between the plan allowance and the billed amount.

Non-participating providers -- You will be responsible for any
difference between the amount non-participating providers charge and our
allowance, in addition to the applicable coinsurance amounts.

**Your catastrophic protection out-of-pocket maximum for coinsurance**

Participating providers -- There is no maximum out-of-pocket limit.

Non-participating providers - After your coinsurance totals \$4,000 per
person or \$8,000 per family enrollment in any calendar year, you do not
have to pay any more for covered services. The plan covers 100% of
covered services. The maximum out-of-pocket expense limits exclude
deductibles and expenses for covered organ transplants.

Be sure to keep accurate records of your coinsurance since you are
responsible for informing us when you reach the maximum.

+-----------------------------------------------------------------------+
| **Section 5. Benefits -- OVERVIEW**                                   |
|                                                                       |
| ***(See page 62 for a benefits summary.)***                           |
+-----------------------------------------------------------------------+

**NOTE**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claims forms,
claims filing advice, or more information about our benefits, contact us
at 1-800/4HUMANA or 1-800/448-6262 or at our website at
feds.humana.com*.*

(a) Medical services and supplies provided by physicians and other
    health care professionals 16-24

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 25-28

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

(c) Services provided by a hospital or other facility, and ambulance
    services 29-31

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

(d) Emergency services/accidents 32-33

> • Medical emergency • Ambulance

(e) Mental health and substance abuse benefits 34-35

(f) Prescription drug benefits 36-37

(g) Special features 38

    -   Flexible benefits option

    -   24-hour nurse line

    -   Services for deaf and hearing impaired

    -   High risk pregnancies

    -   Centers of excellence

    -   Infertility benefits

(h) Dental benefits 39

(i) Non-FEHB benefits available to Plan members 40

Summary of benefits 62

+---+----+--------------------------------+---+---+-----------------+----+---+
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| * |    |                                |   |   |                 |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
|   | *  | **Here are some important      |   |   |                 | *  |   |
|   | *I | things to keep in mind about   |   |   |                 | *I |   |
|   | ** | these benefits:**              |   |   |                 | ** |   |
|   |    |                                |   |   |                 |    |   |
|   | *  | -   Please remember that all   |   |   |                 | *  |   |
|   | *M |     benefits are subject to    |   |   |                 | *M |   |
|   | ** |     the definitions,           |   |   |                 | ** |   |
|   |    |     limitations, and           |   |   |                 |    |   |
|   | *  |     exclusions in this         |   |   |                 | *  |   |
|   | *P |     brochure and are payable   |   |   |                 | *P |   |
|   | ** |     only when we determine     |   |   |                 | ** |   |
|   |    |     they are medically         |   |   |                 |    |   |
|   | *  |     necessary.                 |   |   |                 | *  |   |
|   | *O |                                |   |   |                 | *O |   |
|   | ** | -   The calendar year          |   |   |                 | ** |   |
|   |    |     deductible is:             |   |   |                 |    |   |
|   | *  |                                |   |   |                 | *  |   |
|   | *R | > Participating providers --   |   |   |                 | *R |   |
|   | ** | > You do not have to meet a    |   |   |                 | ** |   |
|   |    | > deductible until your \$500  |   |   |                 |    |   |
|   | *  | > benefit allowance is         |   |   |                 | *  |   |
|   | *T | > depleted. The calendar year  |   |   |                 | *T |   |
|   | ** | > deductible is \$1,500 for    |   |   |                 | ** |   |
|   |    | > self and \$3,000 for self    |   |   |                 |    |   |
|   | *  | > and family.                  |   |   |                 | *  |   |
|   | *A | >                              |   |   |                 | *A |   |
|   | ** | > Non-participating providers  |   |   |                 | ** |   |
|   |    | > -- The \$500 benefit         |   |   |                 |    |   |
|   | *  | > allowance does not apply.    |   |   |                 | *  |   |
|   | *N | > The calendar year deductible |   |   |                 | *N |   |
|   | ** | > is \$3,000 for self and      |   |   |                 | ** |   |
|   |    | > \$6,000 for self and family. |   |   |                 |    |   |
|   | *  |                                |   |   |                 | *  |   |
|   | *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 benefits with |   |   |                 |    |   |
|   |    |     other coverage, including  |   |   |                 |    |   |
|   |    |     with Medicare.             |   |   |                 |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
| > |    |                                | > |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| * |    |                                | * |   |                 |    |   |
| * |    |                                | * |   |                 |    |   |
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| > |    |                                | y |   |                 |    |   |
|   |    |                                | * |   |                 |    |   |
| D |    |                                | * |   |                 |    |   |
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| s |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| p |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| * |    |                                |   |   |                 |    |   |
| * |    |                                |   |   |                 |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
| > |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| * |    |                                |   |   |                 |    |   |
| * |    |                                |   |   |                 |    |   |
| N |    |                                |   |   |                 |    |   |
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| l |    |                                |   |   |                 |    |   |
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| h |    |                                |   |   |                 |    |   |
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|   |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| p |    |                                |   |   |                 |    |   |
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| l |    |                                |   |   |                 |    |   |
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| . |    |                                |   |   |                 |    |   |
| * |    |                                |   |   |                 |    |   |
| * |    |                                |   |   |                 |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
| # |    |                                |   |   |                 |    |   |
| # |    |                                |   |   |                 |    |   |
| # |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| * |    |                                |   |   |                 |    |   |
| * |    |                                |   |   |                 |    |   |
| D |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| g |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| d |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| m |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| v |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| * |    |                                |   |   |                 |    |   |
| * |    |                                |   |   |                 |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
| > |    |                                |   |   | >               |    |   |
|   |    |                                |   |   |  Participating: |    |   |
| P |    |                                |   |   | >               |    |   |
| r |    |                                |   |   | > \$20 per      |    |   |
| o |    |                                |   |   | > office visit  |    |   |
| f |    |                                |   |   | > to a primary  |    |   |
| e |    |                                |   |   | > care          |    |   |
| s |    |                                |   |   | > physician;    |    |   |
| s |    |                                |   |   | > \$35 per      |    |   |
| i |    |                                |   |   | > office visit  |    |   |
| o |    |                                |   |   | > to a          |    |   |
| n |    |                                |   |   | > specialist    |    |   |
| a |    |                                |   |   | > (no           |    |   |
| l |    |                                |   |   | > deductible)   |    |   |
| > |    |                                |   |   | >               |    |   |
|   |    |                                |   |   | > Non           |    |   |
| s |    |                                |   |   | -participating: |    |   |
| e |    |                                |   |   | > 30% after     |    |   |
| r |    |                                |   |   | > deductible    |    |   |
| v |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| > |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| f |    |                                |   |   |                 |    |   |
| > |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| p |    |                                |   |   |                 |    |   |
| h |    |                                |   |   |                 |    |   |
| y |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
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| { |    |                                |   |   |                 |    |   |
| = |    |                                |   |   |                 |    |   |
| h |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| m |    |                                |   |   |                 |    |   |
| l |    |                                |   |   |                 |    |   |
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| < |    |                                |   |   |                 |    |   |
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| O |    |                                |   |   |                 |    |   |
| f |    |                                |   |   |                 |    |   |
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| i |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
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|   |    |                                |   |   |                 |    |   |
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| m |    |                                |   |   |                 |    |   |
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| d |    |                                |   |   |                 |    |   |
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| c |    |                                |   |   |                 |    |   |
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| l |    |                                |   |   |                 |    |   |
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| c |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| u |    |                                |   |   |                 |    |   |
| l |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| - |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| S |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| d |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| u |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| g |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| l |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| p |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
| - |    |                                |   |   | >               |    |   |
|   |    |                                |   |   |  Participating: |    |   |
|   |    |                                |   |   | > \$35 copay    |    |   |
|   |    |                                |   |   | > (no           |    |   |
| I |    |                                |   |   | > deductible)   |    |   |
| n |    |                                |   |   | >               |    |   |
|   |    |                                |   |   | > Non           |    |   |
|   |    |                                |   |   | -participating: |    |   |
|   |    |                                |   |   | > 30% after     |    |   |
|   |    |                                |   |   | > deductible    |    |   |
| a |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| u |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| g |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
| - |    |                                |   |   | >               |    |   |
|   |    |                                |   |   |  Participating: |    |   |
|   |    |                                |   |   | > Nothing after |    |   |
|   |    |                                |   |   | > deductible    |    |   |
| D |    |                                |   |   | >               |    |   |
| u |    |                                |   |   | > Non           |    |   |
| r |    |                                |   |   | -participating: |    |   |
| i |    |                                |   |   | > 30% after     |    |   |
| n |    |                                |   |   | > deductible    |    |   |
| g |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| h |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| p |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| l |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| y |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| - |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| I |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| k |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| l |    |                                |   |   |                 |    |   |
| l |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| d |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| u |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| g |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| f |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| l |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| y |    |                                |   |   |                 |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
| - |    |                                |   |   | >               |    |   |
|   |    |                                |   |   |  Participating: |    |   |
|   |    |                                |   |   | >               |    |   |
|   |    |                                |   |   | > \$20 per      |    |   |
| A |    |                                |   |   | > office visit  |    |   |
| t |    |                                |   |   | > to a primary  |    |   |
|   |    |                                |   |   | > care          |    |   |
|   |    |                                |   |   | > physician;    |    |   |
|   |    |                                |   |   | > \$35 per      |    |   |
|   |    |                                |   |   | > office visit  |    |   |
| h |    |                                |   |   | > to a          |    |   |
| o |    |                                |   |   | > specialist    |    |   |
| m |    |                                |   |   | > (no           |    |   |
| e |    |                                |   |   | > deductible)   |    |   |
|   |    |                                |   |   | >               |    |   |
|   |    |                                |   |   | > Non           |    |   |
|   |    |                                |   |   | -participating: |    |   |
|   |    |                                |   |   | > 30% after     |    |   |
|   |    |                                |   |   | > deductible    |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
| # |    |                                |   |   | > **You pay**   |    |   |
|   |    |                                |   |   |                 |    |   |
| L |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| b |    |                                |   |   |                 |    |   |
| , |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| x |    |                                |   |   |                 |    |   |
| - |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| y |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| d |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| h |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| d |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| g |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
| > |    |                                |   |   | >               |    |   |
|   |    |                                |   |   |  Participating: |    |   |
| T |    |                                |   |   | > Nothing after |    |   |
| e |    |                                |   |   | > deductible    |    |   |
| s |    |                                |   |   | >               |    |   |
| t |    |                                |   |   | > Non           |    |   |
| s |    |                                |   |   | -participating: |    |   |
| , |    |                                |   |   | > 30% after     |    |   |
| > |    |                                |   |   | > deductible    |    |   |
|   |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| u |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| h |    |                                |   |   |                 |    |   |
| > |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| : |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| - |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| B |    |                                |   |   |                 |    |   |
| l |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| d |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
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|   |    |                                |   |   |                 |    |   |
| - |    |                                |   |   |                 |    |   |
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|   |    |                                |   |   |                 |    |   |
| U |    |                                |   |   |                 |    |   |
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| n |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| l |    |                                |   |   |                 |    |   |
| y |    |                                |   |   |                 |    |   |
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|   |    |                                |   |   |                 |    |   |
| N |    |                                |   |   |                 |    |   |
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| n |    |                                |   |   |                 |    |   |
| - |    |                                |   |   |                 |    |   |
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|   |    |                                |   |   |                 |    |   |
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|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| P |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| p |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
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| - |    |                                |   |   |                 |    |   |
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| M |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| m |    |                                |   |   |                 |    |   |
| m |    |                                |   |   |                 |    |   |
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| g |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| m |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| - |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| C |    |                                |   |   |                 |    |   |
| A |    |                                |   |   |                 |    |   |
| T |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
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| S |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
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| / |    |                                |   |   |                 |    |   |
| M |    |                                |   |   |                 |    |   |
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| l |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| s |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| u |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| d |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| - |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| E |    |                                |   |   |                 |    |   |
| l |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| d |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
| o |    |                                |   |   |                 |    |   |
| g |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| m |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| n |    |                                |   |   |                 |    |   |
| d |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| E |    |                                |   |   |                 |    |   |
| E |    |                                |   |   |                 |    |   |
| G |    |                                |   |   |                 |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
| # |    |                                |   |   |                 |    |   |
| # |    |                                |   |   |                 |    |   |
| # |    |                                |   |   |                 |    |   |
| # |    |                                |   |   |                 |    |   |
| # |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| P |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
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| v |    |                                |   |   |                 |    |   |
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| n |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
| i |    |                                |   |   |                 |    |   |
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|   |    |                                |   |   |                 |    |   |
| c |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| r |    |                                |   |   |                 |    |   |
| e |    |                                |   |   |                 |    |   |
| , |    |                                |   |   |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| a |    |                                |   |   |                 |    |   |
| d |    |                                |   |   |                 |    |   |
| u |    |                                |   |   |                 |    |   |
| l |    |                                |   |   |                 |    |   |
| t |    |                                |   |   |                 |    |   |
+---+----+--------------------------------+---+---+-----------------+----+---+
| > |    |                                |   | > |                 |    |   |
|   |    |                                |   |   |                 |    |   |
| W |    |                                |   | P |                 |    |   |
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+---+----+--------------------------------+---+---+-----------------+----+---+

+-------------------------------------------+--------------------------+---+
| #                                         | **You pay**              |   |
| #### Preventive care, adult *(continued)* |                          |   |
+-------------------------------------------+--------------------------+---+
| > *Not covered: Physical exams and        | > *All charges*          |   |
| > immunizations required for obtaining or |                          |   |
| > continuing employment or insurance,     |                          |   |
| > attending schools or camp, or travel.*  |                          |   |
+-------------------------------------------+--------------------------+---+
| > Routine immunizations, limited to:      | > Participating:         |   |
|                                           | >                        |   |
| -   Tetanus-diphtheria (Td) booster --    | > \$20 per office visit  |   |
|     once every 10 years, ages 19 and over | > to a primary care      |   |
|     (except as provided for under         | > physician; \$35 per    |   |
|     *Preventive care, children)*          | > office visit to a      |   |
|                                           | > specialist (no         |   |
| -   Influenza vaccines, annually          | > deductible)            |   |
|                                           | >                        |   |
| -   Pneumococcal vaccines, age 65 and     | > Non-participating: 30% |   |
|     older, or in the presence of high     | > after deductible       |   |
|     risk, chronic conditions              |                          |   |
+-------------------------------------------+--------------------------+---+
| ##### Preventive care, children           |                          |   |
+-------------------------------------------+--------------------------+---+
| > When receiving these services from a    | > Participating:         |   |
| > participating provider, it is not       | >                        |   |
| > necessary to first meet your            | > \$20 per office visit  |   |
| > deductible. The cost of the services    | > to a primary care      |   |
| > does not apply toward your \$500        | > physician; \$35 per    |   |
| > benefit allowance. You only have to pay | > office visit to a      |   |
| > your copayment.                         | > specialist (no         |   |
|                                           | > deductible)            |   |
| -   Childhood immunizations recommended   | >                        |   |
|     by the American Academy of Pediatrics | > Non-participating: 30% |   |
|                                           | > after deductible       |   |
| ```{=html}                                |                          |   |
| <!-- -->                                  |                          |   |
| ```                                       |                          |   |
| -   Well-child care charges for routine   |                          |   |
|     examinations, immunizations and care  |                          |   |
|     (under age 22)                        |                          |   |
|                                           |                          |   |
| -   Examinations, such as:                |                          |   |
|                                           |                          |   |
| ```{=html}                                |                          |   |
| <!-- -->                                  |                          |   |
| ```                                       |                          |   |
| -   Eye exams through age 17 to determine |                          |   |
|     the need for vision correction.       |                          |   |
|                                           |                          |   |
| -   Ear exams through age 17 to determine |                          |   |
|     the need for hearing correction       |                          |   |
|                                           |                          |   |
| -   Examinations done on the day of       |                          |   |
|     immunizations (through age 22)        |                          |   |
+-------------------------------------------+--------------------------+---+
| ######## Maternity care                   | **You pay**              |   |
+-------------------------------------------+--------------------------+---+
| > Complete maternity (obstetrical) care,  | > Participating:         |   |
| > such as:                                | >                        |   |
|                                           | > \$20 per office visit  |   |
| -   Prenatal care                         | > to a primary care      |   |
|                                           | > physician; \$35 per    |   |
| -   Delivery                              | > office visit to a      |   |
|                                           | > specialist (no         |   |
| -   Postnatal care                        | > deductible)            |   |
|                                           | >                        |   |
| > Note: Here are some things to keep in   | > Copay applies to first |   |
| > mind:                                   | > visit only             |   |
|                                           | >                        |   |
| -   You do not need to precertify your    | > Non-participating: 30% |   |
|     normal delivery; see page 11 for      | > after deductible       |   |
|     other circumstances, such as extended |                          |   |
|     stays for you or your baby.           |                          |   |
|                                           |                          |   |
| -   You may remain in the hospital up to  |                          |   |
|     48 hours after a regular delivery and |                          |   |
|     96 hours after a cesarean delivery.   |                          |   |
|     We will extend your inpatient stay if |                          |   |
|     medically necessary.                  |                          |   |
|                                           |                          |   |
| -   We cover routine nursery care of the  |                          |   |
|     newborn child during the covered      |                          |   |
|     portion of the mother's maternity     |                          |   |
|     stay. We will cover other care of an  |                          |   |
|     infant who requires non-routine       |                          |   |
|     treatment only if we cover the infant |                          |   |
|     under a Self and Family enrollment.   |                          |   |
|                                           |                          |   |
| -   We pay hospitalization and surgeon    |                          |   |
|     services (delivery) the same as for   |                          |   |
|     illness and injury. See *Hospital     |                          |   |
|     benefits* (Section 5c) and *Surgery   |                          |   |
|     benefits* (Section 5b)*.*             |                          |   |
+-------------------------------------------+--------------------------+---+
| > *Not covered: Routine sonograms to      | > *All charges*          |   |
| > determine fetal age, size or sex*       |                          |   |
+-------------------------------------------+--------------------------+---+
| ######## Family planning                  |                          |   |
+-------------------------------------------+--------------------------+---+
| > A range of voluntary family planning    | > Participating: Nothing |   |
| > services, limited to:                   | > after deductible       |   |
|                                           | >                        |   |
| -   Surgically implanted contraceptives   | > Non-participating: 30% |   |
|     (such as Norplant)                    | > after deductible       |   |
|                                           |                          |   |
| -   Injectable contraceptive drugs (such  |                          |   |
|     as Depo Provera)                      |                          |   |
|                                           |                          |   |
| -   Intrauterine devices (IUD's)          |                          |   |
|                                           |                          |   |
| -   Diaphragms                            |                          |   |
|                                           |                          |   |
| -   Voluntary sterilization (See          |                          |   |
|     *Surgical Procedures*, Section 5b)    |                          |   |
|                                           |                          |   |
| > Note: We cover oral contraceptives      |                          |   |
| > under the prescription drug benefit.    |                          |   |
+-------------------------------------------+--------------------------+---+
| > *Not covered: Reversal of voluntary     | > *All charges*          |   |
| > surgical sterilization, genetic         |                          |   |
| > counseling*                             |                          |   |
+-------------------------------------------+--------------------------+---+

+-------------------------------------------+--------------------------+
| ######## Infertility services             | **You pay**              |
+-------------------------------------------+--------------------------+
| > Diagnosis and treatment of infertility, | > Participating: 50% of  |
| > such as:                                | > charges after          |
|                                           | > deductible             |
| -   Artificial insemination:              | >                        |
|                                           | > Non-participating: 50% |
| ```{=html}                                | > up to \$5,000 limit    |
| <!-- -->                                  | > per plan year, after   |
| ```                                       | > deductible             |
| -   *intravaginal insemination (IVI)*     |                          |
|                                           |                          |
| -   *intra­cervical insemination (ICI)*    |                          |
|                                           |                          |
| -   *intrauterine insemina­tion (IUI)*     |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   Fertility drugs                       |                          |
|                                           |                          |
| > Note: We cover injectable fertility     |                          |
| > drugs under medical benefits and oral   |                          |
| > fertility drugs under the prescription  |                          |
| > drug benefit.                           |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *Assisted reproductive technology     |                          |
|     (ART) procedures, such as:*           |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   *In vitro fertilization*              |                          |
|                                           |                          |
| -   *Embryo transfer, gamete GIFT and     |                          |
|     zygote ZIFT*                          |                          |
|                                           |                          |
| -   *Zygote transfer*                     |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   *Services and supplies related to     |                          |
|     excluded ART procedures*              |                          |
|                                           |                          |
| -   *Cost of donor sperm*                 |                          |
|                                           |                          |
| -   *Cost of donor egg*                   |                          |
+-------------------------------------------+--------------------------+
| > **Allergy care**                        |                          |
+-------------------------------------------+--------------------------+
| -   Testing and treatment                 | > Participating: \$20    |
|                                           | > per office visit to a  |
|                                           | > primary care           |
|                                           | > physician; \$35 per    |
|                                           | > office visit to a      |
|                                           | > specialist (no         |
|                                           | > deductible when        |
|                                           | > received in            |
|                                           | > physician's office)    |
|                                           |                          |
|                                           | Non-participating: 30%   |
|                                           | after deductible         |
+-------------------------------------------+--------------------------+
| -   Allergy injection                     | Participating: \$5 copay |
|                                           | per visit (no            |
|                                           | deductible)              |
|                                           |                          |
|                                           | Non-participating: 30%   |
|                                           | after deductible         |
+-------------------------------------------+--------------------------+
| -   Allergy serum                         | Participating: Nothing   |
|                                           |                          |
|                                           | Non-participating: 30%   |
|                                           | after deductible         |
+-------------------------------------------+--------------------------+
| > *Not covered: Provocative food testing  | > *All charges*          |
| > and sublingual allergy desensitization* |                          |
+-------------------------------------------+--------------------------+

+-------------------------------------------+--------------------------+
| ######## Treatment therapies              | **You pay**              |
+-------------------------------------------+--------------------------+
| -   Chemotherapy and radiation therapy    | Participating: Nothing   |
|                                           | after deductible         |
| > Note: High dose chemotherapy in         |                          |
| > association with autologous bone marrow | Non-participating: 30%   |
| > transplants is limited to those         | after deductible         |
| > transplants listed under *Organ/Tissue  |                          |
| > Transplants* on page 28.                |                          |
|                                           |                          |
| -   Respiratory and inhalation therapy    |                          |
|                                           |                          |
| -   Dialysis -- hemodialysis and          |                          |
|     peritoneal dialysis                   |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   Intravenous (IV)/Infusion therapy --  |                          |
|     Home IV and antibiotic therapy        |                          |
|                                           |                          |
| -   Growth hormone therapy (GHT)          |                          |
+-------------------------------------------+--------------------------+
| > **Physical, occupational and cardiac    |                          |
| > therapies**                             |                          |
+-------------------------------------------+--------------------------+
| -   60 visits per condition per year for  | Participating: Nothing   |
|     the services of each of the           | after deductible         |
|     following:                            |                          |
|                                           | Non-participating: 30%   |
| ```{=html}                                | after deductible         |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   qualified physical therapists; and    |                          |
|                                           |                          |
| -   occupational therapists.              |                          |
|                                           |                          |
| > Note: We only cover therapy to restore  |                          |
| > bodily function when there has been a   |                          |
| > total or partial loss of bodily         |                          |
| > function due to illness or injury.      |                          |
|                                           |                          |
| -   Cardiac rehabilitation following a    |                          |
|     heart transplant, bypass surgery or a |                          |
|     myocardial infarction, is provided.   |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *Long-term rehabilitative therapy*    |                          |
|                                           |                          |
| -   *Exercise programs*                   |                          |
+-------------------------------------------+--------------------------+
| > **Speech therapy**                      |                          |
+-------------------------------------------+--------------------------+
| -   60 visits per year                    | Participating: Nothing   |
|                                           | after deductible         |
|                                           |                          |
|                                           | Non-participating: 30%   |
|                                           | after deductible         |
+-------------------------------------------+--------------------------+

+-------------------------------------------+--------------------------+
| > **Hearing services (testing, treatment, | **You pay**              |
| > and supplies)**                         |                          |
+-------------------------------------------+--------------------------+
| -   First hearing aid and testing only    | Participating: Nothing   |
|     when necessitated by accidental       | after deductible         |
|     injury                                |                          |
|                                           | Non-participating: 30%   |
| -   Hearing testing for children through  | after deductible         |
|     age 17\                               |                          |
|     (see *Preventive care, children*)     |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *All other hearing testing*           |                          |
|                                           |                          |
| -   *Hearing aids, testing and            |                          |
|     examinations for them*                |                          |
+-------------------------------------------+--------------------------+
| > **Vision services (testing, treatment,  |                          |
| > and supplies)**                         |                          |
+-------------------------------------------+--------------------------+
| -   Diagnosis and treatment of diseases   | Participating: \$20 per  |
|     of the eye                            | office visit to a        |
|                                           | primary care physician;  |
| -   Eye exam to determine the need for    | \$35 per office visit to |
|     vision correction for children        | a specialist (no         |
|     through age 17 (see *Preventive care, | deductible)              |
|     children*)                            |                          |
|                                           | Non-participating: 30%   |
|                                           | after deductible         |
+-------------------------------------------+--------------------------+
| -   One pair of eyeglasses or contact     | Participating: Nothing   |
|     lenses to correct an impairment       | after deductible         |
|     directly caused by accidental ocular  |                          |
|     injury or intraocular surgery (such   | Non-participating: 30%   |
|     as for cataracts)                     | after deductible         |
+-------------------------------------------+--------------------------+
| > *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  | Participating: \$20 per  |
|     active treatment for a metabolic or   | office visit to\         |
|     peripheral vascular disease, such as  | a primary care           |
|     diabetes.                             | physician; \$35 per      |
|                                           | office visit to a        |
| > See *Orthopedic and prosthetic devices* | specialist (no           |
| > for information on podiatric shoe       | deductible)              |
| > inserts.                                |                          |
|                                           | Non-participating: 30%   |
|                                           | after deductible         |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *Cutting, trimming or removal of      |                          |
|     corns, calluses, or the free edge of  |                          |
|     toenails, and similar routine         |                          |
|     treatment of conditions of the foot,  |                          |
|     except as stated above*               |                          |
|                                           |                          |
| -   *Treatment of weak, strained or flat  |                          |
|     feet or bunions or spurs; and of any  |                          |
|     instability, imbalance or subluxation |                          |
|     of the foot (unless the treatment is  |                          |
|     by open cutting surgery)*             |                          |
+-------------------------------------------+--------------------------+

+-------------------------------------------+--------------------------+
| > **Orthopedic and prosthetic devices**   | **You pay**              |
+-------------------------------------------+--------------------------+
| -   Artificial limbs and eyes; stump hose | Participating: Nothing,  |
|                                           | after deductible         |
| -   Externally worn breast prostheses and |                          |
|     surgical bras, including necessary    | Non-participating: 30%   |
|     replacements, following a mastectomy  | after deductible         |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   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.                               |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   Corrective orthopedic appliances for  |                          |
|     non-dental treatment of               |                          |
|     temporomandibular joint (TMJ) pain    |                          |
|     dysfunction syndrome.                 |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | *All charges*            |
|                                           |                          |
| -   *Foot orthotics*                      |                          |
|                                           |                          |
| -   *Orthopedic and corrective shoes*     |                          |
|                                           |                          |
| -   *Arch supports*                       |                          |
|                                           |                          |
| -   *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)  |                          |
+-------------------------------------------+--------------------------+
| > Rental or purchase, at our option,      | Participating: Nothing,  |
| > including repair and adjustment, of     | after deductible         |
| > durable medical equipment prescribed by |                          |
| > your Plan physician, such as oxygen and | > Non-participating: 30% |
| > dialysis equipment. Under this benefit, | > after deductible       |
| > we also cover:                          |                          |
|                                           |                          |
| -   Hospital beds                         |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   Wheelchairs                           |                          |
|                                           |                          |
| -   Crutches                              |                          |
|                                           |                          |
| -   Walkers                               |                          |
|                                           |                          |
| -   Blood glucose monitors; and           |                          |
|                                           |                          |
| -   Insulin pumps                         |                          |
+-------------------------------------------+--------------------------+
| ######## Home health services             |                          |
+-------------------------------------------+--------------------------+
| -   Home health care ordered by a Plan    | Participating: Nothing,  |
|     physician and provided by a           | after deductible         |
|     registered nurse (R.N.), licensed     |                          |
|     practical nurse (L.P.N.), licensed    | > Non-participating: 30% |
|     vocational nurse (L.V.N.), or home    | > after deductible       |
|     health aide.                          |                          |
|                                           |                          |
| -   Services include oxygen therapy,      |                          |
|     intravenous therapy and medications.  |                          |
+-------------------------------------------+--------------------------+
| > Not covered:                            | > *All charges*          |
|                                           |                          |
| -   *Nursing care requested by, or for    |                          |
|     the convenience of, the patient or    |                          |
|     the patient's family*                 |                          |
|                                           |                          |
| -   *Home care primarily for personal     |                          |
|     assistance that does not include a    |                          |
|     medical component and is not          |                          |
|     diagnostic, therapeutic, or           |                          |
|     rehabilitative*                       |                          |
+-------------------------------------------+--------------------------+
| ######## Chiropractic                     | **You pay**              |
+-------------------------------------------+--------------------------+
| > Chiropractic services:                  | Participating: \$35 per  |
|                                           | office visit after       |
| -   Manipulation of the spine and         | deductible               |
|     extremities                           |                          |
|                                           | > Non-participating: 30% |
| ```{=html}                                | > after deductible       |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   Adjunctive procedures such as         |                          |
|     ultrasound, electrical muscle         |                          |
|     stimulation, vibratory therapy, and   |                          |
|     cold pack application.                |                          |
+-------------------------------------------+--------------------------+
| ######## Alternative treatments           |                          |
+-------------------------------------------+--------------------------+
| ## No benefit                             | > All charges            |
+-------------------------------------------+--------------------------+
| ## **Educational classes and programs**   |                          |
+-------------------------------------------+--------------------------+
| ## Coverage is limited to:                | Participating:           |
|                                           |                          |
| ## Diabetes self management training      | \$20 copayment for       |
|                                           | primary care providers;  |
|                                           | \$35 copay for           |
|                                           | specialist (no           |
|                                           | deductible)              |
|                                           |                          |
|                                           | > Non-participating: 30% |
|                                           | > after deductible       |
+-------------------------------------------+--------------------------+
| ## Smoking cessa                          | All costs over \$100     |
| tion - Up to \$100 for one smoking cessat |                          |
| ion program per member per lifetime, incl |                          |
| uding all related expenses such as drugs. |                          |
+-------------------------------------------+--------------------------+

+---+----+----------------------------------+----------------+----+---+
| * |    |                                  |                |    |   |
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| 5 |    |                                  |                |    |   |
| ( |    |                                  |                |    |   |
| b |    |                                  |                |    |   |
| ) |    |                                  |                |    |   |
| . |    |                                  |                |    |   |
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| \ |    |                                  |                |    |   |
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| a |    |                                  |                |    |   |
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| t |    |                                  |                |    |   |
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| c |    |                                  |                |    |   |
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| * |    |                                  |                |    |   |
| * |    |                                  |                |    |   |
+---+----+----------------------------------+----------------+----+---+
|   | *  | **Here are some important things |                | *  |   |
|   | *I | to keep in mind about these      |                | *I |   |
|   | ** | benefits:**                      |                | ** |   |
|   |    |                                  |                |    |   |
|   | *  | -   Please remember that all     |                | *  |   |
|   | *M |     benefits are subject to the  |                | *M |   |
|   | ** |     definitions, limitations,    |                | ** |   |
|   |    |     and exclusions in this       |                |    |   |
|   | *  |     brochure and are payable     |                | *  |   |
|   | *P |     only when we determine they  |                | *P |   |
|   | ** |     are medically necessary.     |                | ** |   |
|   |    |                                  |                |    |   |
|   | *  | ```{=html}                       |                | *  |   |
|   | *O | <!-- -->                         |                | *O |   |
|   | ** | ```                              |                | ** |   |
|   |    | -   The calendar year deductible |                |    |   |
|   | *  |     is:                          |                | *  |   |
|   | *R |                                  |                | *R |   |
|   | ** | > Participating providers -- You |                | ** |   |
|   |    | > do not have to meet a          |                |    |   |
|   | *  | > deductible until your \$500    |                | *  |   |
|   | *T | > benefit allowance is depleted. |                | *T |   |
|   | ** | > The calendar year deductible   |                | ** |   |
|   |    | > is \$1,500 for self and        |                |    |   |
|   | *  | > \$3,000 for self and family.   |                | *  |   |
|   | *A | >                                |                | *A |   |
|   | ** | > Non-participating providers -- |                | ** |   |
|   |    | > The \$500 benefit allowance    |                |    |   |
|   | *  | > does not apply. The calendar   |                | *  |   |
|   | *N | > year deductible is \$3,000 for |                | *N |   |
|   | ** | > self and \$6,000 for self and  |                | ** |   |
|   |    | > family.                        |                |    |   |
|   | *  | >                                |                | *  |   |
|   | *T | > The calendar year deductible   |                | *T |   |
|   | ** | > applies to almost all benefits |                | ** |   |
|   |    | > in this section.               |                |    |   |
|   |    |                                  |                |    |   |
|   |    | -   Be sure to read Section 4,   |                |    |   |
|   |    |     *Your costs for covered      |                |    |   |
|   |    |     services* for valuable       |                |    |   |
|   |    |     information about how cost   |                |    |   |
|   |    |     sharing works. Also read     |                |    |   |
|   |    |     Section 9 about coordinating |                |    |   |
|   |    |     benefits with other          |                |    |   |
|   |    |     coverage, including with     |                |    |   |
|   |    |     Medicare.                    |                |    |   |
|   |    |                                  |                |    |   |
|   |    | -   The amounts listed below are |                |    |   |
|   |    |     for the charges billed by a  |                |    |   |
|   |    |     physician or other health    |                |    |   |
|   |    |     care professional for your   |                |    |   |
|   |    |     surgical care. Look in       |                |    |   |
|   |    |     Section 5(c) for charges     |                |    |   |
|   |    |     associated with the facility |                |    |   |
|   |    |     (i.e. hospital, surgical     |                |    |   |
|   |    |     center, etc.).               |                |    |   |
|   |    |                                  |                |    |   |
|   |    | -   YOUR PHYSICIAN 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.    |                |    |   |
+---+----+----------------------------------+----------------+----+---+
| > |    |                                  | > **You pay**  |    |   |
|   |    |                                  |                |    |   |
| * |    |                                  |                |    |   |
| * |    |                                  |                |    |   |
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| * |    |                                  |                |    |   |
| * |    |                                  |                |    |   |
+---+----+----------------------------------+----------------+----+---+
| > |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
| * |    |                                  |                |    |   |
| * |    |                                  |                |    |   |
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| * |    |                                  |                |    |   |
| * |    |                                  |                |    |   |
+---+----+----------------------------------+----------------+----+---+
| > |    |                                  | Participating: |    |   |
|   |    |                                  | Nothing after  |    |   |
| A |    |                                  | deductible     |    |   |
| > |    |                                  |                |    |   |
|   |    |                                  | > Non-         |    |   |
| c |    |                                  | participating: |    |   |
| o |    |                                  | > 30% after    |    |   |
| m |    |                                  | > deductible   |    |   |
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| * |    |                                  |                |    |   |
+---+----+----------------------------------+----------------+----+---+

+--------------------------------------------+-------------------------+
| > **Oral and maxillofacial surgery**       | **You pay**             |
+--------------------------------------------+-------------------------+
| > Oral surgical procedures, limited to:    | Participating: Nothing  |
|                                            | after deductible        |
| -   Reduction of fractures of the jaws or  |                         |
|     facial bones;                          | Non-participating: 30%  |
|                                            | after deductible        |
| -   Surgical correction of cleft lip,      |                         |
|     cleft palate or severe functional      |                         |
|     malocclusion;                          |                         |
|                                            |                         |
| -   Removal of stones from salivary ducts; |                         |
|                                            |                         |
| -   Excision of leukoplakia or             |                         |
|     malignancies;                          |                         |
|                                            |                         |
| -   Excision of cysts and incision of      |                         |
|     abscesses when done as independent     |                         |
|     procedures; and                        |                         |
|                                            |                         |
| -   Other surgical procedures that do not  |                         |
|     involve the teeth or their supporting  |                         |
|     structures.                            |                         |
+--------------------------------------------+-------------------------+
| > *Not covered:*                           | > *All charges*         |
|                                            |                         |
| -   *Procedures that involve the teeth or  |                         |
|     their supporting structures (such as   |                         |
|     the periodontal membrane, gingiva, and |                         |
|     alveolar bone)*                        |                         |
|                                            |                         |
| -   *Oral implants and transplants*        |                         |
+--------------------------------------------+-------------------------+

+-------------------------------------------+--------------------------+
| > **Organ/tissue transplants**            | **You pay**              |
+-------------------------------------------+--------------------------+
| > Limited to:                             | > Participating: Nothing |
|                                           | > after deductible       |
| -   Cornea                                | >                        |
|                                           | > Non-participating: 30% |
| -   Heart                                 | > after deductible       |
|                                           | >                        |
| -   Heart/lung                            | > Non-participating      |
|                                           | > transplant services do |
| -   Kidney                                | > not apply toward the   |
|                                           | > maximum out-of-pocket  |
| -   Kidney/Pancreas                       | > expense limit          |
|                                           |                          |
| -   Liver                                 |                          |
|                                           |                          |
| -   Lung: Single - Double                 |                          |
|                                           |                          |
| -   Pancreas                              |                          |
|                                           |                          |
| -   Allogeneic (donor) bone marrow        |                          |
|     transplants                           |                          |
|                                           |                          |
| -   Autologous bone marrow transplants    |                          |
|     (autologous stem cell and peripheral  |                          |
|     stem cell support) for the following  |                          |
|     conditions: acute lymphocytic or      |                          |
|     non-lymphocytic leukemia; advanced    |                          |
|     Hodgkin\'s lymphoma; advanced         |                          |
|     non-Hodgkin\'s lymphoma; advanced     |                          |
|     neuroblastoma; breast cancer;         |                          |
|     multiple myeloma; epithelial ovarian  |                          |
|     cancer; and testicular, mediastinal,  |                          |
|     retroperitoneal and ovarian germ cell |                          |
|     tumors.                               |                          |
|                                           |                          |
| -   Intestinal transplants (small         |                          |
|     intestine) and the small intestine    |                          |
|     with the liver or small intestine     |                          |
|     with multiple organs such as the      |                          |
|     liver, stomach, and pancreas.         |                          |
|                                           |                          |
| > Limited Benefits -- Treatment for       |                          |
| > breast cancer, multiple myeloma, and    |                          |
| > epithelial ovarian cancer may be        |                          |
| > provided in an NCI- or NIH-approved     |                          |
| > clinical trial at a Plan-designated     |                          |
| > center of excellence if approved by the |                          |
| > Plan's medical director in accordance   |                          |
| > with the Plan's protocols.              |                          |
| >                                         |                          |
| > Note: We cover related medical and      |                          |
| > hospital expenses of the donor when we  |                          |
| > cover the recipient.                    |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *Donor screening tests and donor      |                          |
|     search expenses, except those         |                          |
|     performed for the actual donor*       |                          |
|                                           |                          |
| -   *Implants of artificial organs*       |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   *Transplants not listed as covered*   |                          |
+-------------------------------------------+--------------------------+
| > **Anesthesia**                          |                          |
+-------------------------------------------+--------------------------+
| > Professional services provided in --    | Participating: Nothing   |
|                                           | after deductible         |
| -   Hospital (inpatient)                  |                          |
|                                           | Non-participating: 30%   |
| ```{=html}                                | after deductible         |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   Hospital outpatient department        |                          |
|                                           |                          |
| -   Skilled nursing facility              |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   Ambulatory surgical center            |                          |
+-------------------------------------------+--------------------------+
| > Professional services provided in --    | > Participating: Nothing |
|                                           | > if you receive these   |
| -   Office                                | > services during an     |
|                                           | > office visit           |
|                                           |                          |
|                                           | Non-participating: 30%   |
|                                           | after deductible         |
+-------------------------------------------+--------------------------+

+---+-----+---------------------------------+-----------------+----+---+
| * |     |                                 |                 |    |   |
| * |     |                                 |                 |    |   |
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| * |     |                                 |                 |    |   |
| * |     |                                 |                 |    |   |
+---+-----+---------------------------------+-----------------+----+---+
|   | **  | > **Here are some important     |                 | *  |   |
|   | I** | > things to remember about      |                 | *I |   |
|   |     | > these benefits:**             |                 | ** |   |
|   | **  |                                 |                 |    |   |
|   | M** | -   Please remember that all    |                 | *  |   |
|   |     |     benefits are subject to the |                 | *M |   |
|   | **  |     definitions, limitations,   |                 | ** |   |
|   | P** |     and exclusions in this      |                 |    |   |
|   |     |     brochure and are payable    |                 | *  |   |
|   | **  |     only when we determine they |                 | *P |   |
|   | O** |     are medically necessary.    |                 | ** |   |
|   |     |                                 |                 |    |   |
|   | **  | -   Be sure to read Section 4,  |                 | *  |   |
|   | R** |     *Your costs for covered     |                 | *O |   |
|   |     |     services* for valuable      |                 | ** |   |
|   | **  |     information about how cost  |                 |    |   |
|   | T** |     sharing works. Also read    |                 | *  |   |
|   |     |     Section 9 about             |                 | *R |   |
|   | **  |     coordinating benefits with  |                 | ** |   |
|   | A** |     other coverage, including   |                 |    |   |
|   |     |     with Medicare.              |                 | *  |   |
|   | **  |                                 |                 | *T |   |
|   | N** | -   The calendar year           |                 | ** |   |
|   |     |     deductible is:              |                 |    |   |
|   | **  |                                 |                 | *  |   |
|   | T** | > Participating providers --    |                 | *A |   |
|   |     | > You do not have to meet a     |                 | ** |   |
|   |     | > deductible until your \$500   |                 |    |   |
|   |     | > benefit allowance is          |                 | *  |   |
|   |     | > depleted. The calendar year   |                 | *N |   |
|   |     | > deductible is \$1,500 for     |                 | ** |   |
|   |     | > self and \$3,000 for self and |                 |    |   |
|   |     | > family.                       |                 | *  |   |
|   |     | >                               |                 | *T |   |
|   |     | > Non-participating providers   |                 | ** |   |
|   |     | > -- The \$500 benefit          |                 |    |   |
|   |     | > allowance does not apply. The |                 |    |   |
|   |     | > calendar year deductible is   |                 |    |   |
|   |     | > \$3,000 for self and \$6,000  |                 |    |   |
|   |     | > for self and family.          |                 |    |   |
|   |     | >                               |                 |    |   |
|   |     | > The calendar year deductible  |                 |    |   |
|   |     | > applies to almost all         |                 |    |   |
|   |     | > benefits in this section.     |                 |    |   |
|   |     |                                 |                 |    |   |
|   |     | -   The amounts listed below    |                 |    |   |
|   |     |     are for the charges billed  |                 |    |   |
|   |     |     by the facility (i.e.,      |                 |    |   |
|   |     |     hospital or surgical        |                 |    |   |
|   |     |     center) or ambulance        |                 |    |   |
|   |     |     service for your surgery or |                 |    |   |
|   |     |     care. Any costs associated  |                 |    |   |
|   |     |     with the professional       |                 |    |   |
|   |     |     charge (i.e., physicians,   |                 |    |   |
|   |     |     etc.) are covered in        |                 |    |   |
|   |     |     Section 5(a) or (b).        |                 |    |   |
|   |     |                                 |                 |    |   |
|   |     | -   **YOUR PHYSICIAN MUST GET   |                 |    |   |
|   |     |     PRECERTIFICATION OF         |                 |    |   |
|   |     |     HOSPITAL STAYS.** Please    |                 |    |   |
|   |     |     refer to Section 3 to be    |                 |    |   |
|   |     |     sure which services require |                 |    |   |
|   |     |     precertification.           |                 |    |   |
+---+-----+---------------------------------+-----------------+----+---+
| > |     |                                 | > **You pay**   |    |   |
|   |     |                                 |                 |    |   |
| * |     |                                 |                 |    |   |
| * |     |                                 |                 |    |   |
| B |     |                                 |                 |    |   |
| e |     |                                 |                 |    |   |
| n |     |                                 |                 |    |   |
| e |     |                                 |                 |    |   |
| f |     |                                 |                 |    |   |
| i |     |                                 |                 |    |   |
| t |     |                                 |                 |    |   |
| > |     |                                 |                 |    |   |
|   |     |                                 |                 |    |   |
| D |     |                                 |                 |    |   |
| e |     |                                 |                 |    |   |
| s |     |                                 |                 |    |   |
| c |     |                                 |                 |    |   |
| r |     |                                 |                 |    |   |
| i |     |                                 |                 |    |   |
| p |     |                                 |                 |    |   |
| t |     |                                 |                 |    |   |
| i |     |                                 |                 |    |   |
| o |     |                                 |                 |    |   |
| n |     |                                 |                 |    |   |
| * |     |                                 |                 |    |   |
| * |     |                                 |                 |    |   |
+---+-----+---------------------------------+-----------------+----+---+
| # |     |                                 |                 |    |   |
| # |     |                                 |                 |    |   |
| # |     |                                 |                 |    |   |
| # |     |                                 |                 |    |   |
| # |     |                                 |                 |    |   |
| # |     |                                 |                 |    |   |
| # |     |                                 |                 |    |   |
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+---+-----+---------------------------------+-----------------+----+---+
| > |     |                                 | >               |    |   |
|   |     |                                 |  Participating: |    |   |
| R |     |                                 | > \$100         |    |   |
| o |     |                                 | > copayment per |    |   |
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| m |     |                                 | > first five    |    |   |
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| n |     |                                 | > deductible    |    |   |
| d |     |                                 | >               |    |   |
| > |     |                                 | > Non           |    |   |
|   |     |                                 | -participating: |    |   |
| b |     |                                 | > 30% after     |    |   |
| o |     |                                 | > deductible    |    |   |
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+---+-----+---------------------------------+-----------------+----+---+

> *Inpatient hospital -- continued on next page*

+-------------------------------------------+---+--------------------------+
| ######## Inpatient hospital *(continued)* |   | **You pay**              |
+-------------------------------------------+---+--------------------------+
| #### Other                                |   | > Nothing after          |
|  hospital services and supplies, such as: |   | > deductible             |
|                                           |   |                          |
| -   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.)                             |   |                          |
+-------------------------------------------+---+--------------------------+
| > *Not covered:*                          |   | > *All charges*          |
|                                           |   |                          |
| -   *Custodial care*                      |   |                          |
|                                           |   |                          |
| -   *Non-covered facilities, such as      |   |                          |
|     nursing homes, schools*               |   |                          |
|                                           |   |                          |
| -   *Personal comfort items, such as      |   |                          |
|     telephone, television, barber         |   |                          |
|     services, guest meals and beds*       |   |                          |
|                                           |   |                          |
| -   *Private nursing care*                |   |                          |
+-------------------------------------------+---+--------------------------+
| #### **Outpatient                         |   |                          |
|  hospital or ambulatory surgical center** |   |                          |
+-------------------------------------------+---+--------------------------+
| -   Operating, recovery, and other        |   | > Participating: \$50    |
|     treatment rooms                       |   | > copay per visit after  |
|                                           |   | > deductible             |
| -   Prescribed drugs and medicines        |   | >                        |
|                                           |   | > Non-participating: 30% |
| ```{=html}                                |   | > after deductible       |
| <!-- -->                                  |   |                          |
| ```                                       |   |                          |
| -   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.                  |   |                          |
+-------------------------------------------+---+--------------------------+
| #### **Outpatient hospital or a           |   | > **You pay**            |
| mbulatory surgical center** *(continued)* |   |                          |
+-------------------------------------------+---+--------------------------+
| # Outpatient non-surgical, such as:       |   | > Participating:         |
|                                           |   | > nothing, after         |
| -   Laboratory tests and x-rays           |   | > deductible             |
|                                           |   | >                        |
|                                           |   | > Non-participating: 30% |
|                                           |   | > after deductible       |
+-------------------------------------------+---+--------------------------+
| # *Not covered: Blood and bloo            |   | > *All charges*          |
| d derivatives not replaced by the member* |   |                          |
+-------------------------------------------+---+--------------------------+
| ######## Extended care benefi             |   | ########                 |
| ts/skilled nursing care facility benefits |   |                          |
+-------------------------------------------+---+--------------------------+
| > Extended care benefit:                  |   | > Participating:         |
| >                                         |   | > nothing, after         |
| > Up to 60 days per calendar year,        |   | > deductible             |
| > including                               |   | >                        |
|                                           |   | > Non-participating: 30% |
| -   bed and board                         |   | > after deductible       |
|                                           |   |                          |
| -   general nursing care                  |   |                          |
|                                           |   |                          |
| -   drugs, biologicals, supplies and      |   |                          |
|     equipment provided by the facility    |   |                          |
|                                           |   |                          |
| > Note: Coverage is provided when         |   |                          |
| > full-time skilled nursing care is       |   |                          |
| > necessary and confinement in a skilled  |   |                          |
| > nursing facility is medically           |   |                          |
| > appropriate as determined by a Plan     |   |                          |
| > doctor and approved by the Plan.        |   |                          |
+-------------------------------------------+---+--------------------------+
| > Not covered: Custodial care             |   | > *All charges*          |
+-------------------------------------------+---+--------------------------+
| #### **Hospice care**                     | # |                          |
|                                           | # |                          |
|                                           | # |                          |
|                                           | # |                          |
|                                           |   |                          |
+-------------------------------------------+---+--------------------------+
| #### Supportive and palliative care       | > |                          |
|  for a terminally ill member is covered i |   |                          |
| n the home or hospice facility. Includes: | P |                          |
|                                           | a |                          |
| #### Inpati                               | r |                          |
| ent and outpatient services and supplies  | t |                          |
|                                           | i |                          |
| > Note: These services must be described  | c |                          |
| > in a Hospice Care program that has been | i |                          |
| > approved by us.                         | p |                          |
|                                           | a |                          |
|                                           | t |                          |
|                                           | i |                          |
|                                           | n |                          |
|                                           | g |                          |
|                                           | : |                          |
|                                           | > |                          |
|                                           |   |                          |
|                                           | n |                          |
|                                           | o |                          |
|                                           | t |                          |
|                                           | h |                          |
|                                           | i |                          |
|                                           | n |                          |
|                                           | g |                          |
|                                           | , |                          |
|                                           | > |                          |
|                                           |   |                          |
|                                           | a |                          |
|                                           | f |                          |
|                                           | t |                          |
|                                           | e |                          |
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+-------------------------------------------+---+--------------------------+
| #### **Ambulance**                        | # |                          |
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+-------------------------------------------+---+--------------------------+
| #### Local professional ambu              | > |                          |
| lance service when medically appropriate. |   |                          |
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+-------------------------------------------+---+--------------------------+

+---+----+----------------------------------+----------------+----+---+
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+---+----+----------------------------------+----------------+----+---+
|   | *  | > **Here are some important      |                | *  | # |
|   | *I | > things to keep in mind about   |                | *I | # |
|   | ** | > these benefits:**              |                | ** | # |
|   |    |                                  |                |    | # |
|   | *  | -   Please remember that all     |                | *  | # |
|   | *M |     benefits are subject to the  |                | *M |   |
|   | ** |     definitions, limitations,    |                | ** |   |
|   |    |     and exclusions in this       |                |    |   |
|   | *  |     brochure and are payable     |                | *  |   |
|   | *P |     only when we determine they  |                | *P |   |
|   | ** |     are medically necessary.     |                | ** |   |
|   |    |                                  |                |    |   |
|   | *  | ```{=html}                       |                | *  |   |
|   | *O | <!-- -->                         |                | *O |   |
|   | ** | ```                              |                | ** |   |
|   |    | -   The calendar year deductible |                |    |   |
|   | *  |     is:                          |                | *  |   |
|   | *R |                                  |                | *R |   |
|   | ** | > Participating providers -- You |                | ** |   |
|   |    | > do not have to meet a          |                |    |   |
|   | *  | > deductible until your \$500    |                | *  |   |
|   | *T | > benefit allowance is depleted. |                | *T |   |
|   | ** | > The calendar year deductible   |                | ** |   |
|   |    | > is \$1,500 for self and        |                |    |   |
|   | *  | > \$3,000 for self and family.   |                | *  |   |
|   | *A | >                                |                | *A |   |
|   | ** | > Non-participating providers -- |                | ** |   |
|   |    | > The \$500 benefit allowance    |                |    |   |
|   | *  | > does not apply. The calendar   |                | *  |   |
|   | *N | > year deductible is \$3,000 for |                | *N |   |
|   | ** | > self and \$6,000 for self and  |                | ** |   |
|   |    | > family.                        |                |    |   |
|   | *  |                                  |                | *  |   |
|   | *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 |                |    |   |
|   |    |     benefits with other          |                |    |   |
|   |    |     coverage, including with     |                |    |   |
|   |    |     Medicare.                    |                |    |   |
+---+----+----------------------------------+----------------+----+---+
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+---+----+----------------------------------+----------------+----+---+
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+---+----+----------------------------------+----------------+----+---+
| > |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
| * |    |                                  |                |    |   |
| * |    |                                  |                |    |   |
| E |    |                                  |                |    |   |
| m |    |                                  |                |    |   |
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| n |    |                                  |                |    |   |
| c |    |                                  |                |    |   |
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| c |    |                                  |                |    |   |
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| s |    |                                  |                |    |   |
| * |    |                                  |                |    |   |
| * |    |                                  |                |    |   |
+---+----+----------------------------------+----------------+----+---+
| - |    |                                  | Participating: |    |   |
|   |    |                                  |                |    |   |
|   |    |                                  | \$20 at a a    |    |   |
|   |    |                                  | primary care   |    |   |
| E |    |                                  | physician's    |    |   |
| m |    |                                  | office; \$35   |    |   |
| e |    |                                  | at a           |    |   |
| r |    |                                  | specialist's   |    |   |
| g |    |                                  | office (no     |    |   |
| e |    |                                  | deductible)    |    |   |
| n |    |                                  |                |    |   |
| c |    |                                  | Non-           |    |   |
| y |    |                                  | participating: |    |   |
|   |    |                                  | 30% after      |    |   |
|   |    |                                  | deductible     |    |   |
|   |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
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|   |    |                                  |                |    |   |
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|   |    |                                  |                |    |   |
| a |    |                                  |                |    |   |
| t |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
| a |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
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|   |    |                                  |                |    |   |
| d |    |                                  |                |    |   |
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| c |    |                                  |                |    |   |
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|   |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
|   |    |                                  |                |    |   |
| o |    |                                  |                |    |   |
| f |    |                                  |                |    |   |
| f |    |                                  |                |    |   |
| i |    |                                  |                |    |   |
| c |    |                                  |                |    |   |
| e |    |                                  |                |    |   |
+---+----+----------------------------------+----------------+----+---+

+-------------------------------------------+--------------------------+
| > **Emergency services** *(continued)*    | **You pay**              |
+-------------------------------------------+--------------------------+
| -   Emergency care at an urgent care      | Participating: \$35      |
|     center                                | copayment (no            |
|                                           | deductible)              |
|                                           |                          |
|                                           | Non-participating: 30%   |
|                                           | after deductible         |
+-------------------------------------------+--------------------------+
| -   Emergency care as an outpatient or    | Participating: \$100     |
|     inpatient at a hospital, including    | copayment after          |
|     doctors' services.                    | deductible (Copayment    |
|                                           | waived if admitted;      |
|                                           | inpatient copayments     |
|                                           | apply)                   |
|                                           |                          |
|                                           | Non-participating: 30%   |
|                                           | after deductible         |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | *All charges*            |
|                                           |                          |
| -   *Elective care or non-emergency care* |                          |
|                                           |                          |
| -   *Emergency care provided outside the  |                          |
|     service area if the need for care     |                          |
|     could have been foreseen before       |                          |
|     leaving the service area*             |                          |
|                                           |                          |
| -   *Medical and hospital costs resulting |                          |
|     from a normal full-term delivery of a |                          |
|     baby outside the service area*        |                          |
+-------------------------------------------+--------------------------+
| > **Ambulance**                           |                          |
+-------------------------------------------+--------------------------+
| -   Professional ambulance service when   | Participating: Nothing   |
|     medically appropriate                 | after deductible         |
|                                           |                          |
| > See 5(c) for non-emergency service.     | Non-participating: 30%   |
|                                           | after deductible (If     |
|                                           | true medical emergency   |
|                                           | -- benefit paid as       |
|                                           | participating)           |
+-------------------------------------------+--------------------------+

+---+----+-----------------------------------+------------------+---+---+---+
| * |    |                                   |                  |   |   |   |
| * |    |                                   |                  |   |   |   |
| S |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| 5 |    |                                   |                  |   |   |   |
| ( |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| ) |    |                                   |                  |   |   |   |
| . |    |                                   |                  |   |   |   |
| M |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| u |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| u |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| f |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| * |    |                                   |                  |   |   |   |
| * |    |                                   |                  |   |   |   |
+---+----+-----------------------------------+------------------+---+---+---+
|   | *  | > When you get our approval for   |                  | * |   |   |
|   | *I | > services and follow a treatment |                  | * |   |   |
|   | ** | > plan we approve, cost-sharing   |                  | I |   |   |
|   |    | > and limitations for Plan mental |                  | * |   |   |
|   | *  | > health and substance abuse      |                  | * |   |   |
|   | *M | > benefits will be no greater     |                  |   |   |   |
|   | ** | > than for similar benefits for   |                  | * |   |   |
|   |    | > other illnesses and conditions. |                  | * |   |   |
|   | *  | >                                 |                  | M |   |   |
|   | *P | > **Here are some important       |                  | * |   |   |
|   | ** | > things to keep in mind about    |                  | * |   |   |
|   |    | > these benefits:**               |                  |   |   |   |
|   | *  |                                   |                  | * |   |   |
|   | *O | -   Please remember that all      |                  | * |   |   |
|   | ** |     benefits are subject to the   |                  | P |   |   |
|   |    |     definitions, limitations, and |                  | * |   |   |
|   | *  |     exclusions in this brochure   |                  | * |   |   |
|   | *R |     and are payable only when we  |                  |   |   |   |
|   | ** |     determine they are medically  |                  | * |   |   |
|   |    |     necessary.                    |                  | * |   |   |
|   | *  |                                   |                  | O |   |   |
|   | *T | -   The calendar year deductible  |                  | * |   |   |
|   | ** |     is:                           |                  | * |   |   |
|   |    |                                   |                  |   |   |   |
|   | *  | -   Participating providers --    |                  | * |   |   |
|   | *A |     You do not have to meet a     |                  | * |   |   |
|   | ** |     deductible until your \$500   |                  | R |   |   |
|   |    |     benefit allowance is          |                  | * |   |   |
|   | *  |     depleted. The calendar year   |                  | * |   |   |
|   | *N |     deductible is \$1,500 for     |                  |   |   |   |
|   | ** |     self and \$3,000 for self and |                  | * |   |   |
|   |    |     family.                       |                  | * |   |   |
|   | *  |                                   |                  | T |   |   |
|   | *T | -   Non-participating providers   |                  | * |   |   |
|   | ** |     -- The \$500 benefit          |                  | * |   |   |
|   |    |     allowance does not apply. The |                  |   |   |   |
|   |    |     calendar year deductible is   |                  | * |   |   |
|   |    |     \$3,000 for self and \$6,000  |                  | * |   |   |
|   |    |     for self and family.          |                  | A |   |   |
|   |    |                                   |                  | * |   |   |
|   |    | ```{=html}                        |                  | * |   |   |
|   |    | <!-- -->                          |                  |   |   |   |
|   |    | ```                               |                  | * |   |   |
|   |    | -   Be sure to read Section 4,    |                  | * |   |   |
|   |    |     *Your costs for covered       |                  | N |   |   |
|   |    |     services* for valuable        |                  | * |   |   |
|   |    |     information about how cost    |                  | * |   |   |
|   |    |     sharing works. Also read      |                  |   |   |   |
|   |    |     Section 9 about coordinating  |                  | * |   |   |
|   |    |     benefits with other coverage, |                  | * |   |   |
|   |    |     including with Medicare.      |                  | T |   |   |
|   |    |                                   |                  | * |   |   |
|   |    | -   **YOU MUST GET                |                  | * |   |   |
|   |    |     PREAUTHORIZATION OF THESE     |                  |   |   |   |
|   |    |     SERVICES.** See the           |                  |   |   |   |
|   |    |     instructions after the        |                  |   |   |   |
|   |    |     benefits description below.   |                  |   |   |   |
+---+----+-----------------------------------+------------------+---+---+---+
| # |    |                                   | ####### You pay  |   |   |   |
| # |    |                                   |                  |   |   |   |
| # |    |                                   |                  |   |   |   |
| # |    |                                   |                  |   |   |   |
| # |    |                                   |                  |   |   |   |
| # |    |                                   |                  |   |   |   |
| # |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| D |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
+---+----+-----------------------------------+------------------+---+---+---+
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| * |    |                                   |                  |   |   |   |
| * |    |                                   |                  |   |   |   |
| N |    |                                   |                  |   |   |   |
| O |    |                                   |                  |   |   |   |
| T |    |                                   |                  |   |   |   |
| E |    |                                   |                  |   |   |   |
| : |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| T |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| y |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| u |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| m |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| f |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| . |    |                                   |                  |   |   |   |
| \ |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| W |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| y |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| " |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| u |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| " |    |                                   |                  |   |   |   |
| w |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| u |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| y |    |                                   |                  |   |   |   |
| . |    |                                   |                  |   |   |   |
| * |    |                                   |                  |   |   |   |
| * |    |                                   |                  |   |   |   |
+---+----+-----------------------------------+------------------+---+---+---+
| # |    |                                   |                  |   |   |   |
| # |    |                                   |                  |   |   |   |
| # |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| * |    |                                   |                  |   |   |   |
| * |    |                                   |                  |   |   |   |
| M |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| u |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| u |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| f |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| * |    |                                   |                  |   |   |   |
| * |    |                                   |                  |   |   |   |
+---+----+-----------------------------------+------------------+---+---+---+
| > |    |                                   | > Your cost      |   |   |   |
|   |    |                                   | > sharing        |   |   |   |
| A |    |                                   | >                |   |   |   |
| l |    |                                   | responsibilities |   |   |   |
| l |    |                                   | > are no greater |   |   |   |
| > |    |                                   | > than for other |   |   |   |
|   |    |                                   | > illnesses or   |   |   |   |
| d |    |                                   | > conditions     |   |   |   |
| i |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| g |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| m |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| v |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| m |    |                                   |                  |   |   |   |
| m |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| y |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| P |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| v |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| m |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| w |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| v |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| . |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| T |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| m |    |                                   |                  |   |   |   |
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| n |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
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| n |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
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| d |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| v |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| , |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| u |    |                                   |                  |   |   |   |
| g |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| , |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| u |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| w |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| u |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| . |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| N |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| : |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| P |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| f |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| y |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| y |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| w |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
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| t |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| m |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
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| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
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| s |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
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| o |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
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| a |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| f |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| m |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| w |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| > |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| v |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| . |    |                                   |                  |   |   |   |
+---+----+-----------------------------------+------------------+---+---+---+
| - |    |                                   | > Participating: |   |   |   |
|   |    |                                   | > \$35 per visit |   |   |   |
|   |    |                                   | > (no            |   |   |   |
|   |    |                                   | > deductible)    |   |   |   |
| P |    |                                   | >                |   |   |   |
| r |    |                                   | > No             |   |   |   |
| o |    |                                   | n-participating: |   |   |   |
| f |    |                                   | > 30% after      |   |   |   |
| e |    |                                   | > deductible     |   |   |   |
| s |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| v |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
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| , |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
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| n |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
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| d |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
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|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
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| p |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| y |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| b |    |                                   |                  |   |   |   |
| y |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| v |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| u |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| y |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
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| a |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
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| s |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
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| , |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| p |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| y |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| h |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| g |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| , |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| l |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| w |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| k |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| r |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| - |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| M |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| d |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| c |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| i |    |                                   |                  |   |   |   |
| o |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| m |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| a |    |                                   |                  |   |   |   |
| g |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| m |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| n |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
+---+----+-----------------------------------+------------------+---+---+---+
| - |    |                                   | > Participating: |   |   |   |
|   |    |                                   | > Nothing if you |   |   |   |
|   |    |                                   | > receive these  |   |   |   |
|   |    |                                   | > services       |   |   |   |
| D |    |                                   | > during an      |   |   |   |
| i |    |                                   | > office visit;  |   |   |   |
| a |    |                                   | > otherwise:     |   |   |   |
| g |    |                                   | > nothing after  |   |   |   |
| n |    |                                   | > deductible.    |   |   |   |
| o |    |                                   | >                |   |   |   |
| s |    |                                   | > No             |   |   |   |
| t |    |                                   | n-participating: |   |   |   |
| i |    |                                   | > 30% after      |   |   |   |
| c |    |                                   | > deductible     |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
|   |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| e |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
| t |    |                                   |                  |   |   |   |
| s |    |                                   |                  |   |   |   |
+---+----+-----------------------------------+------------------+---+---+---+

+--------------------------------------------+-------------------------+
| **Mental health and substance abuse        |                         |
| benefits** *(continued)*                   |                         |
+--------------------------------------------+-------------------------+
| -   Services provided by a hospital or     | > Participating: \$100  |
|     other facility                         | > copay per day for the |
|                                            | > first five days per   |
| -   Services in approved alternative care  | > admission, after      |
|     settings such as partial               | > deductible            |
|     hospitalization, half-way house,       | >                       |
|     residential treatment, full-day        | > Non-participating:    |
|     hospitalization, facility based        | > 30% after deductible  |
|     intensive outpatient treatment         |                         |
|                                            |                         |
| > NOTE: Two partial hospitalization days   |                         |
| > will be considered one confinement day.  |                         |
+--------------------------------------------+-------------------------+
| ## No                                      | > *All charges*         |
| t covered: Services we have not approved.  |                         |
|                                            |                         |
| ## Note:OPM will bas                       |                         |
| e its review of disputes about treatment p |                         |
| lans on the treatment plan\'s clinical app |                         |
| ropriateness. OPM will generally not order |                         |
|  us to pay or provide one clinically appro |                         |
| priate treatment plan in favor of another. |                         |
+--------------------------------------------+-------------------------+

*.*

**Preauthorization** To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization
processes:

-   Please contact the phone number on your identification card.

**Limitation** We may limit your benefits if you do not obtain a
treatment plan.

+----+----+-------------------------------------------------+----+----+
| *  |    |                                                 |    |    |
| *S |    |                                                 |    |    |
| ec |    |                                                 |    |    |
| ti |    |                                                 |    |    |
| on |    |                                                 |    |    |
| 5  |    |                                                 |    |    |
| (f |    |                                                 |    |    |
| ). |    |                                                 |    |    |
| Pr |    |                                                 |    |    |
| es |    |                                                 |    |    |
| cr |    |                                                 |    |    |
| ip |    |                                                 |    |    |
| ti |    |                                                 |    |    |
| on |    |                                                 |    |    |
| dr |    |                                                 |    |    |
| ug |    |                                                 |    |    |
| be |    |                                                 |    |    |
| ne |    |                                                 |    |    |
| fi |    |                                                 |    |    |
| ts |    |                                                 |    |    |
| ** |    |                                                 |    |    |
+----+----+-------------------------------------------------+----+----+
|    | *  | **Here are some important things to keep in     | *  |    |
|    | *I | mind about these benefits:**                    | *I |    |
|    | ** |                                                 | ** |    |
|    |    | -   We cover prescribed drugs and medications,  |    |    |
|    | *  |     as described in the chart beginning on the  | *  |    |
|    | *M |     next page.                                  | *M |    |
|    | ** |                                                 | ** |    |
|    |    | -   Prescription copayments and coinsurance     |    |    |
|    | *  |     amounts do not apply to the benefit         | *  |    |
|    | *P |     allowance or the deductibles when using     | *P |    |
|    | ** |     participating pharmacies.                   | ** |    |
|    |    |                                                 |    |    |
|    | *  | -   All benefits are subject to the             | *  |    |
|    | *O |     definitions, limitations and exclusions in  | *O |    |
|    | ** |     this brochure and are payable only when we  | ** |    |
|    |    |     determine they are medically necessary.     |    |    |
|    | *  |                                                 | *  |    |
|    | *R | ```{=html}                                      | *R |    |
|    | ** | <!-- -->                                        | ** |    |
|    |    | ```                                             |    |    |
|    | *  | -   Be sure to read Section 4, *Your costs for  | *  |    |
|    | *T |     covered services,* for valuable information | *T |    |
|    | ** |     about how cost sharing works. Also read     | ** |    |
|    |    |     Section 9 about coordinating benefits with  |    |    |
|    | *  |     other coverage, including with Medicare.    | *  |    |
|    | *A |                                                 | *A |    |
|    | ** |                                                 | ** |    |
|    |    |                                                 |    |    |
|    | *  |                                                 | *  |    |
|    | *N |                                                 | *N |    |
|    | ** |                                                 | ** |    |
|    |    |                                                 |    |    |
|    | *  |                                                 | *  |    |
|    | *T |                                                 | *T |    |
|    | ** |                                                 | ** |    |
+----+----+-------------------------------------------------+----+----+
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| >  |    |                                                 |    |    |
|  t |    |                                                 |    |    |
| he |    |                                                 |    |    |
| >  |    |                                                 |    |    |
| ap |    |                                                 |    |    |
| pl |    |                                                 |    |    |
| ic |    |                                                 |    |    |
| ab |    |                                                 |    |    |
| le |    |                                                 |    |    |
| >  |    |                                                 |    |    |
| co |    |                                                 |    |    |
| pa |    |                                                 |    |    |
| y. |    |                                                 |    |    |
+----+----+-------------------------------------------------+----+----+

+------------------------------------------+---------------------------+
| > **Benefit Description**                | > **You pay**             |
+------------------------------------------+---------------------------+
| > **Covered medications and supplies**   |                           |
+------------------------------------------+---------------------------+
| > We cover the following medications and | At participating          |
| > supplies prescribed by a plan          | pharmacies:               |
| > physician and obtained from a Plan     |                           |
| > pharmacy or through our mail order     | > \$10 for Level One      |
| > program:                               | > drugs                   |
|                                          | >                         |
| -   Drugs and medicines that by Federal  | > \$25 for Level Two      |
|     law of the United States require a   | > drugs                   |
|     physician's prescription for their   | >                         |
|     purchase, except those listed as     | > \$50 for Level Three    |
|     *Not covered*.                       | > drugs                   |
|                                          | >                         |
| -   Insulin                              | > 25% of the amount that  |
|                                          | > the plan pays to the    |
| -   Disposable needles and syringes for  | > dispensing pharmacy for |
|     the administration of covered        | > Level Four drugs        |
|     medications                          | >                         |
|                                          | > The out of pocket       |
| -   Diabetic supplies including testing  | > maximum for Level Four  |
|     agents, lancet devices, alcohol      | > drugs is \$2,500 per    |
|     swabs, glucose elevating agents,     | > member per calendar     |
|     insulin delivery devices and blood   | > year                    |
|     glucose monitors approved by us      | >                         |
|                                          | > 3 applicable copays for |
| -   Self administered injectable drugs   | > a 90-day supply of      |
|                                          | > prescribed maintenance  |
| ```{=html}                               | > drugs, when ordered     |
| <!-- -->                                 | > through our mail-order  |
| ```                                      | > program                 |
| -   Oral fertility drugs.                |                           |
|                                          | At non-participating      |
| -   Oral contraceptive drugs             | pharmacies:               |
|                                          |                           |
| -   Growth hormone                       | > 30% of charges plus     |
|                                          | > applicable copay        |
| -   Drugs for sexual dysfunction         |                           |
|                                          |                           |
| > Note: Drugs to treat sexual            |                           |
| > dysfunction are limited. Contact the   |                           |
| > Plan for dosage limits. You pay the    |                           |
| > applicable drug copay up to the dosage |                           |
| > limits, and all charges after that.    |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | *All charges*             |
|                                          |                           |
| -   *Drugs available without a           |                           |
|     prescription, or for which there is  |                           |
|     a non-prescription equivalent        |                           |
|     available*                           |                           |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes (such as Rogaine)*          |                           |
|                                          |                           |
| -   *Vitamins, fluoride, nutrients and   |                           |
|     food supplements even if a physician |                           |
|     prescribes or administers them*      |                           |
|                                          |                           |
| -   *Drugs obtained at a non-Plan        |                           |
|     pharmacy except for out of area      |                           |
|     emergencies*                         |                           |
|                                          |                           |
| -   *Drugs to enhance athletic           |                           |
|     performance*                         |                           |
|                                          |                           |
| -   *Smoking cessation drugs and         |                           |
|     medications, including nicotine      |                           |
|     patches*                             |                           |
|                                          |                           |
| -   *Any drug used for the purpose of    |                           |
|     weight control*                      |                           |
|                                          |                           |
| -   *Prescriptions that are to be taken  |                           |
|     by or administered to the member in  |                           |
|     whole or part, while a patient in a  |                           |
|     hospital, skilled nursing facility,  |                           |
|     convalescent hospital, inpatient     |                           |
|     facility or other facility where     |                           |
|     drugs are ordinarily provided by the |                           |
|     facility on an inpatient basis*      |                           |
|                                          |                           |
| -   *Medical supplies such as dressings  |                           |
|     and antiseptics*                     |                           |
+------------------------------------------+---------------------------+

+--------------------------+-------------------------------------------+
| Section 5 (g). Special   |                                           |
| Features                 |                                           |
+==========================+===========================================+
| > **Feature**            | > **Description**                         |
+--------------------------+-------------------------------------------+
| > **Flexible benefits    | > Under the flexible benefits option, we  |
| > 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.                       |
+--------------------------+-------------------------------------------+
| > **24-hour nurse line** | > For any of your health concerns, 24     |
|                          | > hours a day, 7 days a week, you may     |
|                          | > call HumanaFirst^®^ at 1-800-622-9529   |
|                          | > and talk with a registered nurse who    |
|                          | > will discuss treatment options and      |
|                          | > answer your health questions.           |
+--------------------------+-------------------------------------------+
| > **Services for deaf    | > Humana offers telecommunication devices |
| > and hearing impaired** | > for the deaf (TDD) and Teletype (TTY)   |
|                          | > phone lines for the hearing impaired.   |
|                          | > Call 1-800-432-7482 to access the       |
|                          | > service.                                |
+--------------------------+-------------------------------------------+
| > **High risk            | > HumanaBeginnings is an outreach program |
| > pregnancies**          | > that provides high-risk plan members    |
|                          | > support and educational materials so    |
|                          | > care can be actively managed during     |
|                          | > pregnancy. Call 1-888-847-9960.         |
+--------------------------+-------------------------------------------+
| > **Centers of           | > Members can use any facility that is    |
| > excellence**           | > within Humana's contracted National     |
|                          | > Transplant Network. This network has    |
|                          | > over 35 transplant facilities located   |
|                          | > in more than 20 states.                 |
+--------------------------+-------------------------------------------+
| > **Infertility          | > Illinois benefits comply with state     |
| > benefits**             | > mandates.                               |
+--------------------------+-------------------------------------------+

+----+----+---------------------------------+--------------+----+----+
| S  |    |                                 |              |    |    |
| ec |    |                                 |              |    |    |
| ti |    |                                 |              |    |    |
| on |    |                                 |              |    |    |
| 5  |    |                                 |              |    |    |
| (h |    |                                 |              |    |    |
| ). |    |                                 |              |    |    |
| De |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
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| ne |    |                                 |              |    |    |
| fi |    |                                 |              |    |    |
| ts |    |                                 |              |    |    |
+====+====+=================================+==============+====+====+
|    | *  | > **Here are some important     |              | *  |    |
|    | *I | > things to keep in mind about  |              | *I |    |
|    | ** | > these benefits:**             |              | ** |    |
|    |    |                                 |              |    |    |
|    | *  | -   Please remember that all    |              | *  |    |
|    | *M |     benefits are subject to the |              | *M |    |
|    | ** |     definitions, limitations,   |              | ** |    |
|    |    |     and exclusions in this      |              |    |    |
|    | *  |     brochure and are payable    |              | *  |    |
|    | *P |     only when we determine they |              | *P |    |
|    | ** |     are medically necessary.    |              | ** |    |
|    |    |                                 |              |    |    |
|    | *  | -   Plan dentists must provide  |              | *  |    |
|    | *O |     or arrange your care.       |              | *O |    |
|    | ** |                                 |              | ** |    |
|    |    | -   We cover hospitalization    |              |    |    |
|    | *  |     for dental procedures only  |              | *  |    |
|    | *R |     when a nondental physical   |              | *R |    |
|    | ** |     impairment exists which     |              | ** |    |
|    |    |     makes hospitalization       |              |    |    |
|    | *  |     necessary to safeguard the  |              | *  |    |
|    | *T |     health of the patient; see  |              | *T |    |
|    | ** |     Section 5 (c) for inpatient |              | ** |    |
|    |    |     hospital benefits. We do    |              |    |    |
|    | *  |     not cover the dental        |              | *  |    |
|    | *A |     procedure unless it is      |              | *A |    |
|    | ** |     described below.            |              | ** |    |
|    |    |                                 |              |    |    |
|    | *  | ```{=html}                      |              | *  |    |
|    | *N | <!-- -->                        |              | *N |    |
|    | ** | ```                             |              | ** |    |
|    |    | -   Be sure to read Section 4,  |              |    |    |
|    | *  |     *Your costs for covered     |              | *  |    |
|    | *T |     services,* for valuable     |              | *T |    |
|    | ** |     information about how cost  |              | ** |    |
|    |    |     sharing works. Also read    |              |    |    |
|    |    |     Section 9 about             |              |    |    |
|    |    |     coordinating benefits with  |              |    |    |
|    |    |     other coverage, including   |              |    |    |
|    |    |     with Medicare.              |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| #  |    |                                 | ###          |    |    |
| ## |    |                                 |  **You pay** |    |    |
|  * |    |                                 |              |    |    |
| *A |    |                                 |              |    |    |
| cc |    |                                 |              |    |    |
| id |    |                                 |              |    |    |
| en |    |                                 |              |    |    |
| ta |    |                                 |              |    |    |
| l  |    |                                 |              |    |    |
| in |    |                                 |              |    |    |
| ju |    |                                 |              |    |    |
| ry |    |                                 |              |    |    |
|  b |    |                                 |              |    |    |
| en |    |                                 |              |    |    |
| ef |    |                                 |              |    |    |
| it |    |                                 |              |    |    |
| ** |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| >  |    |                                 | > Same as    |    |    |
| We |    |                                 | > any other  |    |    |
| >  |    |                                 | > illness    |    |    |
|  c |    |                                 |              |    |    |
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| >  |    |                                 |              |    |    |
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| es |    |                                 |              |    |    |
| to |    |                                 |              |    |    |
| ra |    |                                 |              |    |    |
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| ve |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| se |    |                                 |              |    |    |
| rv |    |                                 |              |    |    |
| ic |    |                                 |              |    |    |
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| nd |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
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| >  |    |                                 |              |    |    |
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| >  |    |                                 |              |    |    |
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| >  |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
| pa |    |                                 |              |    |    |
| ir |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| (b |    |                                 |              |    |    |
| ut |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
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| ac |    |                                 |              |    |    |
| e) |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  s |    |                                 |              |    |    |
| ou |    |                                 |              |    |    |
| nd |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  n |    |                                 |              |    |    |
| at |    |                                 |              |    |    |
| ur |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| te |    |                                 |              |    |    |
| et |    |                                 |              |    |    |
| h. |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  T |    |                                 |              |    |    |
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| >  |    |                                 |              |    |    |
| ne |    |                                 |              |    |    |
| ed |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  f |    |                                 |              |    |    |
| or |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  t |    |                                 |              |    |    |
| he |    |                                 |              |    |    |
| se |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| se |    |                                 |              |    |    |
| rv |    |                                 |              |    |    |
| ic |    |                                 |              |    |    |
| es |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| mu |    |                                 |              |    |    |
| st |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
| su |    |                                 |              |    |    |
| lt |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| fr |    |                                 |              |    |    |
| om |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| an |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| ac |    |                                 |              |    |    |
| ci |    |                                 |              |    |    |
| de |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  i |    |                                 |              |    |    |
| nj |    |                                 |              |    |    |
| ur |    |                                 |              |    |    |
| y. |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| >  |    |                                 |              |    |    |
| ** |    |                                 |              |    |    |
| De |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| be |    |                                 |              |    |    |
| ne |    |                                 |              |    |    |
| fi |    |                                 |              |    |    |
| ts |    |                                 |              |    |    |
| ** |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| >  |    |                                 |              |    |    |
| We |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| ha |    |                                 |              |    |    |
| ve |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| no |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  o |    |                                 |              |    |    |
| th |    |                                 |              |    |    |
| er |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| de |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  b |    |                                 |              |    |    |
| en |    |                                 |              |    |    |
| ef |    |                                 |              |    |    |
| it |    |                                 |              |    |    |
| s. |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+

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

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

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

Texas, Florida and Chicago area members: Please refer to enclosed
materials for Dental Coverage information.

> Complementary and Alternative Medicine (CAM) is a program offered to
> all Humana members, giving discounted access to supplemental health
> services. Through this program members will receive a discount of up
> to 30% on services by participating providers in the American
> WholeHealth Network.
>
> Alternative medicine is known for its focus on being healthy and
> preventing problems, not just treating illness and injury. To learn
> more about this program go to www.wholehealthmd.com/Humana.
>
> This Vision Discount Program is available to you through EYE-MED,
> which offers access to optometrists, ophthalmologists, and opticians.
> There are no claim forms to fill out and no waiting for reimbursement.
> The discount will be applied to your purchase. The discount card is
> enclosed in this packet. Call 1-866-392-6056 for the EYE-MED provider
> locator service.

Contact us for additional information concerning specific benefits,
exclusions, limitations, eligible providers and other provisions of each
of the above coverages.

.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

**Medical and hospital benefits** In most cases, providers and
facilities file claims for you. Physicians must file on the form
HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at
1-800/4HUMANA or 1-800/448-6262.

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

-   Covered member's name and ID number;

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

-   Dates you received the services or supplies;

-   Diagnosis;

-   Type of each service or supply;

-   The charge for each service or supply;

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

-   Receipts, if you paid for your services.

    **Submit your claims to:**

    **Humana Claims Office**

    **P.O. Box 14601**

    **Lexington, KY 40512-4601**

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

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

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

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

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

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) Write to us within 6 months from the date of our decision;   |
| * |     and                                                          |
| * |                                                                  |
|   | (b) Send your request to us at: Humana Claims Office, Attn:      |
|   |     Grievance & Appeals, P.O. Box 14601, Lexington, KY           |
|   |     40512-4601; and                                              |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or, if applicable, arrange for the health     |
| * |     care provider to give you the care); or                      |
| * |                                                                  |
|   | (b) Write to you and maintain our denial -- go to step 4; or     |
|   |                                                                  |
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request -- go  |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us -- if we did not answer |
|   |     that request in some way within 30 days; or                  |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: United States Office of Personnel Management,   |
|   | Insurance Services Programs, Health Insurance Group 3, 1900 E    |
|   | Street, NW, Washington, DC 20415-3630.                           |
+---+------------------------------------------------------------------+

*The disputed claims process -- Continued on next page*

**The Disputed Claims Process *(continued)***

+---+------------------------------------------------------------------+
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must include a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | If you do not agree with OPM's decision, your only recourse is   |
|   | to sue. If you decide to sue, you must file the suit against OPM |
|   | in Federal court by December 31 of the third year after the year |
|   | in which you received the disputed services, drugs or supplies   |
|   | or from the year in which you were denied precertification or    |
|   | prior approval. This is the only deadline that may not be        |
|   | extended.                                                        |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support their disputed claim decision. This           |
|   | information will become part of the court record.                |
|   |                                                                  |
|   | You may not sue until you have completed the disputed claims     |
|   | process. Further, Federal law governs your lawsuit, benefits,    |
|   | and payment of benefits. The Federal court will base its review  |
|   | on the record that was before OPM when OPM decided to uphold or  |
|   | overturn our decision. You may recover only the amount of        |
|   | benefits in dispute.                                             |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+

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

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at\
    1-800/4HUMANA or 1-800/448-6262 and we will expedite our review; or

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

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

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-   You may call OPM\'s Health Insurance Group 3 at 202/606-0737 between
    8 a.m. and 5 p.m. eastern time.

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

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

**When you have other**

**health coverage** You must tell us if you or a covered family member
have coverage under another group health plan or have automobile
insurance that pays health care expenses without regard to fault. This
is called "double coverage."

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

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

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

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

-   People 65 years of age and older.

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

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

> Medicare has two parts:

-   Part A (Hospital Insurance). Most people do not have to pay for\
    Part A. If you or your spouse worked for at least 10 years in
    Medicare-covered employment, you should be able to qualify for
    premium-free Part A insurance. (Someone who was a Federal employee
    on January 1, 1983 or since automatically qualifies.) Otherwise, if
    you are age 65 or older, you may be able to buy it. Contact
    1-800-MEDICARE for more information.

-   Part B (Medical Insurance). Most people pay monthly for Part B.
    Generally, Part B premiums are withheld from your monthly Social
    Security check or your retirement check.

-   **Should I enroll in Medicare?** The decision to enroll in Medicare
    is yours. We encourage you to apply for Medicare benefits 3 months
    before you turn age 65. It's easy. Just call the Social Security
    Administration toll-free number 1-800-772-1213 to set up an
    appointment to apply. If you do not apply for one or both Parts of
    Medicare, you can still be covered under the FEHB Program.

> If you can get premium-free Part A coverage, we advise you to enroll
> in it. Most Federal employees and annuitants are entitled to Medicare
> Part A at age 65 **without cost**. When you don't have to pay premiums
> for Medicare Part A, it makes good sense to obtain the coverage. It
> can reduce your out-of-pocket expenses as well as costs to the FEHB,
> which can help keep FEHB premiums down.
>
> Everyone is charged a premium for Medicare Part B coverage. The Social
> Security Administration can provide you with premium and benefit
> information. Review the information and decide if it makes sense for
> you to buy the Medicare Part B coverage.
>
> If you are eligible for Medicare, you may have choices in how you get
> your health care. Medicare + Choice is the term used to describe the
> various health plan choices available to Medicare beneficiaries. The
> information in the next few pages shows how we coordinate benefits
> with Medicare, depending on the type of Medicare managed care plan you
> have.

-   **The Original Medicare Plan**

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

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

> **Claims process when you have the Original Medicare Plan** -- You
> probably will never have to file a claim form when you have both our
> Plan and the Original Medicare Plan.
>
> • When we are the primary payer, we process the claim first.
>
> • When Original Medicare is the primary payer, Medicare processes\
> your claim first. In most cases, your claims will be coordinated
> automatically and we will then provide secondary benefits for covered
> charges. You will not need to do anything. To find out if you need to
> do something to file your claim, contact us at 1-800/4HUMANA or\
> 1-800/448-6262, or visit our web site: feds.humana.com.
>
> **We do not waive any costs if the Original Medicare Plan** **is your
> primary payer.**

**(Primary payer chart begins on next page.)**

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

+----------------------------------------------------+------+----------+
| **Primary Payer Chart**                            |      |          |
+----------------------------------------------------+------+----------+
| > **A. When you -- or your covered spouse -- are   | *    |          |
| > age 65 or over and have Medicare\                | *The |          |
| > and you ...**                                    | pri  |          |
|                                                    | mary |          |
|                                                    | p    |          |
|                                                    | ayer |          |
|                                                    | for  |          |
|                                                    | the  |          |
|                                                    | in   |          |
|                                                    | divi |          |
|                                                    | dual |          |
|                                                    | with |          |
|                                                    | Medi |          |
|                                                    | care |          |
|                                                    | is.  |          |
|                                                    | ..** |          |
+----------------------------------------------------+------+----------+
|                                                    | **Me | **This   |
|                                                    | dica | Plan**   |
|                                                    | re** |          |
+----------------------------------------------------+------+----------+
| 1)  Are an active employee with the Federal        |      | >       |
|     government and ...                             |      |          |
|                                                    |      |          |
| -   You have FEHB coverage on your own or through  |      |          |
|     your spouse who is also an active employee     |      |          |
+----------------------------------------------------+------+----------+
| -   You have FEHB coverage through your spouse who |     |          |
|     is an annuitant                                |      |          |
+----------------------------------------------------+------+----------+
| > 2\) Are an annuitant and ...                     |     |          |
|                                                    |      |          |
| -   You have FEHB coverage on your own or through  |      |          |
|     your spouse who is also an annuitant           |      |          |
+----------------------------------------------------+------+----------+
| -   You have FEHB coverage through your spouse who |      | >       |
|     is an active employee                          |      |          |
+----------------------------------------------------+------+----------+
| > 3\) Are a reemployed annuitant with the Federal  | \*  |          |
| > government and your position is excluded from    |      |          |
| > the FEHB (your employing office will know if     |      |          |
| > this is the case)                                |      |          |
+----------------------------------------------------+------+----------+
| > 4\) Are a reemployed annuitant with the Federal  |      |         |
| > government and your position is not excluded     |      |          |
| > from the FEHB (your employing office will know   |      |          |
| > if this is the case) and ...                     |      |          |
|                                                    |      |          |
| -   You have FEHB coverage on your own or through  |      |          |
|     your spouse who is also an active employee     |      |          |
+----------------------------------------------------+------+----------+
| -   You have FEHB coverage through your spouse who |     |          |
|     is an annuitant                                |      |          |
+----------------------------------------------------+------+----------+
| > 5\) Are a Federal judge who retired under title  | ###  |          |
| > 28, U.S.C., or a Tax Court judge who retired     | ###  |          |
| > under Section 7447 of title 26, U.S.C. (or if    |      |          |
| > your covered spouse is this type of judge)       | ###  |          |
|                                                    | ###  |          |
|                                                    |  \* |          |
+----------------------------------------------------+------+----------+
| > 6\) Are enrolled in Part B only, regardless of   |     |  for    |
| > your employment status,                          | for  | other    |
|                                                    | Part | services |
|                                                    | B    |          |
|                                                    | serv |          |
|                                                    | ices |          |
+----------------------------------------------------+------+----------+
| > 7\) Are a former Federal employee receiving      |     |          |
| > Workers' Compensation and the Office of Workers' | \*\* |          |
| > Compensation Programs has determined that you    |      |          |
| > are unable to return to duty                     |      |          |
+----------------------------------------------------+------+----------+
| > **B. When you or a covered family member ...**   |      |          |
+----------------------------------------------------+------+----------+
| ###### Have Medicare solel                         |      | >       |
| y based on end stage renal disease (ESRD) and ...  |      |          |
|                                                    |      |          |
| ###### It is within the first                      |      |          |
|  30 months of eligibility for or entitlement to Me |      |          |
| dicare due to ESRD (30-month coordination period ) |      |          |
+----------------------------------------------------+------+----------+
| -   It is beyond the 30-month coordination period  |     |          |
|     and you or a family member are still entitled  |      |          |
|     to Medicare due to ESRD                        |      |          |
+----------------------------------------------------+------+----------+
| 1)  Become eligible for Medicare due to ESRD while |      |  for    |
|     already a Medicare beneficiary and ...         |      | 30-month |
|                                                    |      | coor     |
| -   This Plan was the primary payer before         |      | dination |
|     eligibility due to ESRD                        |      | period   |
+----------------------------------------------------+------+----------+
| -   Medicare was the primary payer before          |     |          |
|     eligibility due to ESRD                        |      |          |
+----------------------------------------------------+------+----------+
| **C. When either you or your spouse are eligible   |      |          |
| for Medicare solely due to disability and you**    |      |          |
+----------------------------------------------------+------+----------+
| 1)  Are an active employee with the Federal        |      | >       |
|     government and ...                             |      |          |
|                                                    |      |          |
| -   You have FEHB coverage on your own or through  |      |          |
|     your spouse who is also an active employee     |      |          |
+----------------------------------------------------+------+----------+
| -   You have FEHB coverage through your spouse who |     |          |
|     is an annuitant                                |      |          |
+----------------------------------------------------+------+----------+
| > 2\) Are an annuitant and ...                     | -    |          |
|                                                    |      |          |
| -   You have FEHB coverage through your spouse who |      |          |
|     is also an annuitant                           |      |          |
+----------------------------------------------------+------+----------+
| -   You have FEHB coverage through your spouse who |      | >       |
|     is an active employee                          |      |          |
+----------------------------------------------------+------+----------+
| **D. Are covered under the FEHB Spouse Equity      | >   |          |
| provision as a former spouse**                     |      |          |
+----------------------------------------------------+------+----------+

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

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

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

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

**This Plan and our Medicare + Choice plan:** You may enroll in our
Medicare + Choice plan and also remain enrolled in our FEHB plan. \[In
this case, we do waive some cost-sharing for your FEHB coverage.\] \[ In
this case, we do not waive cost-sharing for your FEHB coverage.\]

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

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

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

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

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

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

-   OWCP or a similar agency pays for through a third party injury
    settlement or other similar proceeding that is based on a claim you
    filed under OWCP or similar laws.

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

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

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

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

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

**When others are responsible** When you receive money to compensate you
for medical or hospital

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

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

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

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

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

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

**Consumer Driven Plan** A plan that gives greater control over your
choices of health care expenditures. You decide what health care
services will be reimbursed under the health plan benefit allowance. The
benefit allowance is only used for participating providers. If you spend
the entire benefit allowance before the end of the year, then you must
satisfy your deductible before benefits are payable under the
traditional type of insurance covered by your plan.

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

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

**Custodial care** Services provided to you such as assistance with
dressing, bathing, preparation and feeding of special diets, walking,
supervision of medication which is ordinarily self-administered, getting
in and out of bed, and maintaining continence, which are not likely to
improve your condition. Custodial care that lasts 90 days or more is
sometimes known as long term care.

**Deductible** A deductible is a fixed amount of covered expenses you
must incur for certain covered services and supplies before we start
paying benefits for those services. See page 13.

**Durable Medical Equipment**

**(DME)** Equipment recognized as such by Medicare Part B, that meets
all of the following criteria:

-   it can stand repeated use; and

-   it is primarily and customarily used to serve a medical purpose
    rather than being primarily for comfort or convenience; and

-   it is usually not useful to a person in the absence of sickness or
    injury; and

-   it is appropriate for home use; and

-   it is related to the patient's physical disorder, and the equipment
    must be used in the member's home.

**Experimental or**

**investigational services** A drug, biological product, device, medical
treatment, or procedure is determined to be experimental or
investigational if reliable evidence shows it meets one of the following
criteria:

-   when applied to the circumstances of a particular patient is the
    subject of ongoing phase I, II or III clinical trials, or

-   when applied to the circumstances of a particular patient is under
    study with written protocol to determine maximum tolerated dose,
    toxicity, safety, efficacy, or efficacy in comparison to
    conventional alternatives, or

-   is being delivered or should be delivered subject to the approval
    and supervision of an Institutional Review Board as required and
    defined by the USFDA or Department of Health and Human Services

-   is not generally accepted by the medical community

Reliable evidence means, but is not limited to, published reports and
articles in authoritative medical scientific literature or regulations
and other official actions and publications issued by the USFDA or the
Department of Health and Human Services.

**Medical Necessity** The determination as to whether a medical service
is required to treat a condition, illness, or injury. In order to meet
the standard of medical necessity the service must be consistent with
symptoms, diagnosis, or treatment; consistent with good medical
practice; and the most appropriate level of service that can be safely
provided.

**Morbid Obesity** Morbid or clinically severe obesity correlated with a
Body Mass Index (BMI) of 40k/m2 or with being 100 pounds over ideal body
weight.

**Oral Surgery** Procedures to correct diseases, injuries and defects of
the jaw and mouth structures.

**Out of Pocket** The out-of-pocket amount is the limit on total member
copayments, deductibles, and coinsurance under a benefit contract.

**Participating Provider** A hospital, physician, or any other health
services provider who has been designated to provide services to covered
members under this plan

**Specialist** A specialist is a physician other than a family
practitioner, general practitioner, internist or pediatrician.

**Us/We** Us and we refer to Humana CoverageFirst

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

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

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

**Coverage information**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

**When benefits and**

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

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

**When you lose benefits**

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

-   Your enrollment ends, unless you cancel your enrollment, or

```{=html}
<!-- -->
```
-   You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation
of Coverage (TCC); or a conversion policy (a non-FEHB individual
policy).

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

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

**• Temporary Continuation**

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

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

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

**• Converting to**

> **individual coverage** You may convert to a non-FEHB individual
> policy if:

-   Your coverage under TCC or the spouse equity law ends (if you\
    canceled your coverage or did not pay your premium, you cannot
    convert);

```{=html}
<!-- -->
```
-   You decided not to receive coverage under TCC or the spouse equity
    equity law; or

-   You are not eligible for coverage under TCC or the spouse equity
    law.

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

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

> **• Getting a Certificate of Group**
>
> **Health Plan Coverage** The Health Insurance Portability and
> Accountability Act of 1996 (HIPAA) is a Federal law that offers
> limited Federal protections for health coverage availability and
> continuity to people who lose employer group coverage. If you leave
> the FEHB Program, we will give you a Certificate of Group Health Plan
> Coverage that indicates how long you have been enrolled with us. You
> can use this certificate when getting health insurance or other health
> care coverage. Your new plan must reduce or eliminate waiting periods,
> limitations, or exclusions for health related conditions based on the
> information in the certificate, as long as you enroll within 63 days
> of losing coverage under this Plan. If you have been enrolled with us
> for less than 12 months, but were previously enrolled in other FEHB
> plans, you may also request a certificate from those plans.

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

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

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

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

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

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

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

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

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

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

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

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

You **must make an election** to enroll in an FSA during the FEHB Open
Season. Even if you enrolled during the initial Open Season for 2003,
you must make a new election to continue participating in 2004.
Enrollment is easy!

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

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

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

If you are a Federal employee eligible for FEHB -- even if you're not
enrolled in FEHB -- you can choose to participate in either, or both, of
the flexible spending accounts. If you are not eligible for FEHB, you
are not eligible to enroll for a Health Care FSA. However, almost all
Federal employees are eligible to enroll for the Dependent Care FSA. The
only exception is intermittent (also called when actually employed
\[WAE\]) employees expected to work less than 180 days during the year.

*Note*: FSAFEDS is the FSA Program established for all Executive Branch
employees and Legislative Branch employees whose employers signed on.
Under IRS law, FSAs are not available to annuitants. In addition, the
U.S. Postal Service and the Judicial Branch, among others, are Federal
agencies that have their own plans with slightly different rules, but
the advantages of having an FSA are the same no matter what agency you
work for.

Plan carefully when deciding how much to contribute to an FSA. Because
of the tax benefits of an FSA, the IRS places strict guidelines on them.
You need to estimate how much you want to allocate to an FSA because
current IRS regulations require you forfeit any funds remaining in your
account(s) at the end of the FSA plan year. This is referred to as the
"use-it-or-lose-it" rule. You will have until April 29, 2004 to submit
claims for your eligible expenses incurred during 2003 if you enrolled
in FSAFEDS when it was initially offered. You will have until April 30,
2005 to submit claims for your eligible expenses incurred from January 1
through December 31, 2004 if you elect FSAFEDS during this Open Season.

The **FSAFEDS Calculator** at www.fsafeds.com will help you plan your
FSA allocations and provide an estimate of your tax savings based on
your individual situation.

Every FEHB health plan includes cost sharing features, such as
deductibles you must meet before the Plan provides benefits, coinsurance
or copayments that you pay when you and the Plan share costs, and
medical services and supplies that are not covered by the Plan and for
which you must pay. These out-of-pocket costs are summarized on page 13
and detailed throughout this brochure. Your HCFSA will reimburse you for
such costs when they are for tax deductible medical care for you and
your dependents that is NOT covered by this FEHB Plan or any other
coverage that you have.

Under this Plan, typical out-of-pocket expenses include deductibles,
coinsurance and copayments for office visits, hospital services and
prescription drugs.

The IRS governs expenses reimbursable by a HCFSA. See Publication 502
for a comprehensive list of tax-deductible medical expenses. **Note:
While you will see insurance premiums listed in Publication 502, they
are NOT a reimbursable expense for FSA purposes.** Publication 502 can
be found on the IRS Web site at http://www.irs.gov/pub/irs-pdf/p502.pdf.
If you do not see your service or expense listed in Publication 502,
please call a FSAFEDS Benefit Counselor at\
1-877-FSAFEDS (372-3337), who will be able to answer your specific
questions.

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

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

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

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

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

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

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

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

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

> **Note**: This example is intended to demonstrate a typical tax
> savings based on 27% Federal and 7.65% FICA taxes. Actual savings will
> vary based upon in which retirement system you are enrolled (CSRS or
> FERS), as well as your individual tax situation. In this example, the
> individual received \$2,000 in services for \$1,424, a discount of
> almost 36%! You may also wish to consult a tax professional for more
> information on the tax implications of an FSA.
>
> You cannot claim expenses on your Federal income tax return if you
> receive reimbursement for them from your HCFSA or DCFSA. Below are
> some guidelines that may help you decide whether to participate in
> FSAFEDS.
>
> **Health care expenses** The HCFSA is tax-free from the first dollar.
> In addition, you may be reimbursed from the HCFSA at any time during
> the year for expenses up to the annual amount you've elected to
> contribute.
>
> Only health care expenses exceeding 7.5% of your adjusted gross income
> are eligible to be deducted on your Federal income tax return. Using
> the example listed in the above chart, only health care expenses
> exceeding \$3,750 (7.5% of \$50,000) would be eligible to be deducted
> on your Federal income tax return. In addition, money set aside
> through a HCFSA is also exempt from FICA taxes. This exemption is not
> available on your Federal income tax return.
>
> The DCFSA generally allows many families to save more than they would
> with the Federal tax credit for dependent care expenses. Note that you
> may only be reimbursed from the DCFSA up to your current account
> balance. If you file a claim for more than your current balance, it
> will be held until additional payroll allotments have been added to
> your account.
>
> Visit www.fsafeds.com and download the Dependent Care Tax Credit
> Worksheet from the Quick Links box to help you determine what is best
> for your situation. You may also wish to consult a tax professional
> for more details.
>
> Probably not. While there is an administrative fee of \$4.00 per month
> for an HCFSA and 1.5% of the annual election for a DCFSA, most
> agencies have elected to pay these fees out of their share of
> employment tax savings. To be sure, check the FSAFEDS.com web site or
> call 1-877-FSAFEDS (372-3337). Also, remember that participating in
> FSAFEDS can cost you money if you don't spend your entire account
> balance by the end of the plan year and wind up forfeiting your end of
> year account balance, per the IRS "use-it-or-lose-it" rule.

-   **Contact us** To find out more or to enroll, please visit the
    **FSAFEDS Web site at www.fsafeds.com**, or contact SHPS by e-mail
    or by phone. SHPS Benefit Counselors are available from 9:00 a.m.
    until 9:00 p.m. eastern time, Monday through Friday.

-   E-mail: fsafeds@shps.net

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

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

**The Federal Long Term Care Insurance Program**

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

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

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

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

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

> Call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit
> www.ltcfeds.com.

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

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

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

  -----------------------------------------------------------------------
  **Summary of benefits for Humana CoverageFirst -- 2004**

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

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

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

-   Members have a \$500 benefit allowance to use before they must meet
    a deductible.

+--------------------------------------+-----------------------+------+
| **Benefits**                         | **You Pay**           | **Pa |
|                                      |                       | ge** |
+--------------------------------------+-----------------------+------+
| Medical services provided by         | Office visit copay:   | > 16 |
| physicians:                          | \$20 primary care;    |      |
|                                      | \$35 specialist       |      |
| -   Diagnostic and treatment         |                       |      |
|     services provided in the office  |                       |      |
+--------------------------------------+-----------------------+------+
| Services provided by a hospital:     | > \$100 copay per day | > 2  |
|                                      | > for the first five  | 9-30 |
| -   Inpatient                        | > days per admission, | >    |
|                                      | > after deductible    | > 30 |
| -   Outpatient -- Surgery            | >                     | >    |
|                                      | > \$50 per visit,     | > 31 |
| -   Outpatient -- other services     | > after deductible    |      |
|                                      | >                     |      |
|                                      | > Nothing, after      |      |
|                                      | > deductible          |      |
+--------------------------------------+-----------------------+------+
| Emergency benefits:                  | > \$20 primary care;  | > 3  |
|                                      | > \$35 specialist     | 2-33 |
| -   At a doctor's office or urgent   | >                     |      |
|     care center                      | > \$100 copay (waived |      |
|                                      | > if admitted;        |      |
| -   At a hospital                    | > inpatient copay     |      |
|                                      | > will apply)         |      |
+--------------------------------------+-----------------------+------+
| Mental health and substance abuse    | > Regular cost        | > 3  |
| treatment                            | > sharing             | 4-35 |
+--------------------------------------+-----------------------+------+
| Prescription drugs:                  | > \$10 copay          | > 37 |
|                                      | >                     |      |
| -   Level One drugs                  | > \$25 copay          |      |
|                                      | >                     |      |
| -   Level Two drugs                  | > \$50 copay          |      |
|                                      | >                     |      |
| -   Level Three drugs                | > 25% of the amount   |      |
|                                      | > the plan pays       |      |
| -   Level Four drugs                 | >                     |      |
|                                      | > 3 applicable copays |      |
| -   Maintenance drugs (90-day        |                       |      |
|     supply) when ordered through our |                       |      |
|     mail-order program               |                       |      |
+--------------------------------------+-----------------------+------+
| Dental Care                          | > Same as any other   | > 39 |
|                                      | > injury              |      |
| -   Accidental injury benefit only   |                       |      |
+--------------------------------------+-----------------------+------+
| Vision Care                          | > No benefit          |      |
+--------------------------------------+-----------------------+------+
| > Special features: *Flexible        |                       | > 38 |
| > Benefits Option; TDD and TTY phone |                       |      |
| > lines; HumanaBeginnings; National  |                       |      |
| > Transplant Network; and            |                       |      |
| > HumanaFirst^®^*                    |                       |      |
+--------------------------------------+-----------------------+------+
| Protection against catastrophic      | > None                | > 14 |
| costs (your catastrophic protection  |                       |      |
| out-of-pocket maximum)               |                       |      |
+--------------------------------------+-----------------------+------+

**2004 Rate Information for**

**Humana CoverageFirst**

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

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

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

+-------------+------+-------+-------+-------+-------+-------+-------+
|             |      | **    |       |       |       | **P   |       |
|             |      | Non-P |       |       |       | ostal |       |
|             |      | ostal |       |       |       | Prem  |       |
|             |      | Prem  |       |       |       | ium** |       |
|             |      | ium** |       |       |       |       |       |
+-------------+------+-------+-------+-------+-------+-------+-------+
|             |      | **    |       | *     |       | **    |       |
|             |      | Biwee |       | *Mont |       | Biwee |       |
|             |      | kly** |       | hly** |       | kly** |       |
+-------------+------+-------+-------+-------+-------+-------+-------+
| **Type of   | **Co | **Go  | **Y   | **Go  | **Y   | **U   | **Y   |
| E           | de** | v't** | our** | v't** | our** | SPS** | our** |
| nrollment** |      |       |       |       |       |       |       |
|             |      | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  |
|             |      | are** | are** | are** | are** | are** | are** |
+-------------+------+-------+-------+-------+-------+-------+-------+
| #####       |      |       |       |       |       |       |       |
| # **Arizona |      |       |       |       |       |       |       |
| : Phoenix** |      |       |       |       |       |       |       |
+-------------+------+-------+-------+-------+-------+-------+-------+
| Self Only   | **D  | *     | *     | **    | *     | *     | *     |
|             | B1** | *\$68 | *\$22 | \$148 | *\$49 | *\$81 | *\$10 |
|             |      | .45** | .82** | .31** | .44** | .00** | .27** |
+-------------+------+-------+-------+-------+-------+-------+-------+
| Self and    | **D  | **    | *     | **    | **    | **    | *     |
| Family      | B2** | \$157 | *\$52 | \$341 | \$113 | \$186 | *\$23 |
|             |      | .43** | .48** | .11** | .70** | .30** | .61** |
+-------------+------+-------+-------+-------+-------+-------+-------+

+-------------+------+-------+-------+-------+-------+-------+-------+
| ###### **F  |      |       |       |       |       |       |       |
| lorida: Jac |      |       |       |       |       |       |       |
| ksonville** |      |       |       |       |       |       |       |
+-------------+------+-------+-------+-------+-------+-------+-------+
| Self Only   | **M  | *     | *     | **    | *     | *     | *     |
|             | Q1** | *\$79 | *\$26 | \$171 | *\$57 | *\$93 | *\$11 |
|             |      | .26** | .42** | .73** | .24** | .79** | .89** |
+-------------+------+-------+-------+-------+-------+-------+-------+
| Self and    | **M  | **    | *     | **    | **    | **    | *     |
| Family      | Q2** | \$182 | *\$60 | \$394 | \$131 | \$215 | *\$27 |
|             |      | .30** | .76** | .97** | .66** | .72** | .34** |
+-------------+------+-------+-------+-------+-------+-------+-------+
| ###         |      |       |       |       |       |       |       |
| ### **Flori |      |       |       |       |       |       |       |
| da: Tampa** |      |       |       |       |       |       |       |
+-------------+------+-------+-------+-------+-------+-------+-------+
| Self Only   | **M  | *     | *     | **    | *     | *     | *     |
|             | J1** | *\$75 | *\$25 | \$163 | *\$54 | *\$89 | *\$11 |
|             |      | .66** | .22** | .93** | .64** | .53** | .35** |
+-------------+------+-------+-------+-------+-------+-------+-------+
| Self and    | **M  | **    | *     | **    | **    | **    | *     |
| Family      | J2** | \$174 | *\$58 | \$377 | \$125 | \$205 | *\$26 |
|             |      | .01** | .00** | .02** | .67** | .91** | .10** |
+-------------+------+-------+-------+-------+-------+-------+-------+
| ###### **Fl |      |       |       |       |       |       |       |
| orida: Sout |      |       |       |       |       |       |       |
| h Florida** |      |       |       |       |       |       |       |
+-------------+------+-------+-------+-------+-------+-------+-------+
| Self Only   | **Q  | *     | *     | **    | *     | *     | *     |
|             | P1** | *\$72 | *\$24 | \$156 | *\$52 | *\$85 | *\$10 |
|             |      | .06** | .02** | .13** | .04** | .27** | .81** |
+-------------+------+-------+-------+-------+-------+-------+-------+
| Self and    | **Q  | **    | *     | **    | **    | **    | *     |
| Family      | P2** | \$165 | *\$55 | \$359 | \$119 | \$196 | *\$24 |
|             |      | .73** | .24** | .08** | .69** | .11** | .86** |
+-------------+------+-------+-------+-------+-------+-------+-------+
| ######      |      |       |       |       |       |       |       |
|  **Illinois |      |       |       |       |       |       |       |
| : Chicago** |      |       |       |       |       |       |       |
+-------------+------+-------+-------+-------+-------+-------+-------+
| Self Only   | **M  | *     | *     | **    | *     | *     | **\$8 |
|             | W1** | *\$57 | *\$19 | \$124 | *\$41 | *\$68 | .65** |
|             |      | .65** | .21** | .90** | .63** | .21** |       |
+-------------+------+-------+-------+-------+-------+-------+-------+
| Self and    | **M  | **    | *     | **    | *     | **    | *     |
| Family      | W2** | \$132 | *\$44 | \$287 | *\$95 | \$156 | *\$19 |
|             |      | .58** | .19** | .25** | .75** | .88** | .89** |
+-------------+------+-------+-------+-------+-------+-------+-------+

  -----------------------------------------------------------------------
  **2004 Rate Information for Humana CoverageFirst** *(continued)*

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

+-------------+------+-------+-------+-------+-------+-------+-------+---+
|             |      | **    |       |       |       | **P   |       |   |
|             |      | Non-P |       |       |       | ostal |       |   |
|             |      | ostal |       |       |       | Prem  |       |   |
|             |      | Prem  |       |       |       | ium** |       |   |
|             |      | ium** |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
|             |      | **    |       | *     |       | **    |       |   |
|             |      | Biwee |       | *Mont |       | Biwee |       |   |
|             |      | kly** |       | hly** |       | kly** |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| **Type of   | **Co | **Go  | **Y   | **Go  | **Y   | **U   | **Y   |   |
| E           | de** | v't** | our** | v't** | our** | SPS** | our** |   |
| nrollment** |      |       |       |       |       |       |       |   |
|             |      | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  |   |
|             |      | are** | are** | are** | are** | are** | are** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| ######      |      |       |       |       |       |       |       |   |
|  **Kansas/M |      |       |       |       |       |       |       |   |
| issouri: Ka |      |       |       |       |       |       |       |   |
| nsas City** |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self Only   | **P  | *     | *     | **    | *     | *     | **\$8 |   |
|             | H1** | *\$57 | *\$19 | \$124 | *\$41 | *\$68 | .65** |   |
|             |      | .65** | .21** | .90** | .63** | .21** |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self and    | **P  | **    | *     | **    | *     | **    | *     |   |
| Family      | H2** | \$132 | *\$44 | \$287 | *\$95 | \$156 | *\$19 |   |
|             |      | .58** | .19** | .25** | .75** | .88** | .89** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| ###### **   |      |       |       |       |       |       |       |   |
| Kentucky: L |      |       |       |       |       |       |       |   |
| ouisville** |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self Only   | **B  | *     | *     | **    | *     | **    | *     |   |
|             | M1** | *\$86 | *\$28 | \$187 | *\$62 | \$102 | *\$12 |   |
|             |      | .46** | .82** | .33** | .44** | .31** | .97** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self and    | **B  | **    | *     | **    | **    | **    | *     |   |
| Family      | M2** | \$198 | *\$66 | \$430 | \$143 | \$235 | *\$29 |   |
|             |      | .87** | .29** | .88** | .63** | .33** | .83** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| #           |      |       |       |       |       |       |       |   |
| ##### **Ohi |      |       |       |       |       |       |       |   |
| o: Cincinna |      |       |       |       |       |       |       |   |
| ti/Dayton** |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self Only   | **L  | *     | *     | **    | *     | *     | *     |   |
|             | 81** | *\$72 | *\$24 | \$156 | *\$52 | *\$85 | *\$10 |   |
|             |      | .06** | .02** | .13** | .04** | .27** | .81** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self and    | **L  | **    | *     | **    | **    | **    | *     |   |
| Family      | 82** | \$165 | *\$55 | \$359 | \$119 | \$196 | *\$24 |   |
|             |      | .73** | .24** | .08** | .69** | .11** | .86** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| ######      |      |       |       |       |       |       |       |   |
| **Tennessee |      |       |       |       |       |       |       |   |
| : Memphis** |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self Only   | **L  | *     | *     | **    | *     | *     | *     |   |
|             | 61** | *\$72 | *\$24 | \$156 | *\$52 | *\$85 | *\$10 |   |
|             |      | .06** | .02** | .13** | .04** | .27** | .81** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self and    | **L  | **    | *     | **    | **    | **    | *     |   |
| Family      | 62** | \$165 | *\$55 | \$359 | \$119 | \$196 | *\$24 |   |
|             |      | .73** | .24** | .08** | .69** | .11** | .86** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| ##          |      |       |       |       |       |       |       |   |
| #### **Texa |      |       |       |       |       |       |       |   |
| s: Austin** |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self Only   | **T  | *     | *     | **    | *     | *     | *     |   |
|             | V1** | *\$79 | *\$26 | \$171 | *\$57 | *\$93 | *\$11 |   |
|             |      | .26** | .42** | .73** | .24** | .79** | .89** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self and    | **T  | **    | *     | **    | **    | **    | *     |   |
| Family      | V2** | \$182 | *\$60 | \$394 | \$131 | \$215 | *\$27 |   |
|             |      | .30** | .76** | .97** | .66** | .72** | .34** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| ###### **T  |      |       |       |       |       |       |       |   |
| exas: Corpu |      |       |       |       |       |       |       |   |
| s Christi** |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self Only   | **T  | *     | *     | **    | *     | *     | *     |   |
|             | P1** | *\$75 | *\$25 | \$163 | *\$54 | *\$89 | *\$11 |   |
|             |      | .66** | .22** | .93** | .64** | .53** | .35** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self and    | **T  | **    | *     | **    | **    | **    | *     |   |
| Family      | P2** | \$174 | *\$58 | \$377 | \$125 | \$205 | *\$26 |   |
|             |      | .01** | .00** | .02** | .67** | .91** | .10** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| ##          |      |       |       |       |       |       |       |   |
| #### **Texa |      |       |       |       |       |       |       |   |
| s: Dallas/F |      |       |       |       |       |       |       |   |
| ort Worth** |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self Only   | **T  | *     | *     | **    | *     | *     | *     |   |
|             | 81** | *\$82 | *\$27 | \$179 | *\$59 | *\$98 | *\$12 |   |
|             |      | .87** | .62** | .55** | .85** | .06** | .43** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self and    | **T  | **    | *     | **    | **    | **    | *     |   |
| Family      | 82** | \$190 | *\$63 | \$412 | \$137 | \$225 | *\$28 |   |
|             |      | .58** | .53** | .93** | .64** | .52** | .59** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| **2004 Rate |      |       |       |       |       |       |       |   |
| Information |      |       |       |       |       |       |       |   |
| for Humana  |      |       |       |       |       |       |       |   |
| Cove        |      |       |       |       |       |       |       |   |
| rageFirst** |      |       |       |       |       |       |       |   |
| *(          |      |       |       |       |       |       |       |   |
| continued)* |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
|             |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
|             |      | **    |       |       |       | **P   |       |   |
|             |      | Non-P |       |       |       | ostal |       |   |
|             |      | ostal |       |       |       | Prem  |       |   |
|             |      | Prem  |       |       |       | ium** |       |   |
|             |      | ium** |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
|             |      | **    |       | *     |       | **    |       |   |
|             |      | Biwee |       | *Mont |       | Biwee |       |   |
|             |      | kly** |       | hly** |       | kly** |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| **Type of   | **Co | **Go  | **Y   | **Go  | **Y   | **U   | **Y   |   |
| E           | de** | v't** | our** | v't** | our** | SPS** | our** |   |
| nrollment** |      |       |       |       |       |       |       |   |
|             |      | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  |   |
|             |      | are** | are** | are** | are** | are** | are** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| ###         |      |       |       |       |       |       |       |   |
| ### **Texas |      |       |       |       |       |       |       |   |
| : Houston** |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self Only   | **T  | *     | *     | **    | *     | **    | *     |   |
|             | 21** | *\$86 | *\$28 | \$187 | *\$62 | \$102 | *\$12 |   |
|             |      | .46** | .82** | .33** | .44** | .31** | .97** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self and    | **T  | **    | *     | **    | **    | **    | *     |   |
| Family      | 22** | \$198 | *\$66 | \$430 | \$143 | \$235 | *\$29 |   |
|             |      | .87** | .29** | .88** | .63** | .33** | .83** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| ######      |      |       |       |       |       |       |       |   |
| **Texas: Sa |      |       |       |       |       |       |       |   |
| n Antonio** |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self Only   | **T  | *     | *     | **    | *     | *     | *     |   |
|             | U1** | *\$72 | *\$24 | \$156 | *\$52 | *\$85 | *\$10 |   |
|             |      | .06** | .02** | .13** | .04** | .27** | .81** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self and    | **T  | **    | *     | **    | **    | **    | *     |   |
| Family      | U2** | \$165 | *\$55 | \$359 | \$119 | \$196 | *\$24 |   |
|             |      | .73** | .24** | .08** | .69** | .11** | .86** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| ###### **   |      |       |       |       |       |       |       |   |
| Wisconsin:  |      |       |       |       |       |       |       |   |
| Milwaukee** |      |       |       |       |       |       |       |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self Only   | **F  | *     | *     | **    | *     | *     | *     |   |
|             | B1** | *\$79 | *\$26 | \$171 | *\$57 | *\$93 | *\$11 |   |
|             |      | .26** | .42** | .73** | .24** | .79** | .89** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+
| Self and    | **F  | **    | *     | **    | **    | **    | *     |   |
| Family      | B2** | \$182 | *\$60 | \$394 | \$131 | \$215 | *\$27 |   |
|             |      | .30** | .76** | .97** | .66** | .72** | .34** |   |
+-------------+------+-------+-------+-------+-------+-------+-------+---+