**Presbyterian Health Plan**

http://www.phs.org ![](media/image1.jpeg){width="1.4861111111111112in"
height="0.3055555555555556in"}

**2004**

**Serving:** *All counties of New Mexico, except for Otero*

*and southern Eddy County*

**Enrollment in this Plan is limited. You must live or work in our**

**Geographic service area to enroll. See page 7 for requirements.**

![](media/image3.jpeg){width="1.1895833333333334in"
height="1.2034722222222223in"}

Enrollment codes for this Plan:

**P21 Self Only**

**P22 Self and Family**

![](media/image4.png)

![](media/image6.png){width="4.84375in" height="1.1354166666666667in"}

Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

> Sincerely,
>
> ![](media/image7.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

# ![](media/image8.png){width="1.195138888888889in" height="1.0354166666666667in"} ![](media/image9.png){width="1.1715277777777777in" height="0.9208333333333333in"}

# 

# Notice of the Office of Personnel Management's

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

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

Plain Language 4

Stop Health Care Fraud! 4

Preventing Medical Mistakes 5

Section 1. Facts about this HMO plan 7

How we pay providers 7

Your Rights 7

Service Area 8

Section 2. How we change for 2004 9

Program-wide changes 9

Changes to this Plan 9

Section 3. How you get care 10

Identification cards 10

Where you get covered care 10

Plan providers 10 Plan facilities 10

What you must do to get covered care 10

Primary care 11

Specialty care 11

Hospital care 12

Circumstances beyond our control 12

Services requiring our prior approval 12

Section 4. Your costs for covered services 14

Copayments 14

Deductible 14

Coinsurance 14

Your catastrophic protection out-of-pocket maximum 14

Section 5. Benefits 15

Overview 15

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

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

(c) Services provided by a hospital or other facility, and ambulance
    services 32

(d) Emergency services/accidents 35

(e) Mental health and substance abuse benefits 38

(f) Prescription drug benefits 40

(g) Special Features
    ........................................................................
    ........................43

-   Flexible Benefit Options

-   Services for the Deaf and Hearing Impaired

-   Pregnancies (including High-Risk pregnancies)

-   Presbyterian Healthcare Services

-   Vision Discounts

-   Acupuncture, Chiropractic and Massage Therapy Discounts

(h) Dental
    benefits...........................................................................
    44

(i) Non-FEHB benefits available to Plan members 45

Section 6. General exclusions \-- things we don\'t cover 46

Section 7. Filing a claim for covered services 47

Section 8. The disputed claims process 49

Section 9. Coordinating benefits with other coverage 51

When you have other health coverage 51

What is Medicare 51

-   Should I enroll in Medicare? 51

Medicare + Choice plan 54

-   TRICARE and CHAMPVA 54

-   Workers\' Compensation 55

-   Medicaid 55

-   Other Government agencies 55

-   When others are responsible for injuries 55

Section 10. Definitions of terms we use in this brochure 56

Section 11. FEHB facts 57

Coverage information 57

No pre-existing condition limitation 57

Where you get information about enrolling in the FEHB Program 57

Types of coverage available for you and your family 57

Children's Equity Act 58

When benefits and premiums start 58

When you retire 58

When you lose benefits 59

When FEHB coverage ends 59

Spouse equity coverage 59

Temporary Continuation of Coverage (TCC) 59

Converting to individual coverage 59

Getting a Certificate of Group Health Plan Coverage 60

Two new Federal Programs complement FEHB benefits 61

The Federal Flexible Spending Account Program -- *FSAFEDS* 61

The Federal Long Term Care Insurance Program 64

Index 65

Summary of benefits 66

Rates Back cover

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  Introduction

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This brochure describes the benefits of Presbyterian Health Plan under
our contract (CS2627) with the Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. The address for
Presbyterian Health Plan administrative office is:

Presbyterian Health Plan

501 Buena Vista SE

Albuquerque, NM 87106

Or

PO Box 27489

Albuquerque, NM 87125-7489

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

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

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and changes are summarized on
page 9. 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
    Presbyterian Health Plan*.*

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

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

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

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  Stop Health Care Fraud!

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

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

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

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

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

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

-   Avoid using healthcare 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 505/923-5678
    or toll-free at 1-800-356-2219 or TDD for the hearing impaired at
    505/923-5699 or toll-free at 1-877-298-7407 and explain the
    situation.

-   If we do not resolve the issue:

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

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

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

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

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

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  Preventing Medical Mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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

    Want more information on patient safety?

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

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

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

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

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

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

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

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

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

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

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

How we pay providers

We contract with individual physicians, medical groups, and hospitals to
provide the benefits in this brochure. These Plan providers accept a
negotiated payment from us, and you will only be responsible for your
copayments or coinsurance. Our Fee schedule is based on the Resource
Base Relative Value Scale (RBRVS). The RBRVS method was designed by
physicians to fairly compensate themselves based on:

(1) a nationally uniform relative value for service;

(2) geographic adjustment factor; and

(3) a nationally uniform conversion factor for service.

This method has been adopted by our Federal Centers for Medicare and
Medicaid Services for Medicare reimbursement.

The RBRVS pays higher for evaluation and management services and lower
for procedures. All physicians receive reimbursement for both evaluation
and management services and procedures. The effect upon the individual
physician will vary depending upon how much time they spend in
office-based services as compared to procedural-based services.
Typically, physicians such as primary care physicians, internists,
pediatricians, rheumatologists, and pulmonologists spend more time in
office-based services, and physicians such as surgeons, and
cardiologists spend more time in procedure-based services. Although this
fee schedule is both provider and health plan based, it results in a
high quality health plan for you and your families.

**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.

-   Presbyterian Health Plan (a for profit organization) is owned by
    Presbyterian Healthcare Services (a non-profit organization), which
    has been providing quality care for New Mexicans since 1908

-   Presbyterian Health Plan has over 15 years' experience in improving
    the health of individuals, families and communities

-   Customer Satisfaction Measures

-   Networks and Providers

If you want more information about us, call 800/356-2219 or write to
Presbyterian Health Plan, PO Box 27489 Albuquerque, NM 87125-7489. For
the hearing impaired call our TDD line at 505/923-5699 or toll-free at
877/298-7407. You may also contact us by fax at 505/923-8163 or visit
our website at [www.phs.org](http://www.phs.org/).

**Service Area**

To enroll in this Plan, You must live in or work in our Service Area.
This is where our providers practice. Our service area is all counties
of New Mexico, except for Otero County and southern Eddy County.

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

If you or a covered family member move outside of our service area, you
can enroll in another plan. If your dependents live out of the area (for
example, if your child goes to college in another state), you should
consider enrolling in a fee-for-service plan or an HMO that has
agreements with affiliates in other areas. If you or a family member
move, you do not have to wait until Open Season to change plans. Contact
your employing or retirement office. Full-Time dependent students
attending school outside Presbyterian Health Plan's service area can
receive care at a Student Health Center without a referral from their
Primary Care Physician. Services provided outside of the Student Health
Center are for medically necessary services for the initial care or
treatment of an Emergency or Urgent Care situation.

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

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program - *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 61.

-   We added information regarding Preventing medical mistakes. See page
    5.

-   We added information regarding enrolling in Medicare. See page 51.

-   We revised the Medicare Primary Payer Chart. See page 53.

**Changes to this Plan**

-   Your share of the non-Postal premium will increase by 16.3% for Self
    Only or 22.8% for Self and Family.

-   The copayment for vision testing, treatment and supplies required
    due to accidental injury or surgery has changed from 20% to 30%.

-   The copayment for orthopedic and prosthetic devices has changed from
    20% to 30%.

-   The copayment for Durable Medical Equipment has changed from 20% to
    30%.

-   The copayment for Prescription Drugs has changed as follows:

> [Retail RX]{.underline}
>
> Generic - from \$5 to \$7
>
> Brand (Formulary) - from \$15 to \$17
>
> Non-Formulary - from \$35 to \$34
>
> Per 30-day supply or 100 units, whichever is less
>
> [Mail Order:]{.underline}
>
> Generic -- from \$10 to \$14
>
> Brand (Formulary) -- from \$30 to \$34
>
> Non-Formulary -- from \$70 to \$68
>
> Per 90-day supply or 300 units, whichever is less

-   The copayment for products such as Recombinant DNA and Purified
    Biological Products has increased from 10% to 15% up to a maximum of
    \$250 per prescription/injection.

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

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

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
1-800-356-2219 or TDD for the hearing impaired at (505) 923-5699 or
toll-free at 1-877-298-7407. You may also request replacement cards
through our website at [WWW.PHS.ORG](http://WWW.PHS.ORG/) or write to us
at PO Box 27489 Albuquerque, NM 87125.

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

**Plan providers** Plan providers are physicians and other health care
professionals in our service area that we contract with to provide
covered services to our members. We credential Plan providers according
to national standards. We obtain, verify, review and evaluate
practitioners' competencies and qualifications on an ongoing basis to
determine whether they can participate as providers in our Plan.
Providers we credential include Medical Doctors, Specialists, Physician
Assistants, Certified Nurse Practitioners, Licensed Social Workers, and
licensed Professional counselors.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. The listings are first
organized by region within New Mexico -- Central New Mexico, Northern
New Mexico, and Southern New Mexico. Each region, physicians, other
providers and facilities are organized by Physician directed Teams,
Primary Care Physicians are listed as Family Practice, General Practice,
Internal Medicine, Pediatrics and OB/GYN's acting as PCPs.

**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. Presbyterian Health
Plan's provider directory has a section that lists all participating
facilities, hospitals and pharmacies across the state.

It depends on the type of care you need. First, you and each family
member must choose a primary care physician. This decision is important
since your primary care physician provides or arranges for most of your
health care. You must select a primary care physician from the PHP
provider directory. Locations and telephone numbers of the participating
doctors are listed in the PHP provider directory or can be obtained by
calling the Member Services Department (505) 923-5678 or 1-800-356-2219
or TDD for the hearing impaired at (505) 923-5699 or toll-free at
1-877-298-7407 or by accessing our website at
[www.phs.org](http://www.phs.org/). By selecting a PCP who belongs to
the plan, members are selecting their corresponding network of
specialists, hospitals and other providers to serve their healthcare
needs. A PCP selection form is in your packet. Select your provider by
the 5-digit provider number and mail it in the return envelope. Should
you chose to change your PCP your requested change will be effective the
next business day following your request.

**Primary care** Your primary care physician can be a Family Practice,
General Practice, Internal Medicine, Pediatrics and OB/GYN (if
applicable) acting as a Primary Care Physician. Your primary care
physician will provide most of your health care, or give you a referral
to see a specialist.

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

**Specialty care** Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your
primary care physician, you must return to the primary care physician
after the consultation, unless your primary care physician authorized a
certain number of visits without additional referrals. The primary care
physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives
you a referral. However, you may see a woman's healthcare provider who
has been credentialed by Presbyterian Health Plan to provide
female-related care without a referral. Treatment for Infertility,
Reproductive Endocrinology, and/or Gynecological Oncology may require
pre-authorization. You do not need a referral from your PCP or
Specialist for an evaluation from behavioral health services; however,
you must call (505) 923-5470 (Albuquerque area or 1-800-453-4347
(Outside Albuquerque) to access services.

Except in a medical emergency, or when a primary care doctor has
designated another doctor to see his or her patients, or for
gynecological or maternity care, you must receive a referral from your
primary care doctor before seeing any other doctor or obtaining
specialty services. Referral to a participating specialist is given at
the primary care doctor's discretion, if non-Plan specialist or
consultants are required, the primary care doctor will make arrangements
for appropriate Preauthorizations. All follow-up care must be provided
or arranged by the primary care doctor.

Here are other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician will
issue a referral that will include the expiration date of the referral
and the number of visits. If the consultant suggests additional services
or visits, you must first check with your primary care doctor to develop
a treatment plan that allows you to see your specialist for a certain
number of visits without additional referrals. Your primary care
physician will use our criteria when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).

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

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

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

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

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

-   reduce our service area and you enroll in another FEHB Plan,

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

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

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

    If you are in the hospital when your enrollment in our Plan begins,
    call our Member Services Department immediately at 1-800-356-2219 or
    505/923-5678 or TDD for the hearing impaired at 505/923-5699 or
    1-877-298-7407. 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:

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-   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.

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

We call this review and approval process pre-authorization. Your
physician must obtain pre-authorization for services such as, but not
limited to: Durable Medical Equipment, Home Health, Hospice, Acute
Rehabilitation, Outpatient Rehab, Non-emergent Ambulance, Skilled
Nursing Facilities, Hospitalization and Mental Health/Substance Abuse
care.

Except in a medical emergency, or when a primary care doctor has
designated another doctor to see his or her patients, or for
gynecological or maternity care, you must receive a referral from your
primary care doctor before seeing any other doctor or obtaining
specialty services. Your physician must get our approval before sending
you to a hospital. Referral to a participating specialist is given at
the primary care doctor's discretion. If required medical services are
not available from participating providers, the Primary Care Physician
must request and obtain written authorization from the Presbyterian
Health Plan Medical Director before the Member may receive services.

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

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

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

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

Example: When you see your primary care physician you pay a copayment of
\$10 per office visit and when you go in the hospital, you pay nothing
per admission.

**Deductible** We do not have a deductible*.*

**Coinsurance** Coinsurance is the percentage of our negotiated fee that
you must pay for your care.

Example: In our Plan, you pay 50% of our allowance for infertility
services and 30% of our allowance for durable medical equipment.

After your copayments and/or coinsurance total [\$2000]{.underline} per
person or [\$4000]{.underline} per family enrollment in any calendar
year, you do not have to pay any more for covered services. However,
copayments and/or coinsurance for the following services do not count
toward your catastrophic protection out-of-pocket maximum, and you must
continue to pay copayments and/or coinsurance for these services:

-   Prescription drugs

-   Dental services

-   Vision Services

-   Non-covered charges

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

+-----------------------------------------------------------------------+
| **Section 5. Benefits \-- OVERVIEW**                                  |
|                                                                       |
| ***(See page 9 for how our benefits changed this year and page 61 for |
| a benefits summary.)***                                               |
+-----------------------------------------------------------------------+

**NOTE**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
(505) 923-5678 or toll-free at 1-800-356-2219 or TDD for the hearing
impaired at (505) 923-5699 or toll-free at 1-877-298-7407 or at our
website at www.phs.org.

(a) Medical services and supplies provided by physicians and other
    health care professionals. 16-27

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 28-31

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

(c) Services provided by a hospital or other facility, and ambulance
    services 32-34

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

\(d\) Emergency services/accidents 35-37

Medical emergency

Ambulance

\(e\) Mental health and substance abuse benefits 38-39

\(f\) Prescription drug benefits 40-42

(g) Special
    Features....................................................................................................................................43

> Flexible Benefit Option
>
> Services for deaf and hearing impaired
>
> High risk pregnancies

-   Presbyterian Healthcare Services

-   Vision Discounts

-   Acupuncture, Chiropractic and Massage Therapy Discounts

(h) Dental
    Benefits.....................................................................\.................................................................44

(i) Non-FEHB benefits available to Plan
    members............................................................\....................................45

Summary of benefits. 66

+---+---+------------------------------------+---+---------------------+---+---+
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| * |   |                                    |   |                     |   |   |
| * |   |                                    |   |                     |   |   |
+---+---+------------------------------------+---+---------------------+---+---+
|   | * | **Here are some important things   |   |                     | * |   |
|   | * | to keep in mind about these        |   |                     | * |   |
|   | I | benefits:**                        |   |                     | I |   |
|   | * |                                    |   |                     | * |   |
|   | * | -   Please remember that all       |   |                     | * |   |
|   |   |     benefits are subject to the    |   |                     |   |   |
|   | * |     definitions, limitations, and  |   |                     | * |   |
|   | * |     exclusions in this brochure    |   |                     | * |   |
|   | M |     and are payable only when we   |   |                     | M |   |
|   | * |     determine they are medically   |   |                     | * |   |
|   | * |     necessary.                     |   |                     | * |   |
|   |   |                                    |   |                     |   |   |
|   | * | -   Plan physicians must provide   |   |                     | * |   |
|   | * |     or arrange your care.          |   |                     | * |   |
|   | P |                                    |   |                     | P |   |
|   | * | -   We have no calendar year       |   |                     | * |   |
|   | * |     deducible.                     |   |                     | * |   |
|   |   |                                    |   |                     |   |   |
|   | * | -   Be sure to read Section 4,     |   |                     | * |   |
|   | * |     *Your costs for covered        |   |                     | * |   |
|   | O |     services,* for valuable        |   |                     | O |   |
|   | * |     information about how cost     |   |                     | * |   |
|   | * |     sharing works. Also read       |   |                     | * |   |
|   |   |     Section 9 about coordinating   |   |                     |   |   |
|   | * |     benefits with other coverage,  |   |                     | * |   |
|   | * |     including with Medicare.       |   |                     | * |   |
|   | R |                                    |   |                     | R |   |
|   | * |                                    |   |                     | * |   |
|   | * |                                    |   |                     | * |   |
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|   | * |                                    |   |                     | * |   |
+---+---+------------------------------------+---+---------------------+---+---+
| > |   |                                    |   | **You pay**         |   |   |
|   |   |                                    |   |                     |   |   |
| * |   |                                    |   |                     |   |   |
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+---+---+------------------------------------+---+---------------------+---+---+
| # |   |                                    |   |                     |   |   |
| # |   |                                    |   |                     |   |   |
| # |   |                                    |   |                     |   |   |
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| * |   |                                    |   |                     |   |   |
+---+---+------------------------------------+---+---------------------+---+---+
| P |   |                                    |   | \$10 per office     |   |   |
| r |   |                                    |   | visit               |   |   |
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| i |   |                                    |   |                     |   |   |
| c |   |                                    |   |                     |   |   |
| i |   |                                    |   |                     |   |   |
| a |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| ' |   |                                    |   |                     |   |   |
| s |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| o |   |                                    |   |                     |   |   |
| f |   |                                    |   |                     |   |   |
| f |   |                                    |   |                     |   |   |
| i |   |                                    |   |                     |   |   |
| c |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
+---+---+------------------------------------+---+---------------------+---+---+
| P |   |                                    |   | \$10 per office     |   |   |
| r |   |                                    |   | visit               |   |   |
| o |   |                                    |   |                     |   |   |
| f |   |                                    |   | \$10 in Service     |   |   |
| e |   |                                    |   | Area                |   |   |
| s |   |                                    |   |                     |   |   |
| s |   |                                    |   | \$20 out of Service |   |   |
| i |   |                                    |   | Area                |   |   |
| o |   |                                    |   |                     |   |   |
| n |   |                                    |   | Nothing             |   |   |
| a |   |                                    |   |                     |   |   |
| l |   |                                    |   | Nothing             |   |   |
| s |   |                                    |   |                     |   |   |
| e |   |                                    |   | \$10 per office     |   |   |
| r |   |                                    |   | visit               |   |   |
| v |   |                                    |   |                     |   |   |
| i |   |                                    |   | \$10 per office     |   |   |
| c |   |                                    |   | visit               |   |   |
| e |   |                                    |   |                     |   |   |
| s |   |                                    |   |                     |   |   |
| o |   |                                    |   |                     |   |   |
| f |   |                                    |   |                     |   |   |
| p |   |                                    |   |                     |   |   |
| h |   |                                    |   |                     |   |   |
| y |   |                                    |   |                     |   |   |
| s |   |                                    |   |                     |   |   |
| i |   |                                    |   |                     |   |   |
| c |   |                                    |   |                     |   |   |
| i |   |                                    |   |                     |   |   |
| a |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| s |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| - |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| I |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| a |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| u |   |                                    |   |                     |   |   |
| r |   |                                    |   |                     |   |   |
| g |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| t |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| c |   |                                    |   |                     |   |   |
| a |   |                                    |   |                     |   |   |
| r |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| c |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| t |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
| r |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| ` |   |                                    |   |                     |   |   |
| ` |   |                                    |   |                     |   |   |
| ` |   |                                    |   |                     |   |   |
| { |   |                                    |   |                     |   |   |
| = |   |                                    |   |                     |   |   |
| h |   |                                    |   |                     |   |   |
| t |   |                                    |   |                     |   |   |
| m |   |                                    |   |                     |   |   |
| l |   |                                    |   |                     |   |   |
| } |   |                                    |   |                     |   |   |
| < |   |                                    |   |                     |   |   |
| ! |   |                                    |   |                     |   |   |
| - |   |                                    |   |                     |   |   |
| - |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| - |   |                                    |   |                     |   |   |
| - |   |                                    |   |                     |   |   |
| > |   |                                    |   |                     |   |   |
| ` |   |                                    |   |                     |   |   |
| ` |   |                                    |   |                     |   |   |
| ` |   |                                    |   |                     |   |   |
| - |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| D |   |                                    |   |                     |   |   |
| u |   |                                    |   |                     |   |   |
| r |   |                                    |   |                     |   |   |
| i |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| 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 |   |                                    |   |                     |   |   |
| * |   |                                    |   |                     |   |   |
| : |   |                                    |   |                     |   |   |
| * |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| A |   |                                    |   |                     |   |   |
| d |   |                                    |   |                     |   |   |
| m |   |                                    |   |                     |   |   |
| i |   |                                    |   |                     |   |   |
| s |   |                                    |   |                     |   |   |
| s |   |                                    |   |                     |   |   |
| i |   |                                    |   |                     |   |   |
| o |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| m |   |                                    |   |                     |   |   |
| u |   |                                    |   |                     |   |   |
| s |   |                                    |   |                     |   |   |
| t |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| b |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| a |   |                                    |   |                     |   |   |
| r |   |                                    |   |                     |   |   |
| r |   |                                    |   |                     |   |   |
| a |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| g |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
| d |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| a |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| d |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| p |   |                                    |   |                     |   |   |
| r |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
| a |   |                                    |   |                     |   |   |
| u |   |                                    |   |                     |   |   |
| t |   |                                    |   |                     |   |   |
| h |   |                                    |   |                     |   |   |
| o |   |                                    |   |                     |   |   |
| r |   |                                    |   |                     |   |   |
| i |   |                                    |   |                     |   |   |
| z |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
| d |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| b |   |                                    |   |                     |   |   |
| y |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| t |   |                                    |   |                     |   |   |
| h |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
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| l |   |                                    |   |                     |   |   |
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|   |   |                                    |   |                     |   |   |
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| S |   |                                    |   |                     |   |   |
| k |   |                                    |   |                     |   |   |
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| 6 |   |                                    |   |                     |   |   |
| 0 |   |                                    |   |                     |   |   |
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|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
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|   |   |                                    |   |                     |   |   |
| m |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
| m |   |                                    |   |                     |   |   |
| b |   |                                    |   |                     |   |   |
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| r |   |                                    |   |                     |   |   |
| , |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
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|   |   |                                    |   |                     |   |   |
| * |   |                                    |   |                     |   |   |
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| d |   |                                    |   |                     |   |   |
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| f |   |                                    |   |                     |   |   |
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| m |   |                                    |   |                     |   |   |
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| c |   |                                    |   |                     |   |   |
| o |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| s |   |                                    |   |                     |   |   |
| u |   |                                    |   |                     |   |   |
| l |   |                                    |   |                     |   |   |
| t |   |                                    |   |                     |   |   |
| a |   |                                    |   |                     |   |   |
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| i |   |                                    |   |                     |   |   |
| o |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| s |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| - |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| S |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
| c |   |                                    |   |                     |   |   |
| o |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| d |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| s |   |                                    |   |                     |   |   |
| u |   |                                    |   |                     |   |   |
| r |   |                                    |   |                     |   |   |
| g |   |                                    |   |                     |   |   |
| i |   |                                    |   |                     |   |   |
| c |   |                                    |   |                     |   |   |
| a |   |                                    |   |                     |   |   |
| l |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| o |   |                                    |   |                     |   |   |
| p |   |                                    |   |                     |   |   |
| i |   |                                    |   |                     |   |   |
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| o |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
+---+---+------------------------------------+---+---------------------+---+---+
| A |   |                                    |   | \$10 per visit      |   |   |
| t |   |                                    |   |                     |   |   |
| h |   |                                    |   |                     |   |   |
| o |   |                                    |   |                     |   |   |
| m |   |                                    |   |                     |   |   |
| e |   |                                    |   |                     |   |   |
+---+---+------------------------------------+---+---------------------+---+---+

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

+------------------------------------------+---------------------------+
| # Lab, X-ra                              | **You pay**               |
| y and other diagnostic tests {#lab-x-ray |                           |
| -and-other-diagnostic-tests .unnumbered} |                           |
+------------------------------------------+---------------------------+
| Tests, such as:                          | > Nothing if you receive  |
|                                          | > these services during   |
| -   Blood tests                          | > your office visit;      |
|                                          | > otherwise, \$10 per     |
| -   Urinalysis                           | > office visit            |
|                                          |                           |
| -   Non-routine pap tests                |                           |
|                                          |                           |
| -   Pathology                            |                           |
|                                          |                           |
| -   X-rays                               |                           |
|                                          |                           |
| -   Non-routine mammograms               |                           |
|                                          |                           |
| -   CAT Scans/MRI                        |                           |
|                                          |                           |
| -   Ultrasound                           |                           |
|                                          |                           |
| -   Electrocardiogram and EEG            |                           |
+------------------------------------------+---------------------------+
| ##### Preventive care, adult             |                           |
+------------------------------------------+---------------------------+
| > Routine screenings, such as:           | \$10 per office visit     |
|                                          |                           |
| -   Preventive physical exam             |                           |
|                                          |                           |
| -   Office based health education        |                           |
|                                          |                           |
| -   Glaucoma Testing                     |                           |
|                                          |                           |
| -   Family Planning                      |                           |
|                                          |                           |
| -   Blood lead level -- One annually     |                           |
|                                          |                           |
| -   Total Blood Cholesterol -- once      |                           |
|     every three years                    |                           |
|                                          |                           |
| -   Osteoporosis Screening               |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Colorectal Cancer Screening,         |                           |
|     including                            |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Fecal occult blood test              |                           |
|                                          |                           |
| -   Sigmoidoscopy, screening -- every    |                           |
|     five years starting at age 50        |                           |
|                                          |                           |
| -   Colonoscopy                          |                           |
|                                          |                           |
| -   Double contrast barium enemas (DCBE) |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Chlamydial infection                 |                           |
|                                          |                           |
| -   Routine Prostate Specific Antigen    |                           |
|     (PSA) test\--one annually for men    |                           |
|     age 40 and older                     |                           |
+------------------------------------------+---------------------------+
| -   Routine pap test                     | \$10 per office visit     |
|                                          |                           |
|     Note: The office visit is covered if |                           |
|     pap test is received on the same     |                           |
|     day; see *Diagnosis and Treatment*,  |                           |
|     above.                               |                           |
+------------------------------------------+---------------------------+

*Preventive Care - Adult \-- continued on next page*

+------------------------------------------+---------------------------+
| ##### Pre                                | **You pay**               |
| ventive care, adult *(continued)* {#prev |                           |
| entive-care-adult-continued .unnumbered} |                           |
+------------------------------------------+---------------------------+
| Routine mammogram --covered for women    | > \$10 per office visit   |
| age 35 and older, as follows:            | >                         |
|                                          | > **You pay nothing for   |
| -   From age 35 through 39, one during   | > mammograms.**           |
|     this five year period                | >                         |
|                                          | > **Additional mammograms |
| -   From age 40 through 64, one every    | > are**                   |
|     calendar year                        | >                         |
|                                          | > **covered when a        |
| ```{=html}                               | > participating**         |
| <!-- -->                                 | >                         |
| ```                                      | > **provider determines   |
| -   At age 65 and older, one every two   | > that they are**         |
|     consecutive calendar years           | >                         |
|                                          | > **medically             |
|                                          | > necessary.**            |
+------------------------------------------+---------------------------+
| > *Not covered: Physical exams required  | > *All charges.*          |
| > for obtaining or continuing employment |                           |
| > or insurance, attending schools or     |                           |
| > camp, or travel.*                      |                           |
+------------------------------------------+---------------------------+
| > Routine immunizations, limited to:     | > \$10 per office visit   |
|                                          |                           |
| -   Tetanus-diphtheria (Td) booster --   |                           |
|     once every 10 years, ages 19 and     |                           |
|     over (except as provided for under   |                           |
|     Childhood immunizations)             |                           |
|                                          |                           |
| -   Influenza vaccines, annually         |                           |
|                                          |                           |
| -   Pneumococcal vaccine, age 65 and     |                           |
|     over                                 |                           |
+------------------------------------------+---------------------------+
| ##### Preventive care, children          |                           |
+------------------------------------------+---------------------------+
| -   Childhood immunizations recommended  | > \$10 per office visit   |
|     by the American Academy of           |                           |
|     Pediatrics                           |                           |
+------------------------------------------+---------------------------+
| -   Well-child care charges for routine  | \$10 per office visit     |
|     examinations, immunizations and care |                           |
|     (through age 22)                     |                           |
|                                          |                           |
| -   Examinations, such as:               |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Eye exams through age 17 to          |                           |
|     determine the need for vision        |                           |
|     correction.                          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Ear exams through age 17 to          |                           |
|     determine the need for hearing       |                           |
|     correction                           |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Examinations done on the day of      |                           |
|     immunizations (under age 22)         |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ######## Mate                            | **You pay**               |
| rnity care {#maternity-care .unnumbered} |                           |
+------------------------------------------+---------------------------+
| Complete maternity (obstetrical) care,   | > \$10 per office visit   |
| such as:                                 | > up to a maximum of      |
|                                          | > \$100 per pregnancy     |
| -   Prenatal care                        |                           |
|                                          |                           |
| -   Delivery                             |                           |
|                                          |                           |
| -   Postnatal care                       |                           |
|                                          |                           |
| > Note: Here are some things to keep in  |                           |
| > mind:                                  |                           |
|                                          |                           |
| -   You do not need to precertify your   |                           |
|     normal delivery; see page 32 for     |                           |
|     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)*.*             |                           |
|                                          |                           |
| -   Circumcisions -- when performed      |                           |
|     during the newborn's Hospital stay.  |                           |
+------------------------------------------+---------------------------+
| > *Not covered: Routine sonograms to     | > *All charges.*          |
| > determine fetal age, size or sex*      |                           |
| >                                        |                           |
| > *Circumcisions performed other than    |                           |
| > during the newborn Hospital stay are   |                           |
| > only Covered when Medically            |                           |
| > Necessary.*                            |                           |
+------------------------------------------+---------------------------+
| ######## Family planning                 |                           |
+------------------------------------------+---------------------------+
| A broad range of voluntary family        | \$10 per office visit --  |
| planning services, limited to:           | outpatient                |
|                                          |                           |
| -   Voluntary sterilization              | Nothing- Inpatient        |
|                                          |                           |
| -   Surgically implanted contraceptives  | 50% of all                |
|     (such as Norplant)                   | charges-insertion         |
|                                          |                           |
| -   Injectable contraceptive drugs (such | \$10 per visit-removal    |
|     as Depo provera)                     |                           |
|                                          | 50% of all charges        |
| -   Intrauterine devices (IUDs)          |                           |
|                                          | 50% of all charges        |
| -   Diaphragms                           |                           |
|                                          | \$10 per visit            |
| -   Norplant (a surgically implanted     |                           |
|     contraceptive) and intrauterine      | 50% of all charges        |
|     devices (IUDs). **Note:** Devices    |                           |
|     are covered under 5 (a).             |                           |
|                                          |                           |
|     NOTE: We cover oral contraceptives   |                           |
|     under the prescription drug benefit. |                           |
+------------------------------------------+---------------------------+
| *Not covered: reversal of voluntary      | *All charges.*            |
| surgical sterilization, genetic          |                           |
| counseling,*                             |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ######## Infertility serv                | **You pay**               |
| ices {#infertility-services .unnumbered} |                           |
+------------------------------------------+---------------------------+
| Diagnosis and treatment of infertility,  | 50% of all charges        |
| such as:                                 |                           |
|                                          | 50% of all charges        |
| -   Artificial insemination:             |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *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       |                           |
|     medical benefits. Artificial         |                           |
|     insemination is covered up to 3      |                           |
|     inseminations.                       |                           |
+------------------------------------------+---------------------------+
| *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                    | \$10 per office visit     |
|                                          |                           |
| Allergy injection                        |                           |
+------------------------------------------+---------------------------+
| Allergy serum                            | Nothing                   |
+------------------------------------------+---------------------------+
| *Not covered: provocative food testing   | *All charges.*            |
| and sublingual allergy desensitization*  |                           |
+------------------------------------------+---------------------------+
| ######## Treatment ther                  | **You pay**               |
| apies {#treatment-therapies .unnumbered} |                           |
+------------------------------------------+---------------------------+
| -   Chemotherapy and radiation therapy   | > \$10 per office visit   |
|                                          |                           |
|     **Note:** High dose chemotherapy in  | 15% up to a maximum of    |
|     association with autologous bone     | \$250 per prescription.   |
|     marrow transplants are limited to    |                           |
|     those transplants listed under       |                           |
|     Organ/Tissue Transplants on page 31. |                           |
|                                          |                           |
| -   Respiratory and inhalation therapy   |                           |
|                                          |                           |
| -   Dialysis -- hemodialysis and         |                           |
|     peritoneal dialysis                  |                           |
|                                          |                           |
| -   Intravenous (IV)/Infusion Therapy -- |                           |
|     Home IV and antibiotic therapy       |                           |
|                                          |                           |
| -   Growth hormone therapy (GHT)         |                           |
|                                          |                           |
| -   Recombinant DNA and Purified         |                           |
|     biological products (see also Home   |                           |
|     health services)                     |                           |
|                                          |                           |
| > Note: -- We will only cover GHT when   |                           |
| > we preauthorize the treatment. Growth  |                           |
| > Hormone is covered for children with   |                           |
| > growth potential who have total or     |                           |
| > partial growth hormone deficiency      |                           |
| > (idiopathic or organic). The diagnosis |                           |
| > of growth hormone deficiency must be   |                           |
| > confirmed by at least two stimulation  |                           |
| > tests. Growth hormone injections are   |                           |
| > specifically excluded in Member's with |                           |
| > Turner's syndrome or Down's syndrome,  |                           |
| > unless growth hormone deficiency can   |                           |
| > be documented, and when preauthorized  |                           |
| > by us. For adults, growth hormone is   |                           |
| > covered only for non-functioning or    |                           |
| > surgically removed pituitary glands    |                           |
| > with demonstrated low levels of growth |                           |
| > hormone. Growth hormone injections are |                           |
| > excluded for chronic renal failure or  |                           |
| > other chronic disease regardless of    |                           |
| > stimulated growth hormone levels.      |                           |
| >                                        |                           |
| > We will ask that your physician to     |                           |
| > submit information that establishes    |                           |
| > that the GHT is medically necessary.   |                           |
| > Ask us to authorize GHT before you     |                           |
| > begin treatment; otherwise, we will    |                           |
| > only cover GHT services from the date  |                           |
| > you submit the information. If you do  |                           |
| > not ask or if we determine GHT is not  |                           |
| > medically necessary, we will not cover |                           |
| > the GHT or related services and        |                           |
| > supplies. See *Services requiring our  |                           |
| > prior approval* in Section 3.          |                           |
| > Continuation of therapy using any drug |                           |
| > is dependent upon its demonstrable     |                           |
| > efficacy.                              |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| > **Physical and occupational            | > **You pay**             |
| > therapies**                            |                           |
+------------------------------------------+---------------------------+
| -   Provided in-patient or out-patient   | > \$15 per visit          |
|     up to 2 months per condition if      |                           |
|     significant improvement is expected  |                           |
|     for the services of each of the      |                           |
|     following:                           |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   qualified physical therapists; and   |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   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. In-patient or  |                           |
| out-patient therapy may be extended 2    |                           |
| additional months if significant         |                           |
| improvement is expected to continue and  |                           |
| must be preauthorized by PHP             |                           |
|                                          |                           |
| Significant improvement means:           |                           |
|                                          |                           |
| -   The patient is likely to meet all    |                           |
|     therapy goals for the first two      |                           |
|     months of therapy; or                |                           |
|                                          |                           |
| -   The patient has met all therapy      |                           |
|     goals in the preceding two months of |                           |
|     therapy, as specifically documented  |                           |
|     in the therapy record.               |                           |
|                                          |                           |
| This benefit is *not* renewable each     |                           |
| calendar year.                           |                           |
|                                          |                           |
| -   Cardiac rehabilitation following a   |                           |
|     heart transplant, bypass surgery or  |                           |
|     a myocardial infarction is provided  |                           |
|     for up to 12 sessions with           |                           |
|     continuous electrocardiogram (ECG)   |                           |
|     monitoring or up to 24 sessions with |                           |
|     intermittent ECG monitoring at an    |                           |
|     approved facility.                   |                           |
+------------------------------------------+---------------------------+
| *Not covered*:                           | > *All charges.*          |
|                                          |                           |
| -   *Long-term rehabilitative therapy    |                           |
|     includes treatment of chronic or     |                           |
|     incurable conditions for which       |                           |
|     rehabilitation produces minimal or   |                           |
|     temporary change or relief.          |                           |
|     Treatment of chronic conditions is   |                           |
|     no covered. Chronic conditions       |                           |
|     include, but are not limited to      |                           |
|     Muscular Dystrophy, Down's Syndrome  |                           |
|     and Cerebral Palsy.*                 |                           |
|                                          |                           |
|     *(Any therapy beyond 6 consecutive   |                           |
|     months is defined as long term       |                           |
|     therapy.)*                           |                           |
|                                          |                           |
| -   *Exercise programs*                  |                           |
+------------------------------------------+---------------------------+
| ######## Speech therapy                  | ########                  |
+------------------------------------------+---------------------------+
| Speech Therapy is covered for up to 2    | > \$15 per visit          |
| months when provided by a licensed or    |                           |
| certified speech therapist subject to    |                           |
| the following:                           |                           |
|                                          |                           |
| -   Speech Therapy is medically          |                           |
|     necessary                            |                           |
|                                          |                           |
| -   Speech Therapy *must be*             |                           |
|     preauthorized by us.                 |                           |
|                                          |                           |
| Following the initial 2 months of        |                           |
| treatment, in-patient or outpatient      |                           |
| Speech Therapy may be extended for a     |                           |
| period not to exceed 2 additional        |                           |
| 2-month periods.                         |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*.          |
|                                          |                           |
| -   *Speech Therapy beyond 6 consecutive |                           |
|     months.*                             |                           |
+------------------------------------------+---------------------------+
| > **Hearing services (testing,           | **You pay**               |
| > treatment, and supplies)**             |                           |
+------------------------------------------+---------------------------+
| -   First hearing aid and testing only   | \$10 per office visit     |
|     when necessitated by accidental      |                           |
|     injury                               |                           |
|                                          |                           |
| -   Hearing testing for children through |                           |
|     age 17 (see *Preventive care,        |                           |
|     children*)                           |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges.*          |
|                                          |                           |
| -   *all other hearing testing*          |                           |
|                                          |                           |
| -   *hearing aids, testing and           |                           |
|     examinations for them*               |                           |
+------------------------------------------+---------------------------+
| > **Vision services (testing, treatment, |                           |
| > and supplies)**                        |                           |
+------------------------------------------+---------------------------+
| -   One pair of eyeglasses or contact    | > 30% of all charges      |
|     lenses to correct an impairment      |                           |
|     directly caused by accidental ocular |                           |
|     injury or intraocular surgery (such  |                           |
|     as for cataracts)                    |                           |
+------------------------------------------+---------------------------+
| -   Eye exam to determine the need for   | > \$10 per office visit   |
|     vision correction for children       |                           |
|     through age 17 (see Preventive care, |                           |
|     children)                            |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | *All charges.*            |
|                                          |                           |
| -   *Eyeglasses or contact lenses and,   |                           |
|     after age 17, examinations for them* |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Eye exercises and orthopedics*      |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Replacement of all items referenced |                           |
|     in this section due to wear, loss,   |                           |
|     or damage*                           |                           |
+------------------------------------------+---------------------------+
| ####                                     |                           |
| #### Foot care  {#foot-care .unnumbered} |                           |
+------------------------------------------+---------------------------+
| Routine foot care when you are under     | \$10 per office visit     |
| active treatment for a metabolic or      |                           |
| peripheral vascular disease, such as     |                           |
| diabetes.                                |                           |
|                                          |                           |
| See orthopedic and prosthetic devices    |                           |
| for information on podiatric shoe        |                           |
| inserts.                                 |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges.*          |
|                                          |                           |
| -   *Cutting, trimming or removal of     |                           |
|     corns, calluses, or the free edge of |                           |
|     toenails, and similar routine        |                           |
|     treatment of conditions of the foot, |                           |
|     except as stated above*              |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *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                                 |   |                          |
|                                          | 3 |                          |
| -   Externally worn breast prostheses    | 0 |                          |
|     and surgical bras, including         | % |                          |
|     necessary replacements, following a  | > |                          |
|     mastectomy                           |   |                          |
|                                          | o |                          |
| -   Internal prosthetic devices, such as | f |                          |
|     artificial joints, pacemakers,       | > |                          |
|     cochlear implants, and surgically    |   |                          |
|     implanted breast implant following   | a |                          |
|     mastectomy. *Note:* We pay internal  | l |                          |
|     prosthetic devices as hospital       | l |                          |
|     benefits; see Section 5 (c) for      | > |                          |
|     payment information. See 5(b) for    |   |                          |
|     coverage of the surgery to insert    | c |                          |
|     the device.                          | h |                          |
|                                          | a |                          |
| -   Corrective orthopedic appliances for | r |                          |
|     non-dental treatment of              | g |                          |
|     tempormanibular joint (TMJ) pain     | e |                          |
|     dysfunction syndrome.                | s |                          |
|                                          |   |                          |
| > Prosthetics devices are covered only   |   |                          |
| > when they replace a limb or other part |   |                          |
| > of the body after accidental or        |   |                          |
| > surgical removal and/or when the       |   |                          |
| > body's growth necessitates             |   |                          |
| > replacement.                           |   |                          |
| >                                        |   |                          |
| > For diabetics, covered services        |   |                          |
| > include foot appliances, including     |   |                          |
| > therapeutic molded or depth-inlay      |   |                          |
| > shoes, functional orthotics, custom    |   |                          |
| > molded inserts, replacement inserts,   |   |                          |
| > preventive devices and shoe            |   |                          |
| > modifications for prevention and       |   |                          |
| > treatment.                             |   |                          |
| >                                        |   |                          |
| > Penile Prostheses are limited to the   |   |                          |
| > reasonable charge for semi-rigid or    |   |                          |
| > flexible rod prostheses. Benefits for  |   |                          |
| > inflatable penile prostheses may be    |   |                          |
| > provided when medically necessary.     |   |                          |
| >                                        |   |                          |
| > Prosthetic Devices will be provided    |   |                          |
| > when determined to be medically        |   |                          |
| > necessary by the plan physician.       |   |                          |
| > Prosthetic devices must be             |   |                          |
| >                                        |   |                          |
| > preauthorized by us.                   |   |                          |
+------------------------------------------+---+--------------------------+
| > *Not covered:*                         |   | > *All charges.*         |
|                                          |   |                          |
| -   *orthopedic and corrective shoes*    |   |                          |
|                                          |   |                          |
| -   *arch supports*                      |   |                          |
|                                          |   |                          |
| -   *foot orthotics*                     |   |                          |
|                                          |   |                          |
| -   *heel pads and heel cups*            |   |                          |
|                                          |   |                          |
| -   *corsets, trusses, elastic           |   |                          |
|     stockings, support hose, and other   |   |                          |
|     supportive devices, except for       |   |                          |
|     gradient compression hose.*          |   |                          |
|                                          |   |                          |
| -   *prosthetic replacements provided    |   |                          |
|     less than 3 years after the last one |   |                          |
|     we covered*                          |   |                          |
|                                          |   |                          |
| -   *speech synthesis devices*           |   |                          |
+------------------------------------------+---+--------------------------+
| ######## Durable medical equipment (DME) |   | **You pay**              |
+------------------------------------------+---+--------------------------+
| > Rental or purchase, at our option,     |   | > 30% of all charges     |
| > including repair and adjustment, of    |   |                          |
| > durable medical equipment prescribed   |   |                          |
| > by your Plan physician, such as oxygen |   |                          |
| > and dialysis equipment.                |   |                          |
| > Pre-authorization may be required.     |   |                          |
| > Under this benefit, we also cover:     |   |                          |
|                                          |   |                          |
| -   hospital beds;                       |   |                          |
|                                          |   |                          |
| -   wheelchairs;                         |   |                          |
|                                          |   |                          |
| -   crutches;                            |   |                          |
|                                          |   |                          |
| -   walkers;                             |   |                          |
|                                          |   |                          |
| -   blood glucose monitors; and          |   |                          |
|                                          |   |                          |
| -   insulin pumps.                       |   |                          |
+------------------------------------------+---+--------------------------+
| > *Not covered:*                         |   | > *All charges.*         |
|                                          |   |                          |
| -   *deluxe equipment such as motor      |   |                          |
|     driven wheelchairs, chair lifts, or  |   |                          |
|     beds, when standard equipment is     |   |                          |
|     available and adequate.*             |   |                          |
|                                          |   |                          |
| -   *Replacement of Durable Medical      |   |                          |
|     Equipment, Orthotic Appliances and   |   |                          |
|     Prosthetic Devices due to normal     |   |                          |
|     wear, loss or damage.*               |   |                          |
+------------------------------------------+---+--------------------------+
| ######## Home health services            |   |                          |
+------------------------------------------+---+--------------------------+
| -   Home health care ordered by a Plan   |   | Nothing                  |
|     physician provided by a registered   |   |                          |
|     nurse (R.N.), licensed practical     |   | 15% up to a maximum of   |
|     nurse (L.P.N.), licensed vocational  |   | \$250 per prescription.  |
|     nurse (L.V.N.), or home health aide  |   |                          |
|     and Pre-authorized by us.            |   |                          |
|                                          |   |                          |
| -   Services include oxygen therapy,     |   |                          |
|     intravenous therapy and medications. |   |                          |
|                                          |   |                          |
| -   Recombinant DNA and Purified         |   |                          |
|     Biological Products (see also        |   |                          |
|     Treatment therapies)                 |   |                          |
+------------------------------------------+---+--------------------------+
| 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 -- 18 visits per |   | > \$15 per office visit  |
| > year if medically necessary. A         |   |                          |
| > Referral from your Primary Care        |   |                          |
| > Physician is required.                 |   |                          |
|                                          |   |                          |
| -   Your plan physician must determine   |   |                          |
|     that your treatment will result in   |   |                          |
|     significant improvement in your      |   |                          |
|     condition within 2 months.           |   |                          |
|                                          |   |                          |
| ```{=html}                               |   |                          |
| <!-- -->                                 |   |                          |
| ```                                      |   |                          |
| -   Chiropractic treatment is            |   |                          |
|     specifically limited to treatment by |   |                          |
|     means of manual manipulation, by the |   |                          |
|     use of hands, and ultrasound         |   |                          |
|     therapy.                             |   |                          |
|                                          |   |                          |
| -   Subluxation must be documented by    |   |                          |
|     chiropractic examination and         |   |                          |
|     documented in the chiropractic       |   |                          |
|     records.                             |   |                          |
|                                          |   |                          |
| -   Chiropractic x-rays are only covered |   |                          |
|     when performed by a chiropractor for |   |                          |
|     the following clinical situations,   |   |                          |
|     unless clinically relevant x-rays    |   |                          |
|     already exist:                       |   |                          |
|                                          |   |                          |
| ```{=html}                               |   |                          |
| <!-- -->                                 |   |                          |
| ```                                      |   |                          |
| -   Acute trauma with a suspected        |   |                          |
|     fracture, such as motor vehicle      |   |                          |
|     accidents or slip and fall accidents |   |                          |
|                                          |   |                          |
| -   Clinical evidence of significant     |   |                          |
|     osteoporosis: recent fracture of the |   |                          |
|     spine, wrist or hip; loss of height  |   |                          |
|     over ½ inch, or spine curvature      |   |                          |
|     consistent with osteoporotic         |   |                          |
|     fractures; or                        |   |                          |
|                                          |   |                          |
| -   Abnormal neurologic or orthopedic    |   |                          |
|     findings suggesting spinal nerve     |   |                          |
|     impingement.                         |   |                          |
+------------------------------------------+---+--------------------------+
| > *Not covered:*                         |   | > *All charges.*         |
| >                                        |   |                          |
| > *Chiropractic treatment for chronic    |   |                          |
| > subluxation of rheumatoid arthritis,   |   |                          |
| > allergy, muscular dystrophy, multiple  |   |                          |
| > sclerosis, pneumonia, chronic lung     |   |                          |
| > disease, and other                     |   |                          |
| > diseases/conditions.*                  |   |                          |
| >                                        |   |                          |
| > *Diagnostic or therapeutic service     |   |                          |
| > furnished by a chiropractor including  |   |                          |
| > magnetherm, or any other mechanical    |   |                          |
| > form of treatment*                     |   |                          |
| >                                        |   |                          |
| > *Rolfing*                              |   |                          |
| >                                        |   |                          |
| > *Massage therapy*                      |   |                          |
| >                                        |   |                          |
| > *Naturopathic services*                |   |                          |
| >                                        |   |                          |
| > *Hynotherapy*                          |   |                          |
+------------------------------------------+---+--------------------------+
| ######## Alternative treatments          |   |                          |
+------------------------------------------+---+--------------------------+
| > Acupuncture-- 20 visits per year if    |   | > \$15 per office visit  |
| > determined medically necessary by a    |   |                          |
| > doctor of medicine or osteopathy, for  |   |                          |
| > anesthesia or chronic or acute pain    |   |                          |
| > relief. A Referral is required from    |   |                          |
| > your plan physician.                   |   |                          |
| >                                        |   |                          |
| > Acupuncture treatment for other        |   |                          |
| > medical conditions will be covered     |   |                          |
| > only if the following conditions are   |   |                          |
| > met:                                   |   |                          |
| >                                        |   |                          |
| > There is evidence-based medical        |   |                          |
| > literature that clearly supports the   |   |                          |
| > safety, efficacy and appropriateness   |   |                          |
| > of this treatment for the specific     |   |                          |
| > medical condition for which            |   |                          |
| > authorization is requested.            |   |                          |
| >                                        |   |                          |
| > Acupuncture must be part of a          |   |                          |
| > coordinated plan of care.              |   |                          |
|                                          |   |                          |
| ##  Biofeedback -- is only covered for   |   |                          |
| treatment of Raynaud's disease or phenom |   |                          |
| enon and urinary or fecal incontinence.  |   |                          |
+------------------------------------------+---+--------------------------+
| ## Not covered:                          |   | > *All charges.*         |
|                                          |   |                          |
| ## naturopathic services                 |   |                          |
|                                          |   |                          |
| ## hypnotherapy                          |   |                          |
+------------------------------------------+---+--------------------------+
| #                                        |   |                          |
| ### **Educational classes and programs** |   |                          |
+------------------------------------------+---+--------------------------+
| > No Benefit.                            |   | > *All charges.*         |
+------------------------------------------+---+--------------------------+

+---+---+-----------------------------------+---+---+-------------------+---+---+
| * |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
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|   |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
| a |   |                                   |   |   |                   |   |   |
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| d |   |                                   |   |   |                   |   |   |
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| t |   |                                   |   |   |                   |   |   |
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| p |   |                                   |   |   |                   |   |   |
| r |   |                                   |   |   |                   |   |   |
| o |   |                                   |   |   |                   |   |   |
| f |   |                                   |   |   |                   |   |   |
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| s |   |                                   |   |   |                   |   |   |
| s |   |                                   |   |   |                   |   |   |
| i |   |                                   |   |   |                   |   |   |
| o |   |                                   |   |   |                   |   |   |
| n |   |                                   |   |   |                   |   |   |
| a |   |                                   |   |   |                   |   |   |
| l |   |                                   |   |   |                   |   |   |
| s |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
+---+---+-----------------------------------+---+---+-------------------+---+---+
|   | * | > **Here are some important       |   |   |                   | * |   |
|   | * | > things to keep in mind about    |   |   |                   | * |   |
|   | I | > these benefits:**               |   |   |                   | I |   |
|   | * |                                   |   |   |                   | * |   |
|   | * | -   Please remember that all      |   |   |                   | * |   |
|   |   |     benefits are subject to the   |   |   |                   |   |   |
|   | * |     definitions, limitations, and |   |   |                   | * |   |
|   | * |     exclusions in this brochure   |   |   |                   | * |   |
|   | M |     and are payable only when we  |   |   |                   | M |   |
|   | * |     determine they are medically  |   |   |                   | * |   |
|   | * |     necessary.                    |   |   |                   | * |   |
|   |   |                                   |   |   |                   |   |   |
|   | * | -   Plan physicians must provide  |   |   |                   | * |   |
|   | * |     or arrange your care.         |   |   |                   | * |   |
|   | P |                                   |   |   |                   | P |   |
|   | * | -   We have no calendar year      |   |   |                   | * |   |
|   | * |     deductible.                   |   |   |                   | * |   |
|   |   |                                   |   |   |                   |   |   |
|   | * | -   Be sure to read Section 4,    |   |   |                   | * |   |
|   | * |     *Your costs for covered       |   |   |                   | * |   |
|   | O |     services,* for valuable       |   |   |                   | O |   |
|   | * |     information about how cost    |   |   |                   | * |   |
|   | * |     sharing works. Also read      |   |   |                   | * |   |
|   |   |     Section 9 about coordinating  |   |   |                   |   |   |
|   | * |     benefits with other coverage, |   |   |                   | * |   |
|   | * |     including with Medicare.      |   |   |                   | * |   |
|   | R |                                   |   |   |                   | R |   |
|   | * | -   The amounts listed below are  |   |   |                   | * |   |
|   | * |     for the charges billed by a   |   |   |                   | * |   |
|   |   |     physician or other health     |   |   |                   |   |   |
|   | * |     care professional for your    |   |   |                   | * |   |
|   | * |     surgical care. Look in        |   |   |                   | * |   |
|   | T |     Section 5(c) for charges      |   |   |                   | T |   |
|   | * |     associated with the facility  |   |   |                   | * |   |
|   | * |     (i.e. hospital, surgical      |   |   |                   | * |   |
|   |   |     center, etc.).                |   |   |                   |   |   |
|   | * |                                   |   |   |                   | * |   |
|   | * | -   YOUR PHYSICIAN MUST GET       |   |   |                   | * |   |
|   | A |     PRECERTIFICATION OF SOME      |   |   |                   | A |   |
|   | * |     SURGICAL PROCEDURES. Please   |   |   |                   | * |   |
|   | * |     refer to the precertification |   |   |                   | * |   |
|   |   |     information shown in Section  |   |   |                   |   |   |
|   | * |     3 to be sure which services   |   |   |                   | * |   |
|   | * |     require precertification and  |   |   |                   | * |   |
|   | N |     identify which surgeries      |   |   |                   | N |   |
|   | * |     require precertification.     |   |   |                   | * |   |
|   | * |                                   |   |   |                   | * |   |
|   |   |                                   |   |   |                   |   |   |
|   | * |                                   |   |   |                   | * |   |
|   | * |                                   |   |   |                   | * |   |
|   | T |                                   |   |   |                   | T |   |
|   | * |                                   |   |   |                   | * |   |
|   | * |                                   |   |   |                   | * |   |
+---+---+-----------------------------------+---+---+-------------------+---+---+
| > |   |                                   |   |   | **You pay**       |   |   |
|   |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
| B |   |                                   |   |   |                   |   |   |
| e |   |                                   |   |   |                   |   |   |
| n |   |                                   |   |   |                   |   |   |
| e |   |                                   |   |   |                   |   |   |
| f |   |                                   |   |   |                   |   |   |
| i |   |                                   |   |   |                   |   |   |
| t |   |                                   |   |   |                   |   |   |
| > |   |                                   |   |   |                   |   |   |
|   |   |                                   |   |   |                   |   |   |
| D |   |                                   |   |   |                   |   |   |
| e |   |                                   |   |   |                   |   |   |
| s |   |                                   |   |   |                   |   |   |
| c |   |                                   |   |   |                   |   |   |
| r |   |                                   |   |   |                   |   |   |
| i |   |                                   |   |   |                   |   |   |
| p |   |                                   |   |   |                   |   |   |
| t |   |                                   |   |   |                   |   |   |
| i |   |                                   |   |   |                   |   |   |
| o |   |                                   |   |   |                   |   |   |
| n |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
+---+---+-----------------------------------+---+---+-------------------+---+---+
| > |   |                                   |   |   |                   |   |   |
|   |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
| S |   |                                   |   |   |                   |   |   |
| u |   |                                   |   |   |                   |   |   |
| r |   |                                   |   |   |                   |   |   |
| g |   |                                   |   |   |                   |   |   |
| i |   |                                   |   |   |                   |   |   |
| c |   |                                   |   |   |                   |   |   |
| a |   |                                   |   |   |                   |   |   |
| l |   |                                   |   |   |                   |   |   |
| > |   |                                   |   |   |                   |   |   |
|   |   |                                   |   |   |                   |   |   |
| p |   |                                   |   |   |                   |   |   |
| r |   |                                   |   |   |                   |   |   |
| o |   |                                   |   |   |                   |   |   |
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| d |   |                                   |   |   |                   |   |   |
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| * |   |                                   |   |   |                   |   |   |
| * |   |                                   |   |   |                   |   |   |
+---+---+-----------------------------------+---+---+-------------------+---+---+
| A |   |                                   |   |   | > \$10 per office |   |   |
| c |   |                                   |   |   | > visit --        |   |   |
| o |   |                                   |   |   | > Outpatient      |   |   |
| m |   |                                   |   |   | >                 |   |   |
| p |   |                                   |   |   | > Nothing--       |   |   |
| r |   |                                   |   |   | > Inpatient       |   |   |
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+---+---+-----------------------------------+---+---+-------------------+---+---+
| - |   |                                   |   |   |                   |   |   |
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| - |   |                                   |   |   |                   |   |   |
| > |   |                                   |   |   |                   |   |   |
| ` |   |                                   |   |   |                   |   |   |
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|   |   |                                   |   |   |                   |   |   |
|   |   |                                   |   |   |                   |   |   |
| a |   |                                   |   |   |                   |   |   |
| l |   |                                   |   |   |                   |   |   |
| v |   |                                   |   |   |                   |   |   |
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| l |   |                                   |   |   |                   |   |   |
| a |   |                                   |   |   |                   |   |   |
| r |   |                                   |   |   |                   |   |   |
|   |   |                                   |   |   |                   |   |   |
|   |   |                                   |   |   |                   |   |   |
|   |   |                                   |   |   |                   |   |   |
|   |   |                                   |   |   |                   |   |   |
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| * |   |                                   |   |   |                   |   |   |
+---+---+-----------------------------------+---+---+-------------------+---+---+

+------------------------------------------+---------------------------+
| **Organ/tissue transplants**             | **You pay**               |
+------------------------------------------+---------------------------+
| Limited to:                              | > \$10 per visit --       |
|                                          | > Outpatient              |
| -   Cornea                               | >                         |
|                                          | > Nothing -- Inpatient    |
| -   Heart                                |                           |
|                                          |                           |
| -   Heart/lung                           |                           |
|                                          |                           |
| -   Lung                                 |                           |
|                                          |                           |
| -   Kidney                               |                           |
|                                          |                           |
| -   Kidney/Pancreas                      |                           |
|                                          |                           |
| -   Liver                                |                           |
|                                          |                           |
| -   Lung: Single --Double                |                           |
|                                          |                           |
| -   Pancreas                             |                           |
|                                          |                           |
| -   Pancreas islet cell infusion         |                           |
|                                          |                           |
| -   Allogeneic (donor) bone marrow       |                           |
|     transplants                          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   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                          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Intestinal transplants (small        |                           |
|     intestine) and the small intestine   |                           |
|     with the liver or small intestine    |                           |
|     with multiple organs such as the     |                           |
|     liver, stomach, and pancreas         |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   National Transplant Program (NTP) -- |                           |
|     All organ transplants must be        |                           |
|     medically necessary. Transplants     |                           |
|     will be performed as a site approved |                           |
|     by us.                               |                           |
|                                          |                           |
| > Limited Benefits -- Treatment for      |                           |
| > breast cancer, multiple myeloma, and   |                           |
| > epithelial ovarian cancer may be       |                           |
| > provided in an NCI- or NIH-approved    |                           |
| > clinical trial at a Plan-designated    |                           |
| > center of excellence and if approved   |                           |
| > by the Plan\'s medical director in     |                           |
| > accordance with the Plan's protocols.  |                           |
| >                                        |                           |
| > Note: We cover related medical and     |                           |
| > hospital expenses of the donor when we |                           |
| > cover the recipient. The plan will pay |                           |
| > reasonable and customary charges for   |                           |
| > hospital, surgical, laboratory and     |                           |
| > x-ray services for a donor who is not  |                           |
| > entitled to benefits under any other   |                           |
| > health benefit plan or policy. Donor   |                           |
| > charges must result from the medically |                           |
| > necessary covered transplant of an     |                           |
| > organ or body tissue to a member of    |                           |
| > the plan.                              |                           |
| >                                        |                           |
| > Limited travel benefits are available  |                           |
| > for the transplant recipient and one   |                           |
| > other person. Transportation costs     |                           |
| > will be covered only if out-of-state   |                           |
| > travel is required. Reasonable         |                           |
| > expenses for lodging and meals will be |                           |
| > covered for both out-of-state and      |                           |
| > in-state, up to a maximum of \$150 a   |                           |
| > day for both combined. All benefits    |                           |
| > for transportation, lodging and meals  |                           |
| > are limited to a maximum of \$10,000.  |                           |
+------------------------------------------+---------------------------+
| > *Organ/Tissue Transplants -- continued |                           |
| > on next page*                          |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| > **Organ/tissue transplants             | > **You pay**             |
| > *(Continued)***                        |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | *All charges.*            |
|                                          |                           |
| -   *Donor screening tests and donor     |                           |
|     search expenses, except those        |                           |
|     performed for the actual donor*      |                           |
|                                          |                           |
| -   *Implants of artificial organs*      |                           |
|                                          |                           |
| -   *Transplants not listed as covered*  |                           |
|                                          |                           |
| -   *Non-human organ transplants, except |                           |
|     for porcine (pig) heart valves*      |                           |
+------------------------------------------+---------------------------+
| **Anesthesia**                           |                           |
+------------------------------------------+---------------------------+
| Professional services provided in --     | []{.mark}                 |
|                                          |                           |
| -   Hospital (inpatient)                 | Nothing                   |
+------------------------------------------+---------------------------+
| Professional services provided in --     | \$10 per office visit     |
|                                          |                           |
| -   Hospital outpatient department       |                           |
|                                          |                           |
| -   Skilled nursing facility             |                           |
|                                          |                           |
| -   Ambulatory surgical center           |                           |
|                                          |                           |
| -   Office                               |                           |
+------------------------------------------+---------------------------+

+---+---+-----------------------------------+-------------------+---+---+
| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
| S |   |                                   |                   |   |   |
| e |   |                                   |                   |   |   |
| c |   |                                   |                   |   |   |
| t |   |                                   |                   |   |   |
| i |   |                                   |                   |   |   |
| o |   |                                   |                   |   |   |
| n |   |                                   |                   |   |   |
| 5 |   |                                   |                   |   |   |
| ( |   |                                   |                   |   |   |
| c |   |                                   |                   |   |   |
| ) |   |                                   |                   |   |   |
| . |   |                                   |                   |   |   |
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| v |   |                                   |                   |   |   |
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| , |   |                                   |                   |   |   |
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| * |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
| a |   |                                   |                   |   |   |
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| d |   |                                   |                   |   |   |
| a |   |                                   |                   |   |   |
| m |   |                                   |                   |   |   |
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| l |   |                                   |                   |   |   |
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| n |   |                                   |                   |   |   |
| c |   |                                   |                   |   |   |
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| s |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
+---+---+-----------------------------------+-------------------+---+---+
|   | * | **Here are some important things  |                   | * |   |
|   | * | to remember about these           |                   | * |   |
|   | I | benefits:**                       |                   | I |   |
|   | * |                                   |                   | * |   |
|   | * | -   Please remember that all      |                   | * |   |
|   |   |     benefits are subject to the   |                   |   |   |
|   | * |     definitions, limitations, and |                   | * |   |
|   | * |     exclusions in this brochure   |                   | * |   |
|   | M |     and are payable only when we  |                   | M |   |
|   | * |     determine they are medically  |                   | * |   |
|   | * |     necessary.                    |                   | * |   |
|   |   |                                   |                   |   |   |
|   | * | -   Plan physicians must provide  |                   | * |   |
|   | * |     or arrange your care and you  |                   | * |   |
|   | P |     must be hospitalized in a     |                   | P |   |
|   | * |     Plan facility.                |                   | * |   |
|   | * |                                   |                   | * |   |
|   |   | -   Be sure to read Section 4,    |                   |   |   |
|   | * |     *Your costs for covered       |                   | * |   |
|   | * |     services,* for valuable       |                   | * |   |
|   | O |     information about how cost    |                   | O |   |
|   | * |     sharing works. Also read      |                   | * |   |
|   | * |     Section 9 about coordinating  |                   | * |   |
|   |   |     benefits with other coverage, |                   |   |   |
|   | * |     including with Medicare.      |                   | * |   |
|   | * |                                   |                   | * |   |
|   | R | -   The amounts listed below are  |                   | R |   |
|   | * |     for the charges billed by the |                   | * |   |
|   | * |     facility (i.e., hospital or   |                   | * |   |
|   |   |     surgical center) or ambulance |                   |   |   |
|   | * |     service for your surgery or   |                   | * |   |
|   | * |     care. Any costs associated    |                   | * |   |
|   | T |     with the professional charge  |                   | T |   |
|   | * |     (i.e., physicians, etc.) are  |                   | * |   |
|   | * |     covered in Sections 5(a) or   |                   | * |   |
|   |   |     (b).                          |                   |   |   |
|   | * |                                   |                   | * |   |
|   | * | -   **YOUR PHYSICIAN MUST GET     |                   | * |   |
|   | A |     PRECERTIFICATION OF HOSPITAL  |                   | A |   |
|   | * |     STAYS -- Please refer to      |                   | * |   |
|   | * |     Section 3 to be sure which    |                   | * |   |
|   |   |     services require              |                   |   |   |
|   | * |     precertification.**           |                   | * |   |
|   | * |                                   |                   | * |   |
|   | N |                                   |                   | N |   |
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|   | * |                                   |                   | * |   |
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|   | * |                                   |                   | * |   |
|   | T |                                   |                   | T |   |
|   | * |                                   |                   | * |   |
|   | * |                                   |                   | * |   |
+---+---+-----------------------------------+-------------------+---+---+
| * |   |                                   | **You pay**       |   |   |
| * |   |                                   |                   |   |   |
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| # |   |                                   | ########  {#secti |   |   |
| # |   |                                   | on-3 .unnumbered} |   |   |
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| * |   |                                   | > *All charges*   |   |   |
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| r |   |                                   |                   |   |   |
| m |   |                                   |                   |   |   |
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| > |   |                                   |                   |   |   |
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| e |   |                                   |                   |   |   |
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| d |   |                                   |                   |   |   |
| o |   |                                   |                   |   |   |
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| n |   |                                   |                   |   |   |
| o |   |                                   |                   |   |   |
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| c |   |                                   |                   |   |   |
| o |   |                                   |                   |   |   |
| v |   |                                   |                   |   |   |
| e |   |                                   |                   |   |   |
| r |   |                                   |                   |   |   |
| > |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
| t |   |                                   |                   |   |   |
| h |   |                                   |                   |   |   |
| e |   |                                   |                   |   |   |
| > |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
| d |   |                                   |                   |   |   |
| e |   |                                   |                   |   |   |
| n |   |                                   |                   |   |   |
| t |   |                                   |                   |   |   |
| a |   |                                   |                   |   |   |
| l |   |                                   |                   |   |   |
| > |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
| p |   |                                   |                   |   |   |
| r |   |                                   |                   |   |   |
| o |   |                                   |                   |   |   |
| c |   |                                   |                   |   |   |
| e |   |                                   |                   |   |   |
| d |   |                                   |                   |   |   |
| u |   |                                   |                   |   |   |
| r |   |                                   |                   |   |   |
| e |   |                                   |                   |   |   |
| s |   |                                   |                   |   |   |
| . |   |                                   |                   |   |   |
+---+---+-----------------------------------+-------------------+---+---+
| # |   |                                   | ########          |   |   |
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+---+---+-----------------------------------+-------------------+---+---+
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| . |   |                                   |                   |   |   |
+---+---+-----------------------------------+-------------------+---+---+
| > |   |                                   | > *All charges.*  |   |   |
|   |   |                                   |                   |   |   |
| N |   |                                   |                   |   |   |
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+---+---+-----------------------------------+-------------------+---+---+
| # |   |                                   | #### **You pay**  |   |   |
| # |   |                                   |                   |   |   |
| # |   |                                   |                   |   |   |
| # |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
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| > |   |                                   | > *All charges.*  |   |   |
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+---+---+-----------------------------------+-------------------+---+---+
| # |   |                                   | ######## You pay  |   |   |
| # |   |                                   |                   |   |   |
| # |   |                                   |                   |   |   |
| # |   |                                   |                   |   |   |
| # |   |                                   |                   |   |   |
| # |   |                                   |                   |   |   |
| # |   |                                   |                   |   |   |
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|   |   |                                   |                   |   |   |
| A |   |                                   |                   |   |   |
| m |   |                                   |                   |   |   |
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| n |   |                                   |                   |   |   |
| c |   |                                   |                   |   |   |
| e |   |                                   |                   |   |   |
+---+---+-----------------------------------+-------------------+---+---+
| L |   |                                   | > \$50 copay per  |   |   |
| o |   |                                   | > occurrence      |   |   |
| c |   |                                   | >                 |   |   |
| a |   |                                   | > \$100 copay per |   |   |
| l |   |                                   | > occurrence      |   |   |
| p |   |                                   |                   |   |   |
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|   |   |                                   |                   |   |   |
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| n |   |                                   |                   |   |   |
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+---+---+-----------------------------------+-------------------+---+---+

+---+---+-------------------------------------+---------------------+---+---+---+
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| S |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| 5 |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| ( |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| ) |   |                                     |                     |   |   |   |
| . |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| E |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| g |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| y |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| v |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| / |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
+---+---+-------------------------------------+---------------------+---+---+---+
|   | * | > Here are some important things to |                     | * | # |   |
|   | * | > keep in mind about these          |                     | * | # |   |
|   | I | > benefits:                         |                     | I | # |   |
|   | * |                                     |                     | * | # |   |
|   | * | -   Please remember that all        |                     | * | # |   |
|   |   |     benefits are subject to the     |                     |   |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |   |
|   | * |     exclusions in this brochure and |                     | * |   |   |
|   | M |     are payable only when we        |                     | M |   |   |
|   | * |     determine they are medically    |                     | * |   |   |
|   | * |     necessary.                      |                     | * |   |   |
|   |   |                                     |                     |   |   |   |
|   | * | ```{=html}                          |                     | * |   |   |
|   | * | <!-- -->                            |                     | * |   |   |
|   | P | ```                                 |                     | P |   |   |
|   | * | -   We have no calendar year        |                     | * |   |   |
|   | * |     deductible.                     |                     | * |   |   |
|   |   |                                     |                     |   |   |   |
|   | * | -   Be sure to read Section 4,      |                     | * |   |   |
|   | * |     *Your costs for covered         |                     | * |   |   |
|   | O |     services,* for valuable         |                     | O |   |   |
|   | * |     information about how cost      |                     | * |   |   |
|   | * |     sharing works. Also read        |                     | * |   |   |
|   |   |     Section 9 about coordinating    |                     |   |   |   |
|   | * |     benefits with other coverage,   |                     | * |   |   |
|   | * |     including with Medicare.        |                     | * |   |   |
|   | R |                                     |                     | R |   |   |
|   | * | #####                               |                     | * |   |   |
|   | * |                                     |                     | * |   |   |
|   |   |                                     |                     |   |   |   |
|   | * |                                     |                     | * |   |   |
|   | * |                                     |                     | * |   |   |
|   | T |                                     |                     | T |   |   |
|   | * |                                     |                     | * |   |   |
|   | * |                                     |                     | * |   |   |
|   |   |                                     |                     |   |   |   |
|   | * |                                     |                     | * |   |   |
|   | * |                                     |                     | * |   |   |
|   | A |                                     |                     | A |   |   |
|   | * |                                     |                     | * |   |   |
|   | * |                                     |                     | * |   |   |
|   |   |                                     |                     |   |   |   |
|   | * |                                     |                     | * |   |   |
|   | * |                                     |                     | * |   |   |
|   | N |                                     |                     | N |   |   |
|   | * |                                     |                     | * |   |   |
|   | * |                                     |                     | * |   |   |
|   |   |                                     |                     |   |   |   |
|   | * |                                     |                     | * |   |   |
|   | * |                                     |                     | * |   |   |
|   | T |                                     |                     | T |   |   |
|   | * |                                     |                     | * |   |   |
|   | * |                                     |                     | * |   |   |
+---+---+-------------------------------------+---------------------+---+---+---+
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
| W |   |                                     |                     |   |   |   |
| h |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
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|   |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
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|   |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
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| d |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
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|   |   |                                     |                     |   |   |   |
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| m |   |                                     |                     |   |   |   |
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| r |   |                                     |                     |   |   |   |
| g |   |                                     |                     |   |   |   |
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| c |   |                                     |                     |   |   |   |
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| * |   |                                     |                     |   |   |   |
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|   |   |                                     |                     |   |   |   |
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| v |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
+---+---+-------------------------------------+---------------------+---+---+---+
| - |   |                                     | \$10 per visit      |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     | \$20 per visit      |   |   |   |
|   |   |                                     |                     |   |   |   |
| E |   |                                     | \$50 per visit      |   |   |   |
| m |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| g |   |                                     |                     |   |   |   |
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| r |   |                                     |                     |   |   |   |
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| c |   |                                     |                     |   |   |   |
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| n |   |                                     |                     |   |   |   |
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| m |   |                                     |                     |   |   |   |
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|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
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| n |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| g |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| \ |   |                                     |                     |   |   |   |
| ' |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
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| r |   |                                     |                     |   |   |   |
| v |   |                                     |                     |   |   |   |
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| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
+---+---+-------------------------------------+---------------------+---+---+---+
| * |   |                                     | *All charges.*      |   |   |   |
| N |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
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| m |   |                                     |                     |   |   |   |
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| r |   |                                     |                     |   |   |   |
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| * |   |                                     |                     |   |   |   |
+---+---+-------------------------------------+---------------------+---+---+---+
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
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| v |   |                                     |                     |   |   |   |
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| a |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| { |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| g |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| y |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| v |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| . |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| b |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| } |   |                                     |                     |   |   |   |
+---+---+-------------------------------------+---------------------+---+---+---+
| - |   |                                     | > \$10 per visit    |   |   |   |
|   |   |                                     | >                   |   |   |   |
|   |   |                                     | > \$20 per visit    |   |   |   |
|   |   |                                     | >                   |   |   |   |
| E |   |                                     | > \$50 per visit    |   |   |   |
| m |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| g |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| y |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| \ |   |                                     |                     |   |   |   |
| ' |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
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|   |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
| # |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
| M |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| h |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| p |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| g |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| f |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| f |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| v |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| y |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| f |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| b |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| b |   |                                     |                     |   |   |   |
| y |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| h |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| v |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
+---+---+-------------------------------------+---------------------+---+---+---+
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
| A |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| b |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
+---+---+-------------------------------------+---------------------+---+---+---+
| > |   |                                     | > \$50 per          |   |   |   |
|   |   |                                     | > occurrence        |   |   |   |
| P |   |                                     | >                   |   |   |   |
| r |   |                                     | > \$100 per         |   |   |   |
| o |   |                                     | > occurrence        |   |   |   |
| f |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| b |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| v |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| w |   |                                     |                     |   |   |   |
| h |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| y |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| p |   |                                     |                     |   |   |   |
| p |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| p |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| . |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| S |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| 5 |   |                                     |                     |   |   |   |
| ( |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| ) |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| f |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| g |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| y |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| v |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| . |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| G |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| A |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| b |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| A |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| A |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| b |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
+---+---+-------------------------------------+---------------------+---+---+---+
| > |   |                                     | > Nothing           |   |   |   |
|   |   |                                     | >                   |   |   |   |
| I |   |                                     | > \$100 per         |   |   |   |
| n |   |                                     | > occurrence        |   |   |   |
| t |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
| F |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| y |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| T |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| f |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| : |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| G |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| A |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| b |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| A |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| A |   |                                     |                     |   |   |   |
| m |   |                                     |                     |   |   |   |
| b |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
+---+---+-------------------------------------+---------------------+---+---+---+
| > |   |                                     | > *All charges.*    |   |   |   |
|   |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
| N |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| v |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| : |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| I |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| - |   |                                     |                     |   |   |   |
| F |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| l |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| y |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| T |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| f |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| S |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| v |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| c |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| s |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| f |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| n |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| > |   |                                     |                     |   |   |   |
|   |   |                                     |                     |   |   |   |
| p |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| a |   |                                     |                     |   |   |   |
| u |   |                                     |                     |   |   |   |
| t |   |                                     |                     |   |   |   |
| h |   |                                     |                     |   |   |   |
| o |   |                                     |                     |   |   |   |
| r |   |                                     |                     |   |   |   |
| i |   |                                     |                     |   |   |   |
| z |   |                                     |                     |   |   |   |
| e |   |                                     |                     |   |   |   |
| d |   |                                     |                     |   |   |   |
| * |   |                                     |                     |   |   |   |
+---+---+-------------------------------------+---------------------+---+---+---+

+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| S |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
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| s |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
|   | * | When you get our approval for       |                     | * |   |
|   | * | services and follow a treatment     |                     | * |   |
|   | I | plan we approve, cost-sharing and   |                     | I |   |
|   | * | limitations for Plan mental health  |                     | * |   |
|   | * | and substance abuse benefits will   |                     | * |   |
|   |   | be no greater than for similar      |                     |   |   |
|   | * | benefits for other illnesses and    |                     | * |   |
|   | * | conditions.                         |                     | * |   |
|   | M |                                     |                     | M |   |
|   | * | > **Here are some important things  |                     | * |   |
|   | * | > to keep in mind about these       |                     | * |   |
|   |   | > benefits:**                       |                     |   |   |
|   | * | >                                   |                     | * |   |
|   | * | > All benefits are subject to the   |                     | * |   |
|   | P | > definitions, limitations, and     |                     | P |   |
|   | * | > exclusions in this brochure and   |                     | * |   |
|   | * | > are payable only when we          |                     | * |   |
|   |   | > determine they are medically      |                     |   |   |
|   | * | > necessary.                        |                     | * |   |
|   | * | >                                   |                     | * |   |
|   | O | > Be sure to read Section 4, *Your  |                     | O |   |
|   | * | > costs for covered services,* for  |                     | * |   |
|   | * | > valuable information about how    |                     | * |   |
|   |   | > cost sharing works. Also read     |                     |   |   |
|   | * | > Section 9 about coordinating      |                     | * |   |
|   | * | > benefits with other coverage,     |                     | * |   |
|   | R | > including with Medicare.          |                     | R |   |
|   | * | >                                   |                     | * |   |
|   | * | > **YOU MUST GET PREAUTHORIZATION   |                     | * |   |
|   |   | > OF THESE SERVICES.** See the      |                     |   |   |
|   | * | > instructions after the benefits   |                     | * |   |
|   | * | > description below.                |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
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|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| > |   |                                     | **You pay**         |   |   |
|   |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
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| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     | ###                 |   |   |
| # |   |                                     |                     |   |   |
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| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| > |   |                                     | > Your cost sharing |   |   |
|   |   |                                     | > responsibilities  |   |   |
| A |   |                                     | > are no greater    |   |   |
| l |   |                                     | > than for other    |   |   |
| l |   |                                     | > illness or        |   |   |
| > |   |                                     | > conditions.       |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     | > *All charges.*    |   |   |
| # |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

+-----------------------------------------------------------------------+
| **Preauthorization** To be eligible to receive these enhanced mental  |
| health and substance abuse benefits you must follow your treatment    |
| plan and all the following authorization processes:                   |
|                                                                       |
| -   To access mental health services, simply contact the Presbyterian |
|     Health Plan Behavioral Health Unit at 923-5470 or 1-800-453-4347  |
|     to receive a referral to a behavioral health provider. The        |
|     behavioral health provider is responsible for any authorizations. |
+-----------------------------------------------------------------------+
| **Limitation** We may limit your benefits if you do not obtain a      |
| treatment plan.                                                       |
+-----------------------------------------------------------------------+

+---+---+----------------------------------------------------------+---+---+
| * |   |                                                          |   |   |
| * |   |                                                          |   |   |
| S |   |                                                          |   |   |
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| * |   |                                                          |   |   |
| * |   |                                                          |   |   |
+---+---+----------------------------------------------------------+---+---+
|   | * | **Here are some important things to keep in mind about   | * |   |
|   | * | these benefits:**                                        | * |   |
|   | I |                                                          | I |   |
|   | * | -   We cover prescribed drugs and medications, as        | * |   |
|   | * |     described in the chart beginning on the next page.   | * |   |
|   |   |                                                          |   |   |
|   | * | -   All benefits are subject to the definitions,         | * |   |
|   | * |     limitations and exclusions in this brochure and are  | * |   |
|   | M |     payable only when we determine they are medically    | M |   |
|   | * |     necessary.                                           | * |   |
|   | * |                                                          | * |   |
|   |   | -   Be sure to read Section 4, *Your costs for covered   |   |   |
|   | * |     services,* for valuable information about how cost   | * |   |
|   | * |     sharing works. Also read Section 9 about             | * |   |
|   | P |     coordinating benefits with other coverage, including | P |   |
|   | * |     with Medicare.                                       | * |   |
|   | * |                                                          | * |   |
|   |   |                                                          |   |   |
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+---+---+----------------------------------------------------------+---+---+
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+---+---+----------------------------------------------------------+---+---+

+------------------------------------------+---------------------------+
| > **Benefit Description**                | **You pay**               |
+------------------------------------------+---------------------------+
| > **Covered medications and supplies**   |                           |
+------------------------------------------+---------------------------+
| > We cover the following medications and | > \$7 per generic -- 30   |
| > supplies prescribed by a Plan          | > day supply or 100 units |
| > physician and obtained from a Plan     | > whichever is less       |
| > pharmacy or through our mail order     | >                         |
| > program:                               | > \$17 per brand --       |
|                                          | > listed on the PHP Drug  |
| -   Drugs and medicines that by Federal  | > Formulary 30 day supply |
|     law of the United States require a   | > or 100 units whichever  |
|     physician's prescription for their   | > is less                 |
|     purchase, except those listed as     | >                         |
|     *Not covered*.                       | > \$34 Non-formulary --   |
|                                          | > 30 day supply or 100    |
| -   Insulin                              | > units whichever is less |
|                                          | >                         |
| -   Diabetic supplies, including insulin | > **Mail order**          |
|     syringes, needles, blood test        | >                         |
|     strips, urine test tape, and acetone | > \$14 per generic -- 90  |
|     test tablets. (Glucose monitors are  | > day supply or 300 units |
|     covered as durable medical           | > whichever is less.      |
|     equipment, see under DME section)    | >                         |
|                                          | > \$34 per brand --       |
| -   All FDA-approved oral and injectable | > listed on the PHP Drug  |
|     contraceptive drugs and              | > Formulary 90 day supply |
|     contraceptive devices                | > or 300 units whichever  |
|                                          | > is less                 |
| -   Disposable needles and syringes for  | >                         |
|     the administration of covered        | > \$68 Non-formulary --   |
|     medication                           | > 90 day supply or 300    |
|                                          | > units whichever is less |
| -   Drugs for sexual dysfunction (see    | >                         |
|     Prior authorization below)           | > Note: If there is no    |
|                                          | > generic equivalent      |
| -   Contraceptive drugs and devices      | > available, you will     |
|                                          | > still have to pay the   |
| ```{=html}                               | > brand name copay.       |
| <!-- -->                                 | >                         |
| ```                                      | > 50% of all charges      |
| -   Fertility drugs, oral or injectable, | >                         |
|     including those provided in a        | > 15% of all charges up   |
|     physician's office.                  | > to a maximum of \$250   |
|                                          | > per prescription        |
| -   Injectable drugs or products         |                           |
|     (recombinant DNA & Purified          |                           |
|     Bilological Products)                |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes*                            |                           |
|                                          |                           |
| -   *Drugs to enhance athletic           |                           |
|     performance*                         |                           |
|                                          |                           |
| -   *Drugs obtained at a non-Plan        |                           |
|     pharmacy; except for out-of-area     |                           |
|     emergencies*                         |                           |
|                                          |                           |
| -   *Vitamins, nutrients and food        |                           |
|     supplements that can be purchased    |                           |
|     without a prescription*              |                           |
|                                          |                           |
| -   *Replacement prescriptions resulting |                           |
|     from loss, theft, or destruction*    |                           |
|                                          |                           |
| -   *Drugs from which there is a         |                           |
|     nonprescription equivalent           |                           |
|     available*                           |                           |
|                                          |                           |
| -   *Medical supplies such as dressings  |                           |
|     and antiseptics*                     |                           |
|                                          |                           |
| -   *Nonprescription medicines*          |                           |
+------------------------------------------+---------------------------+

+----------------------+-----------------------------------------------+
| > Section 5 (g).     |                                               |
| > Special features   |                                               |
+======================+===============================================+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| > **Flexible         | > Under the flexible benefits option, we      |
| > benefits option**  | > determine the most effective way to provide |
|                      | > services.                                   |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   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.                                  |
+----------------------+-----------------------------------------------+
| > **Services for     | > Contact Member services at 505/923-5699 or  |
| > deaf and hearing   | > toll-free at 1-877-298-7407                 |
| > impaired**         |                                               |
+----------------------+-----------------------------------------------+
| > **Pregnancies      | -   PRESiouis Beginnings is a statewide       |
| > (Including         |     program that determines high-risk         |
| > High-Risk          |     pregnancies and offers care management,   |
| > Pregnancies)**     |     literature and use of videos. Peri-Natal  |
|                      |     nurses are available for questions Monday |
|                      |     through Friday 8:30A to 5:00P to assist   |
|                      |     with high-risk pregnancy questions. For   |
|                      |     additional information, call 505/724-6500 |
|                      |                                               |
|                      | -   Doula services are available for Members  |
|                      |     who deliver at Presbyterian Hospital. For |
|                      |     more information, call 505/724-6500.      |
+----------------------+-----------------------------------------------+
| > **Presbyterian     | > PHS offers several health improvement       |
| > Healthcare         | > classes to PHP Members and the general      |
| > Services**         | > public. Fees vary according to status of    |
|                      | > participant. Visit our website at           |
|                      | > [www.phs.org](http://WWW.PHS.ORG/) or call  |
|                      | > Member Services at 505/923-5678 or          |
|                      | > toll-free at 1-800-356-2219 or for the      |
|                      | > hearing impaired 505/923-5699 or toll-free  |
|                      | > 1-877-298-7407.                             |
+----------------------+-----------------------------------------------+
| > **Vision           | > The Access Plan available through Vision    |
| > Discounts**        | > Service Plan (VSP) offers vision services   |
|                      | > at discounted rates through VSP Providers.  |
|                      | > Please refer to the Presbyterian Value      |
|                      | > Added flyer for more details or visit       |
|                      | > [www.vsp.com](http://www.vsp.com/) for      |
|                      | > further information.                        |
+----------------------+-----------------------------------------------+
| > **Acupuncture,     | > Discounted services are available through   |
| > Chiropractic and   | > Benefit Source and their contracted         |
| > Massage Therapy    | > providers. Please refer to the Presbyterian |
| > Discounts**        | > Value Added flyer or visit                  |
|                      | > [www.bene                                   |
|                      | fitsource.org](http://www.benefitsource.org/) |
|                      | > for further details.                        |
+----------------------+-----------------------------------------------+

+---+---+------------------------------------+--------------------+---+---+
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| S |   |                                    |                    |   |   |
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|   |   |                                    |                    |   |   |
| 5 |   |                                    |                    |   |   |
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
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| s |   |                                    |                    |   |   |
+===+===+====================================+====================+===+===+
|   | * | **Here are some important things   |                    | * |   |
|   | * | to keep in mind about these        |                    | * |   |
|   | I | benefits:**                        |                    | I |   |
|   | * |                                    |                    | * |   |
|   | * | -   Please remember that all       |                    | * |   |
|   |   |     benefits are subject to the    |                    |   |   |
|   | * |     definitions, limitations, and  |                    | * |   |
|   | * |     exclusions in this brochure    |                    | * |   |
|   | M |     and are payable only when we   |                    | M |   |
|   | * |     determine they are medically   |                    | * |   |
|   | * |     necessary.                     |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   Plan dentists must provide or  |                    | * |   |
|   | * |     arrange your care.             |                    | * |   |
|   | P |                                    |                    | P |   |
|   | * | -   We have no calendar year       |                    | * |   |
|   | * |     deductible.                    |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   We cover hospitalization for   |                    | * |   |
|   | * |     dental procedures only when a  |                    | * |   |
|   | O |     nondental physical impairment  |                    | O |   |
|   | * |     exists which makes             |                    | * |   |
|   | * |     hospitalization necessary to   |                    | * |   |
|   |   |     safeguard the health of the    |                    |   |   |
|   | * |     patient; See Section 5(c) for  |                    | * |   |
|   | * |     inpatient hospital benefits.   |                    | * |   |
|   | R |     We do not cover the dental     |                    | R |   |
|   | * |     procedure unless it is         |                    | * |   |
|   | * |     described below.               |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   Be sure to read Section 4,     |                    | * |   |
|   | * |     *Your costs for covered        |                    | * |   |
|   | T |     services,* for valuable        |                    | T |   |
|   | * |     information about how cost     |                    | * |   |
|   | * |     sharing works. Also read       |                    | * |   |
|   |   |     Section 9 about coordinating   |                    |   |   |
|   | * |     benefits with other coverage,  |                    | * |   |
|   | * |     including with Medicare.       |                    | * |   |
|   | A |                                    |                    | A |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
|   | N |                                    |                    | N |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
|   | T |                                    |                    | T |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
+---+---+------------------------------------+--------------------+---+---+
| # |   |                                    | > **You pay**      |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
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| * |   |                                    |                    |   |   |
| * |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| > |   |                                    | > \$10 per visit   |   |   |
|   |   |                                    |                    |   |   |
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+---+---+------------------------------------+--------------------+---+---+
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+---+---+------------------------------------+--------------------+---+---+
| > |   |                                    | > \$10 per visit   |   |   |
|   |   |                                    |                    |   |   |
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|   |   |                                    |                    |   |   |
| 5 |   |                                    |                    |   |   |
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| ) |   |                                    |                    |   |   |
| . |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+

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

> The exclusions in this section apply to all benefits. **Although we
> may list a specific service as a benefit, we will not cover it unless
> your Plan doctor determines it is medically necessary to prevent,
> diagnose, or treat your illness, disease, injury, or condition and we
> agree, as discussed under What Services Require Our Prior Approval on
> page 12.**
>
> We do not cover the following:

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

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

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

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

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

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

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

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

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

-   Travel expenses.

  -----------------------------------------------------------------------
  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 505/923-5678
or toll-free at 1-800-356-2219 or for the hearing impaired at
505/923-5699 or toll-free at 1-877-298-7407

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;

-   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.

-   For emergency and urgent care services outside the United States you
    are responsible for ensuring that claims are appropriately
    translated and that the monetary exchange, on the date of service,
    is clearly identified when submitting claims.

> **Submit your claims to:**
>
> **Presbyterian Health Plan**
>
> **PO Box 27489**
>
> **Albuquerque, NM 87125-7489**

**Prescription drugs** If a charge is made to you for covered pharmacy
benefits, you must provide proof of such charge with a copy of the
pharmacy receipt with the name of the drug, quantity dispensed, and
National Drug Code (NDC) number. Any charge shall be paid only upon
receipt of proof satisfactory to the Plan of the occurrence, character
and extent of the event and services for which claim is made.

> **Submit your claims to:**
>
> **Presbyterian Health Plan**
>
> **Attn: Pharmacy**
>
> **PO Box 27489**
>
> **Albuquerque, NM 87125-7489**

**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: PO Box 27489 Albuquerque, NM     |
|   |     87125-7489; 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\' letter, operative reports, bills, medical       |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | \(a\) Pay the claim (or, if applicable, arrange for the health   |
| * | care provider to give you the care); or                          |
| * |                                                                  |
|   | (b) Write to you and maintain our denial \-- go to step 4; or    |
|   |                                                                  |
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request--- go  |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us \-- if we did not       |
|   |     answer that request in some way within 30 days; or           |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: Office of Personnel Management, Office of       |
|   | Insurance Programs, Contracts Division 3, 1900 E Street, NW,     |
|   | Washington, DC 20415-3630.                                       |
+---+------------------------------------------------------------------+
|   | **The Disputed Claims process *(Continued) ***                   |
|   |                                                                  |
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | ```{=html}                                                       |
|   | <!-- -->                                                         |
|   | ```                                                              |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | ```{=html}                                                       |
|   | <!-- -->                                                         |
|   | ```                                                              |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | ```{=html}                                                       |
|   | <!-- -->                                                         |
|   | ```                                                              |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | ```{=html}                                                       |
|   | <!-- -->                                                         |
|   | ```                                                              |
|   | -   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 800/356-2219 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

```{=html}
<!-- -->
```
-   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. We follow
the NAIC guidelines regarding Coordination of Benefits.

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

-   People 65 years of age and older.

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

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

    Medicare has two parts:

```{=html}
<!-- -->
```
-   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***.***

```{=html}
<!-- -->
```
-   **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 + Choice plan you have.

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

When you are enrolled in Original Medicare along with this Plan, you
still need to follow the rules in this brochure for us to cover your
care. Your care must continue to be authorized by your Plan PCP, or
precertified as required.

**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 then provide secondary benefits for covered
    charges. You will not need to do anything. To find out if you need
    to do something to file your claims, call us at 800/356-2219.

> **We do not waive any costs if the Original Medicare Plan is your
> primary payer.**
>
> **Primary 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  | **The   |        |
| 65 or over and have Medicare and you...**         | primary |        |
|                                                   | payer   |        |
|                                                   | for the |        |
|                                                   | ind     |        |
|                                                   | ividual |        |
|                                                   | with    |        |
|                                                   | M       |        |
|                                                   | edicare |        |
|                                                   | is...** |        |
+---------------------------------------------------+---------+--------+
|                                                   | **Med   | **This |
|                                                   | icare** | Plan** |
+---------------------------------------------------+---------+--------+
| 1)  Are an active employee with the Federal       |         |        |
|     government and**...**                         |         |        |
|                                                   |         |        |
|     -   You have FEHB coverage on your own or     |         |        |
|         through your spouse who is also an active |         |        |
|         employee                                  |         |        |
+---------------------------------------------------+---------+--------+
| -   You have FEHB coverage through your spouse    |         |        |
|     who is an annuitant                           |         |        |
+---------------------------------------------------+---------+--------+
| 2)  Are an annuitant and**...**                   |         |        |
|                                                   |         |        |
|     -   You have FEHB coverage on your own or     |         |        |
|         through your spouse who is also an        |         |        |
|         annuitant                                 |         |        |
+---------------------------------------------------+---------+--------+
| -   You have FEHB coverage through your spouse    |         |        |
|     who is an active employee                     |         |        |
+---------------------------------------------------+---------+--------+
| 3)  Are a reemployed annuitant with the Federal   | \*      |        |
|     government and your position is excluded from |         |        |
|     the FEHB (your employing office will know if  |         |        |
|     this is the case)                             |         |        |
+---------------------------------------------------+---------+--------+
| 4)  Are a reemployed annuitant with the Federal   |         |        |
|     government and your position is not excluded  |         |        |
|     from the FEHB (your employing office will     |         |        |
|     know if this is the case) and**...**          |         |        |
|                                                   |         |        |
|     -   You have FEHB coverage on your own or     |         |        |
|         through your spouse who is also an active |         |        |
|         employee                                  |         |        |
+---------------------------------------------------+---------+--------+
| -   You have FEHB coverage through your spouse    |         |        |
|     who is an annuitant                           |         |        |
+---------------------------------------------------+---------+--------+
| 5)  Are a Federal judge who retired under title   | ##      |        |
|     28, U.S.C., or a Tax Court judge who retired  | #### \* |        |
|     under Section 7447 of title 26, U.S.C. (or if |         |        |
|     your covered spouse is this type of judge)    |         |        |
+---------------------------------------------------+---------+--------+
| 6)  Are enrolled in Part B only, regardless of    | for     | for    |
|     your employment status                        | Part B  | other  |
|                                                   | s       | se     |
|                                                   | ervices | rvices |
+---------------------------------------------------+---------+--------+
| 7)  Are a former Federal employee receiving       | \*\*    |        |
|     Workers' Compensation and the Office of       |         |        |
|     Workers' Compensation Programs has determined |         |        |
|     that you are unable to return to duty)        |         |        |
+---------------------------------------------------+---------+--------+
| **B. When you or a covered family member...**     |         |        |
+---------------------------------------------------+---------+--------+
| ###### Have Medicare solely b                     |         |        |
| ased 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      |         | for    |
|     while already a Medicare beneficiary          |         | 30     |
|     and**...**                                    |         | -month |
|                                                   |         | coordi |
| -   This Plan was the primary payer before        |         | nation |
|     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**...**                   |         | []{    |
|                                                   |         | .mark} |
|     -   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                     |         |        |
+---------------------------------------------------+---------+--------+
| **D. Are covered under the FEHB Spouse Equity     |         |        |
| provision as a former spouse**                    |         |        |
+---------------------------------------------------+---------+--------+

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

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

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

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 cost-sharing for your FEHB coverage such as,
preventative care including one (1) annual physical exam. Cost-sharing
is also waived for Medicare approved durable medical equipment (DME),
prosthetic devices, blood glucose monitors, lancets, blood testing
strips and diabetes self-management training. In addition, we provide
reduced copays on your FEHB coverage for primary care practitioner
visits, outpatient rehabilitation services and Medicare approved
chiropractic services. We provide increased benefits for such services
as annual routine hearing exam, annual routine vision exam and
outpatient rehabilitation services such as, physical, speech and
occupational therapy services.

**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, but we will not waive any of our copayments,
coinsurance, or deductibles. You must use our provider network to
receive secondary benefits from us. If you enroll in a Medicare + Choice
plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare + Choice plan so we can correctly
coordinate benefits with Medicare.

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

-   **If you do not enroll in** If you do not have one or both parts of
    Medicare, you can still be covered under the

**Medicare Part A or Part B** FEHB Program. We will not require you to
enroll in Medicare Part B and, if you can't

get premium-free Part A, we will not ask you to enroll in it.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care. See page 14.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 14.

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

**Custodial care** Care provided primarily for maintenance of the
patient and designed essentially to assist in meeting the patient's
daily activities. It is not provided for its therapeutic value in the
treatment of an illness, disease, accidental injury, or condition.
Custodial Care includes, but is not limited to, help in walking,
bathing, dressing, eating, preparation of special diets, and supervision
over self-administation of medication not requiring the constant
attention of trained medical personnel.

The plan evaluates any new procedures, drug therapies, treatments,
devices, etc. to determine if they are experimental/investigational in
nature. This evaluation includes review of current literature published
in peer review journals and appropriate information from governmental
regulatory bodies, such as the FDA. We also utilize reliable evidence
(consensus of opinion in the medical community) to determine if the
procedure, drug therapies, treatments, devices, etc. is contraindicated
for the particular indication which it has been prescribed. Please
contact the plan for a more detailed explanation of this evaluation
process.

**Medical necessity** Appropriate or necessary services as determined by
our plan doctor in consultation with the plan, which are given to you
for any covered condition requiring, according to generally accepted
principles of good medical practice, the diagnosis or direct care and
treatment of an illness, injury, or medical condition, and are not
services provided only as a convenience.

**Plan allowance** Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Fee-for-service plans
determine their allowances in different ways. We determine our allowance
as follows: Total allowable charges for plan providers may not exceed
the amount the provider service and for non-plan providers, the total
allowable charges may not exceed the plan allowance as determined by the
plan for a service.

**Us/We** Us and we refer to Presbyterian Health Plan

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

See [www.opm.gov/insure]{.underline}. Also, your employing or retirement
office can answer your questions, and give you a *Guide to Federal
Employees Health Benefits Plans,* brochures for other plans, and other
materials you need to make an informed decision about your FEHB
coverage. These materials tell you:

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

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

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

The benefits in this brochure are effective 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}
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```
-   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 continue

    **coverage** 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 family member, you may be
    eligible for Temporary Continuation of Coverage (TCC). For example,
    you can receive TCC if you are not able to continue your FEHB
    enrollment after you retire, if you lose your job, if you are a
    covered dependent child and you turn 22 or marry, etc

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

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

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

    **individual coverage**

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

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```
-   You decided not to receive coverage under TCC or the spouse equity
    law; or

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

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

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

> **Getting a Certificate of** The Health Insurance Portability and
> Accountability of 1996 (HIPAA) is a

**Group Health Plan Coverage** Federal law that offers limited Federal
protections for health coverage availability and continuity to people
who lose employer group coverage. If you leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how
long you have been enrolled with us. You can use this certificate when
getting health insurance or other health care coverage. Your new plan
must reduce or eliminate waiting periods, limitations, or exclusions for
health related conditions based on the information in the certificate,
as long as you enroll within 63 days of losing coverage under this Plan.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate from those plans. For more information, get OPM pamphlet RI
79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program.
See also the FEHB web site (www.opm.gov/insure/health); refer to the
\"TCC and HIPAA\" frequently asked question. These highlight HIPAA
rules, such as the requirement that Federal employees must exhaust any
TCC eligibility as one condition for guaranteed access to individual
health coverage under HIPAA, and have information about Federal and
State agencies you can contact for more information.

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

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

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

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

#  What is an FSA? It is a tax-favored benefit that allows you to set aside pre-tax money from your paychecks to pay for a variety of eligible expenses. *By using an FSA,* *you can reduce your taxes while paying for services you would have to pay for anyway, producing a discount that can be over 40%!!*

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

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

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

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

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

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

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

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

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

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

> **What is SHPS?** SHPS is a third-party administrator hired by OPM to
> manage the FSAFEDS Program. SHPS is the largest FSA administrator in
> the nation and will be responsible for enrollment, claims processing,
> customer service, and day-to-day operations of FSAFEDS.
>
> **Who is eligible to enroll?** If you are a Federal employee eligible
> for FEHB -- even if you're not enrolled in FEHB-- you can choose to
> participate in either, or both, of the flexible spending accounts. If
> you are not eligible for FEHB, you are not eligible to enroll for a
> Health Care FSA. However, almost all Federal employees are eligible to
> enroll for the Dependent Care FSA. The only exception is intermittent
> (also called when actually employed \[WAE\]) employees expected to
> work less than 180 days during the year.
>
> *Note:* FSAFEDS is the FSA Program established for all Executive
> Branch employees and Legislative Branch employees whose employers
> signed on. Under IRS law, FSAs are not available to annuitants. In
> addition, the U.S. Postal Service and the Judicial Branch, among
> others, are Federal agencies that have their own plans with slightly
> different rules, but the advantages of having an FSA are the same no
> matter what agency you work for.
>
> 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](http://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 66 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 the High Option of this Plan, typical out-of-pocket expenses
> include:
>
> Prescription drug and office visit copayments and Durable Medical
> Equipment coinsurance.
>
> All expenses relating to certain Chiropractic services, deluxe Durable
> Medical Equipment and certain orthopedic shoes and supports.
>
> The IRS governs expenses reimbursable by a HCFSA. See Publication 502
> for a comprehensive list of tax-deductible medical expenses.  **Note:
> While you will see insurance premiums listed in Publication 502, they
> are NOT a reimbursable expense for FSA purposes**.  Publication 502
> can be found on the IRS Web site at
> <http://www.irs.gov/pub/irs-pdf/p502.pdf>.  If you do not see your
> service or expense listed in Publication 502, please call a FSAFEDS
> Benefit Counselor at 1-877-FSAFEDS (372-3337), who will be able to
> answer your specific questions.
>
> **Tax savings with an FSA** An FSA lets you allot money for eligible
> expenses ***before*** your agency deducts taxes from your paycheck.
> This means the amount of income that your taxes are based on will be
> lower, so your tax liability will also be lower. Without an FSA, you
> would still pay for these expenses, but you would do so using money
> remaining in your paycheck after Federal (and often state and local)
> taxes are deducted. The following chart illustrates a typical tax
> savings example:

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

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

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

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

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

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

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

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

> **Note:** This example is intended to demonstrate a typical tax
> savings based on 27% Federal and 7.65% FICA taxes. Actual savings will
> vary based upon in which retirement system you are enrolled (CSRS or
> FERS), as well as your individual tax situation. In this example, the
> individual received \$2,000 in services for \$1,424, a discount of
> almost 36%! You may also wish to consult a tax professional for more
> information on the tax implications of an FSA.
>
> 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.
>
> **Dependent care expenses** The DCFSA generally allows many families
> to save more than they would with the Federal tax credit for dependent
> care expenses. Note that you may only be reimbursed from the DCFSA up
> to your current account balance. If you file a claim for more than
> your current balance, it will be held until additional payroll
> allotments have been added to your account.
>
> Visit [www.fsafeds.com](http://www.fsafeds.com/) and download the
> Dependent Care Tax Credit Worksheet from the Quick Links box to help
> you determine what is best for your situation. You may also wish to
> consult a tax professional for more details.
>
> **Does it cost me anything** Probably not. While there is an
> administrative fee of \$4.00 per month for an
>
> **to participate in FSAFEDS?** 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**](http://www.fsafeds.com/), or contact SHPS by
> email or by phone**.** SHPS Benefit Counselors are available from 9:00
> a.m. until 9:00 p.m. eastern time, Monday through Friday.
>
> E-mail: <fsafeds@shps.net>
>
> Telephone: 1-877-FSAFEDS (372-3337)
>
> TTY: 1-800-952-0450 (for hearing impaired individuals that would like
> to utilize a text messaging service)

**The Federal Long Term Care Insurance Program**

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

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

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

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

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

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

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

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

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

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

**A**ccidental injury 45

Allergy tests 21

Alternative treatment 28

Allogeneic (donor) bone marrow transplant 31

Ambulance 35

Anesthesia 32

Autologous bone marrow transplant 31

**B**iopsies 29

Blood and blood plasma 33

Breast cancer-screening 19

**C**asts 33

Changes for 2004 9

Chemotherapy 22

Childbirth 20

Chiropractic 27, 44

Cholesterol tests 18

Claims 47

Coinsurance 14

Colorectal cancer screening 18

Congenital anomalies 29

Contraceptive devices and drugs 20, 43

Coordination of benefits 51

Covered services 57

Crutches 26

**D**eductible 14

Definitions 57

Dental care 44

Diagnostic services 17

Disputed claims review 49

Donor expenses (transplants) 31

Dressings 43

Durable medical equipment (DME) 26

**E**ducational classes and programs 28

Emergency 36

Eyeglasses 24

**F**amily planning 18

Fecal occult blood test 18

**G**eneral Exclusions 46

**H**earing services 24

Home health services 26

Hospice care 35

Home nursing care 26

Hospital 32

**I**mmunizations 19

Infertility 21

Inpatient Hospital Benefits 32

Insulin 43

**L**aboratory and pathological services 18

**M**agnetic Resonance Imaging (MRIs) 18

Mail Order Prescription Drugs 43

Mammograms 18

Maternity Benefits 20

Medicaid 56

Medically necessary 57

Medicare 52

Mental Conditions/Substance Abuse Benefits 38

**N**ewborn care 20

Non-FEHB Benefits 45

Nurse

Licensed Practical Nurse 26

Registered Nurse 26

Nursery charges 20

**O**bstetrical care 20

Occupational therapy 20

Ocular injury 24

Oral and maxillofacial surgery 30

Orthopedic devices 25

Out-of-pocket expenses 14

Outpatient facility care 34

Oxygen 26

**P**ap test 18

Physical therapy 23

Physician 16

Preventive care, adult 18

Preventive care, children 19

Prescription drugs 40

Preventive services 18

Prior approval 12

Prostate cancer screening 18

Prosthetic devices 25

Psychologist 38

**R**enal dialysis 22, 52

Room and board 32

**S**econd surgical opinion 16

Skilled nursing facility care 34

Speech therapy 23

Splints 33

Sterilization procedures 20

Subrogation 56

Substance abuse 38

Surgery 28

-   Anesthesia 32

-   Oral 45

-   Outpatient 34

-   Reconstructive 30

Syringes 43

**T**emporary continuation of coverage 59

Transplants 31

Treatment therapies 22

**V**ision services 24, 43

**W**ell child care 19

Wheelchairs 26

Workers' compensation 54

**X**-rays 18

  -----------------------------------------------------------------------
  **Summary of benefits for the Presbyterian Health Plan - 2004**

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

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

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

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

+-------------------------------------+--------------------------+----+
| **Benefits**                        | **You Pay**              | ** |
|                                     |                          | Pa |
|                                     |                          | ge |
|                                     |                          | ** |
+-------------------------------------+--------------------------+----+
| Medical services provided by        | Office visit copay: \$10 | 16 |
| physicians:                         | primary care             |    |
|                                     |                          |    |
| -   Diagnostic and treatment        |                          |    |
|     services provided in the office |                          |    |
+-------------------------------------+--------------------------+----+
| Services provided by a hospital:    | Nothing                  | 32 |
|                                     |                          |    |
| -   Inpatient                       | Nothing                  | 33 |
|                                     |                          |    |
| -   Outpatient                      |                          |    |
+-------------------------------------+--------------------------+----+
| Emergency benefits:                 | \$50 outpatient hospital | 36 |
|                                     | visit                    |    |
| -   In-area                         |                          | 36 |
|                                     | \$10 urgent care center  |    |
| -   Out-of-area                     |                          |    |
|                                     | \$20 urgent care center  |    |
+-------------------------------------+--------------------------+----+
| Mental health and substance abuse   | Regular cost sharing.    | 38 |
| treatment                           |                          |    |
+-------------------------------------+--------------------------+----+
| Prescription drugs                  | \$7 generic drugs        | 40 |
|                                     |                          |    |
|                                     | \$17 brand name drugs    |    |
|                                     |                          |    |
|                                     | \$34 non-brand name      |    |
|                                     | drugs                    |    |
+-------------------------------------+--------------------------+----+
| Dental Care                         | Limited benefit.         | 44 |
|                                     |                          |    |
|                                     | \$10 per visit           |    |
+-------------------------------------+--------------------------+----+
| Vision Care                         | 30% of all charges       | 23 |
|                                     | (materials)              |    |
|                                     |                          |    |
|                                     | \$10 per office visit    |    |
|                                     | (eye exam for children). |    |
+-------------------------------------+--------------------------+----+
| Special Features: Flexible benefits |                          | 43 |
| option; Services for deaf and       |                          |    |
|                                     |                          |    |
| hearing impaired, pregnancies,      |                          |    |
| Presbyterian Healthcare Services    |                          |    |
+-------------------------------------+--------------------------+----+
| Protection against catastrophic     | Nothing after            | 14 |
| costs                               | \$2,000/Self Only or     |    |
|                                     | \$4,000/Family           |    |
| (your out-of-pocket maximum)        | enrollment per year      |    |
|                                     |                          |    |
|                                     | Some costs do not count  |    |
|                                     | toward this protection   |    |
+-------------------------------------+--------------------------+----+

**2004 Rate Information for**

**Presbyterian Health Plan**

**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   | **Yo |
|              | de** | v't** | our** | v't** | our** | SPS** | ur** |
| **           |      |       |       |       |       |       |      |
| Enrollment** |      | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  | *    |
|              |      | are** | are** | are** | are** | are** | *Sha |
|              |      |       |       |       |       |       | re** |
+--------------+------+-------+-------+-------+-------+-------+------+

All Counties of New Mexico, except for Otero and Southern Eddy County

  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------
  **Self Only**   **P21**   **\$108.26**   **\$36.09**   **\$234.57**   **\$78.19**    **\$128.11**   **\$16.24**

  **Self and      **P22**   **\$277.09**   **\$99.36**   **\$600.36**   **\$215.28**   **\$327.12**   **\$49.33**
  Family**                                                                                            
  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------