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Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

> Sincerely,
>
> ![](media/image3.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

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height="1.0354166666666667in"}
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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 United States Office of Personnel Management (OPM), which
administers the Federal Employees Health Benefits (FEHB) Program, is
required to protect the privacy of your personal medical information.
OPM is also required to give you this notice to tell you how OPM may use
and give out ("disclose") your personal medical information held by OPM.

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

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  Table of Contents
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Introduction............................................................................
5

Plain Language 5

Stop Health Care Fraud! 5

Preventing medical mistakes 6

Section 1. Facts about this HMO plan 8

How we pay providers 8

Your Rights 8

Service Area 8

Section 2. How we change for 2004 11

Program-wide changes 11

Changes to this Plan 11

Section 3. How you get care 12

Identification cards 12

Where you get covered care 12

-   Plan providers 12

-   Plan facilities 12

What you must do to get covered care 12

-   Primary care 13

-   Specialty care 13

-   Hospital care 15

Circumstances beyond our control 15

Services requiring our prior approval 15

Section 4. Your costs for covered services 17

-   Copayments 17

-   Deductible 17

-   Coinsurance 17

> Your catastrophic protection out-of-pocket maximum 17

Section 5. Benefits 18

Overview 18

(a) Medical services and supplies provided by physicians and other
    health care professionals 19

(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 35

(e) Mental health and substance abuse benefits 37

(f) Prescription drug benefits 39

(g) Special features 42

-   Flexible benefits option 42

-   Out-of-area student benefits 42

-   Services for the deaf and hearing impaired 43

-   Interpreter services 43

-   Peace of Mind Program™ 43

(h) Dental benefits 44

(i) Non-FEHB benefits available to Plan members 46

Section 6. General exclusions \-- things we don\'t cover 47

Section 7. Filing a claim for covered services 48

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

-   Medicare + Choice plan 54

-   TRICARE and CHAMPVA 54

-   Workers\' Compensation 54

-   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 can get information about enrolling in the FEHB Program 57

-   Types of coverage available for you and your family 57

-   Children's Equity Act 57

-   When benefits and premiums start 58

-   When you retire 58

> When you lose benefits 58

-   When FEHB coverage ends 58

-   Spouse equity coverage 58

-   Temporary Continuation of Coverage (TCC) 59

-   Converting to individual coverage 59

-   Getting a Certificate of Group Health Plan Coverage 59

Two new Federal Programs complement FEHB benefits 60

The Federal Flexible Spending Account Program --
FSAFEDS.............................................. ................60

The Federal Long Term Care Insurance Program 63

Index\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....64

Summary of benefits 65

Rates Back cover

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  Introduction

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This brochure describes the benefits of Fallon Community Health Plan
under our contract (CS 1917) with the Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. The
address for Fallon Community Health Plan administrative offices is:

Fallon Community Health Plan

10 Chestnut St.

Worcester, MA 01608

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 11. 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
    Fallon Community Health Plan*.*

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

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

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

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  Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at
    1-800-868-5200 (TDD/TTY: 1-877-608-7677) 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:

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

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

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

-   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.

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-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

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

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

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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-   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 also 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
copayment when you receive a covered service.

**Your Rights**

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

-   Fallon Community Health Plan is licensed in the Commonwealth of
    Massachusetts as an HMO. We also qualify under Federal law as an
    HMO.

-   We have been in existence since 1977.

-   Fallon Community Health Plan is a not-for-profit organization.

If you want more information about us, call 1-800-868-5200 (TDD/TTY:
1-877-608-7677), or write to Fallon Community Health Plan, 10 Chestnut
St., Worcester, MA 01608. You may also contact us by fax at
1-508-831-0912 or visit our website at www.fchp.org.

**Service Area**

To enroll in this Plan, you must live in or work in our Select Care
service area. This is where our providers practice. Our service area
includes providers throughout Essex, Middlesex, Norfolk, Suffolk and
Worcester Counties, and in parts of Bristol, Franklin, Hampden,
Hampshire and Plymouth Counties. The following is a list of the cities
and towns in the Select Care service area:

Abington

Acton

Allston

Amesbury

Andover

Arlington

Ashburnham

Ashby

Ashland

Assonet

Athol

Attleboro

Auburn

Auburndale

Avon

Ayer

Baldwinville

Barre

Bedford

Bellingham

Belmont

Berkley

Berlin

Beverly

Billerica

Blackstone

Bolton

Boston

Boxborough

Boxford

Boylston

Braintree

Bridgewater

Brighton

Brimfield

Brockton

Brookfield

Brookline

Burlington

Cambridge

Canton

Carlisle

Charlestown

Charlton

Chelmsford

Chelsea

Cherry Valley

Chestnut Hill

Clinton

Cohasset

Concord

Danvers

Dedham

Dighton

Dorchester

Douglas

Dover

Dracut

Dudley

Dunstable

Duxbury

East Boston

East Bridgewater

East Brookfield

East Douglas

East Taunton

East Walpole

Easton

Erving

Essex

Everett

Fall River

Fiskdale

Fitchburg

Foxborough

Framingham

Franklin

Freetown

Gardner

Georgetown

Gilbertville

Gloucester

Grafton

Groton

Groveland

Halifax

Hamilton

Hanover

Hanson

Hardwick

Harvard

Haverhill

Hingham

Holbrook

Holden

Holland

Holliston

Hopedale

Hopkinton

Hubbardston

Hudson

Hull

Hyde Park

Ipswich

Jamaica Plain

Jefferson

Kingston

Lakeville

Lancaster

Lawrence

Leicester

Leominster

Lexington

Lincoln

Littleton

Lowell

Lunenburg

Lynn

Lynnfield

Malden

Manchester

Mansfield

Marblehead

Marlborough

Marshfield

Mattapan

Maynard

Medfield

Medford

Medway

Melrose

Mendon

Merrimac

Methuen

Middleborough

Middleton

Milford

Millbury

Millis

Millville

Milton

Monson

Nahant

Natick

Needham

New Braintree

New Salem

Newbury

Newburyport

Newton

Norfolk

North Andover

North

Attleboro

North Billerica

North Brookfield

North

Chelmsford

North Dighton

North Easton

North Grafton

North Oxford

North Reading

Northborough

Northbridge

Norton

Norwell

Norwood

Oakham

Orange

Oxford

Palmer

Paxton

Peabody

Pembroke

Pepperell

Petersham

Phillipston

Plainville

Plympton

Princeton

Quincy

Randolph

Raynham

Reading

Rehoboth

Revere

Rochdale

Rockland

Rockport

Roslindale

Rowley

Roxbury

Royalston

Rutland

Salem

Salisbury

Saugus

Scituate

Seekonk

Sharon

Sherborn

Shirley

Shrewsbury

Somerset

Somerville

South Boston

South Easton

South Grafton

South Hamilton

South Walpole

Southborough

Southbridge

Spencer

Sterling

Stoneham

Stoughton

Stow

Sturbridge

Sudbury

Sutton

Swampscott

Swansea

Taunton

Templeton

Tewksbury

Three Rivers

Topsfield

Townsend

Tyngsborough

Upton

Uxbridge

Waban

Wakefield

Wales

Walpole

Waltham

Ware

Warren

Warwick

Watertown

Wayland

Webster

Wellesley

Wendell

Wenham

West Boylston

West

Bridgewater

West

Brookfield

West Newbury

West Newton

West Roxbury

West

Townsend

Westborough

Westford

Westminster

Weston

Westwood

Weymouth

Whitinsville

Whitman

Wilmington

Winchendon

Winchester

Winthrop

Woburn

Worcester

Wrentham

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 moves outside of our service area, you
can enroll in another plan. If you or a family member moves, you do not
have to wait until Open Season to change plans. Contact your employing
or retirement office. If your dependents live out of the area (for
example, if your child goes to college in another state), we provide
coverage for a limited number of services, when authorized in advance by
the Plan. See Section 5(g) Special features.

*.*

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program - *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 60.

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

-   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 62.1% for Self
    Only or 38.4% for Self and Family.

-   We have eliminated the two-tier chiropractic benefit. Your copayment
    for each covered visit with a chiropractor is \$10.

-   You have a \$100 copayment for each inpatient admission to a
    hospital or other facility.

-   Your copayments for covered prescriptions obtained at a Plan
    pharmacy have increased. You will pay \$20 for up to a 30-day supply
    of a Tier-2 medication, and \$40 for up to a 30-day supply of a
    Tier-3 medication

-   When you refill your prescription through our mail-order program you
    will pay \$10 for up to a 90-day supply of a Tier-1 medication, \$40
    for up to a 90-day supply of a Tier-2 medication, and \$120 for up
    to a 90-day supply of a Tier-3 medication.

-   Your copayments for minor restorative dental care (such as metal or
    composite fillings) have increased. Copayments vary from \$16 to
    \$49. See Section 5 (h) Dental benefits*.*

-   The Plan covers injectable contraceptive drugs, such as Depo
    Provera, under the prescription drug benefit. We also cover certain
    other contraceptives, such as the contraceptive patch, under the
    prescription drug benefit.

-   If you decide that you may be discharged sooner than 48 hours
    following a vaginal delivery or 96 hours following a Caesarean
    section delivery, you are entitled to one home visit by a registered
    nurse, physician or certified nurse midwife.

-   Students attending school outside the service area have coverage for
    as many visits as are medically necessary to treat the abuse of or
    addiction to alcohol or drugs. See Section 5(g) Special features.

-   Students attending school outside the service area have coverage for
    up to 60 consecutive days or 20 nonconsecutive visits for short-term
    physical or occupational therapy (whichever is greater) per illness
    or injury in each calendar year (combined with any in-area visits).
    See Section 5(g) Special features.

> []{.mark}

[]{.mark}

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

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**Identification cards** We will send you an identification (ID) card
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
1-800-868-5200 (TDD/TTY: 1-877-608-7677) or write to us at Fallon
Community Health Plan, Customer Service Department, 10 Chestnut St.,
Worcester, MA 01608*.* You may also request replacement cards through
our website at www.fchp.org*.*

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

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

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

**•Plan facilities** Plan facilities are hospitals and other facilities
in our service area that we contract with to provide covered services to
our members. We list these in the provider directory, which we update
periodically. The list is also on our website. If there is a specific
hospital or other facility you want to use, you should check the
provider directory or our website to make sure the primary care
physician you have chosen has admitting privileges to that hospital.

It depends on the type of care you need. First, you and each family
member must choose a primary care provider. This decision is important
since your primary care provider provides or arranges for most of your
health care.

Once you become a Plan member, we will generally only pay for services
that you receive from Plan providers. However, there are certain
circumstances in which we will temporarily pay for services that you
receive from a non-Plan provider if you had been receiving care from
that provider before becoming a member of the Plan:

-   If your prior primary care provider is not a participating provider
    in any health plan offered by the FEHB Program we will pay for
    services from that provider for 30 days from your effective date.

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-   If you are receiving an ongoing course of treatment from a provider
    who is not a participating provider in any health insurance plan
    that the FEHB Program offers, we will pay for services from that
    provider for 30 days from your effective date.

-   If you are in the second or third trimester of pregnancy and you are
    receiving services related to your pregnancy from a provider who is
    not a participating provider in any health insurance plan that the
    FEHB Program offers we will pay for services from that provider
    through your postpartum period.

-   If you are terminally ill and you are receiving ongoing treatment
    from a provider who is not a participating provider in any other
    health insurance plan that the FEHB Program offers we will pay for
    services from that provider until your death.

In all cases, the provider must agree to accept reimbursement for
services at our rates, and adhere to our quality assurance standards and
other policies and procedures such as obtaining appropriate referrals
and authorizations. You will be eligible for benefits as if the provider
was under contract with us.

**• Primary care** Your primary care provider can be a family
practitioner, internist or pediatrician (or in some cases, a physician
assistant or nurse practitioner, who works under the supervision of a
physician). Your primary care provider will provide most of your health
care, or give you a referral to see a specialist.

If you want to change primary care providers call us. We will help you
select a new one. You can also notify us when you want to change your
primary care provider on our website at
[www.fchp.org](http://www.fchp.org/).

If your primary care provider leaves the Plan we will notify you in
writing, either 30 days prior to the date of termination or as soon as
we are notified of the termination, whichever is later (except in cases
where the provider is terminated for reasons involving fraud, patient
safety or quality of care). You may continue to receive treatment from
your primary care provider for 30 days beyond the date of termination of
our contract. You will be required to choose a new primary care
provider.

**• Specialty care** In some instances you can self refer to a
specialist. This means that you can call the specialist and make the
appointment yourself. You do not need to have a referral from your
primary care physician but you must see a Plan provider.

Services you can self refer for:

-   Office visits with a Fallon Clinic specialist (physician, physician
    assistant, nurse midwife or nurse practitioner only) if you have a
    Fallon Clinic primary care provider.

-   Services with an obstetrician or gynecologist. This includes an
    annual gynecological examination, Pap smear, and routine mammogram;
    services for acute or emergent gynecological conditions; and
    maternity care. It does not include inpatient admissions or
    infertility treatment (unless provided by a Fallon Clinic specialist
    and you have a Fallon Clinic primary care provider); see page 22 for
    more information on "Infertility/assisted reproductive technology
    services").

-   Office visits to an oral surgeon for extraction of impacted teeth.
    Visits to an oral surgeon for any other procedure require a referral
    and authorization. See page 29 for more information on covered oral
    surgery services.

-   Routine eye examinations with an ophthalmologist or optometrist.

-   Routine dental care

-   Outpatient mental health and substance abuse services. For help in
    finding a network provider, call 1-888-421-8861 (TDD/TTY:
    781-994-7660).

> For certain other specialist visits and specialty services, your
> primary care provider will refer you to a specialist for needed care.
> When you receive a referral from your primary care provider, you must
> return to the primary care provider after the consultation, unless
> your primary care provider authorized a certain number of visits
> without additional referrals. The primary care provider must provide
> or authorize all follow-up care. Do not go to the specialist for
> return visits unless your primary care provider gives you a referral.
>
> Services that need a referral from your primary care provider:

-   Office visits with a specialist (if you have a Fallon Clinic primary
    care provider you may self refer to a Fallon Clinic specialist);
    your primary care provider or specialist must obtain authorization
    from the Plan for most specialty services.

-   Initial visit to a chiropractor or podiatrist; the chiropractor or
    podiatrist must obtain authorization from the Plan for all
    subsequent visits.

-   Physical, occupational and speech therapy; your primary care
    provider completes a prescription to a therapist. Coverage is
    provided for up to six visits, the therapist must obtain
    authorization from the Plan for any additional visits.

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 provider will
give you a standing referral that allows you to see your specialist for
a certain number of visits without additional referrals. Your primary
care provider and the specialist will work together to develop a
treatment plan for you and the specialist will keep your primary care
physician up-to-date on your treatment. (For certain specialist visits
and for certain types of specialty services your primary care provider
or specialist may have to get authorization from the Plan beforehand.)

• If you are seeing a specialist when you enroll in our Plan, talk to
your primary care provider. Your primary care provider 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. (See below for a list
of circumstances in which we will temporarily pay for services with a
non-Plan provider.)

-   We will provide coverage of pediatric specialty care, including
    mental health care, to a child requiring such care, when provided by
    a provider with recognized expertise in specialty pediatrics.

We cannot guarantee that any one physician, hospital or other provider
will remain under contract with us. We reserve the right at any time to
end our contract with any Plan provider who may be furnishing you with
care. If this occurs, we will generally no longer pay for services
provided to you by that provider, except in the circumstances listed
below.

• If you are seeing a specialist and your specialist leaves the Plan,
call your primary care provider, 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 are terminally ill and our contract with a provider from whom
    you are receiving treatment related to that illness ends, you may
    continue to receive treatment from that provider.

• 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,

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-   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.

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-   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 provider or specialist will make
necessary hospital arrangements and supervise your care. This includes
admission to a skilled nursing or other type of facility.

> If you are in the hospital when your enrollment in our Plan begins,
> call our Customer Service Department immediately at 1-800-868-5200
> (TDD/TTY: 1-877-608-7677). If you are new to the FEHB Program, we will
> arrange for you to receive care.

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

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

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

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

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

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

Your primary care provider has authority to refer you for most services.
For certain services, however, your primary care provider must obtain
prior 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
provider must obtain pre-authorization for the following services:

-   All elective admissions to a hospital or other inpatient facility

-   Services with a non-Plan provider

-   Peace of Mind Program^™^

-   Organ transplant evaluation and services

-   Reconstructive surgery

-   Infertility/assisted reproductive technology services

-   Oral surgery (with the exception of the extraction of impacted
    teeth)

-   Genetic testing

-   Neuropsychological testing

-   Prosthetics/orthotics and durable medical equipment

-   Home health care (including hospice care)

-   Non-emergency ambulance

-   PET scans

When your primary care provider needs pre-authorization from the Plan,
he or she will send a *"Request for Authorization"* to the Plan. We will
review the request and make an authorization decision within two
business days of receipt of the medical information. We will tell your
primary care provider of our decision within 24 hours thereafter.

If we authorize the service, we will send you and your primary care
provider confirmation within two business days of the decision. When you
get the authorization letter you can call the specialist to make the
appointment. The authorization letter will state the services the Plan
has approved for coverage. If the specialist feels you need services
beyond those we have approved, he or she will ask for authorization
directly from the Plan. If we approve the request for additional
services we will send you and your primary care provider an
authorization letter.

If we do not authorize a service, we will send you and your primary care
provider a denial letter within one business day of the decision. The
denial letter will explain our reasons for the decision and your right
to file a grievance. If we do not authorize the service, you will be
financially responsible.

  -----------------------------------------------------------------------
  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 provider you pay a copayment of
\$10 per office visit

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

**•Coinsurance** We do not have coinsurance.

We do not have a catastrophic protection out-of-pocket maximum.

**Your catastrophic protection**

**out-of-pocket maximum**

+-----------------------------------------------------------------------+
| **Section 5. Benefits \-- OVERVIEW**                                  |
|                                                                       |
| ***(See page 11 for how our benefits changed this year and page 65    |
| 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
*1-800-868-5200 (TDD/TTY: 1-877-608-7677)* or at our website at
www.fchp.org.

(a) Medical services and supplies provided by physicians and other
    health care professionals 19-27

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 27-30

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

(c) Services provided by a hospital or other facility, and ambulance
    services 31-33

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

(d) Emergency services/accidents 34-35

> •Medical emergency •Ambulance

(e) Mental health and substance abuse benefits 36-37

(f) Prescription drug benefits 38-41

(g) Special features 42-43

-   Flexible benefits option

-   Out-of-area student benefits

-   Services for the hearing impaired

-   Interpreter services

-   Peace of Mind Program^™^

(h) Dental benefits 44-45

(i) Non-FEHB benefits available to Plan members 46

Summary of benefits 65

+---+---+------------------------------------+---+---------------------+---+---+
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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 providers must provide    |   |                     | * |   |
|   | * |     your care.                     |   |                     | * |   |
|   | P |                                    |   |                     | P |   |
|   | * | -   Be sure to read Section 3,     |   |                     | * |   |
|   | * |     *How you get care,* for        |   |                     | * |   |
|   |   |     important information on what  |   |                     |   |   |
|   | * |     you must do to get covered     |   |                     | * |   |
|   | * |     care.                          |   |                     | * |   |
|   | O |                                    |   |                     | O |   |
|   | * | -   You are responsible for        |   |                     | * |   |
|   | * |     copayments when you receive    |   |                     | * |   |
|   |   |     certain services. Also read    |   |                     |   |   |
|   | * |     Section 9 about coordinating   |   |                     | * |   |
|   | * |     benefits with other coverage,  |   |                     | * |   |
|   | R |     including with Medicare.       |   |                     | R |   |
|   | * |                                    |   |                     | * |   |
|   | * |                                    |   |                     | * |   |
|   |   |                                    |   |                     |   |   |
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+---+---+------------------------------------+---+---------------------+---+---+
| > |   |                                    |   | **You pay**         |   |   |
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+---+---+------------------------------------+---+---------------------+---+---+
| # |   |                                    |   |                     |   |   |
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| * |   |                                    |   |                     |   |   |
+---+---+------------------------------------+---+---------------------+---+---+
| > |   |                                    |   | > \$10 per office   |   |   |
|   |   |                                    |   | > visit             |   |   |
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+---+---+------------------------------------+---+---------------------+---+---+
| > |   |                                    |   | > Nothing           |   |   |
|   |   |                                    |   |                     |   |   |
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| d |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| u |   |                                    |   |                     |   |   |
| r |   |                                    |   |                     |   |   |
| s |   |                                    |   |                     |   |   |
| i |   |                                    |   |                     |   |   |
| n |   |                                    |   |                     |   |   |
| g |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
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| f |   |                                    |   |                     |   |   |
| a |   |                                    |   |                     |   |   |
| c |   |                                    |   |                     |   |   |
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| t |   |                                    |   |                     |   |   |
| y |   |                                    |   |                     |   |   |
+---+---+------------------------------------+---+---------------------+---+---+
| > |   |                                    |   | > \$10 per home     |   |   |
|   |   |                                    |   | > visit             |   |   |
| P |   |                                    |   |                     |   |   |
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| > |   |                                    |   | > Nothing           |   |   |
|   |   |                                    |   | >                   |   |   |
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| o |   |                                    |   | > these services    |   |   |
| u |   |                                    |   | > during an office  |   |   |
| t |   |                                    |   | > visit a \$10      |   |   |
| i |   |                                    |   | > copay applies to  |   |   |
| n |   |                                    |   | > the office visit  |   |   |
| e |   |                                    |   | > only)             |   |   |
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+---+---+------------------------------------+---+---------------------+---+---+
| > |   |                                    |   | > Nothing           |   |   |
|   |   |                                    |   | >                   |   |   |
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| o |   |                                    |   | > these services    |   |   |
| u |   |                                    |   | > during an office  |   |   |
| t |   |                                    |   | > visit a \$10      |   |   |
| i |   |                                    |   | > copay applies to  |   |   |
| n |   |                                    |   | > the office visit  |   |   |
| e |   |                                    |   | > only)             |   |   |
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|   |   |                                    |   |                     |   |   |
| 6 |   |                                    |   |                     |   |   |
| 5 |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
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| d |   |                                    |   |                     |   |   |
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|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
|   |   |                                    |   |                     |   |   |
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| r |   |                                    |   |                     |   |   |
+---+---+------------------------------------+---+---------------------+---+---+

+------------------------------------------+---------------------------+---+
| ##### Preventive care, children          | ##### You pay             |   |
+------------------------------------------+---------------------------+---+
| -   Childhood immunizations recommended  | > Nothing                 |   |
|     by the American Academy of           | >                         |   |
|     Pediatrics                           | > (If you receive these   |   |
|                                          | > services during an      |   |
| -   Hereditary and metabolic screening   | > office visit a \$10     |   |
|     at birth, tuberculin tests,          | > copay applies to the    |   |
|     hematocrit, hemoglobin or other      | > office visit only)      |   |
|     appropriate blood tests, and         |                           |   |
|     urinalysis as recommended by the     |                           |   |
|     provider                             |                           |   |
|                                          |                           |   |
| -   Screening of all children under six  |                           |   |
|     years of age for the presence of     |                           |   |
|     lead poisoning                       |                           |   |
+------------------------------------------+---------------------------+---+
| -   Well-child care charges for routine  | > \$10 per office visit   |   |
|     examinations, immunizations and care |                           |   |
|     (through age 22)                     |                           |   |
|                                          |                           |   |
| -   Physical examination, history,       |                           |   |
|     measurements, sensory screening,     |                           |   |
|     neuropsychiatric evaluation,         |                           |   |
|     development screening and assessment |                           |   |
|     six times during the child's first   |                           |   |
|     year after birth, three times during |                           |   |
|     the next year, and annually until    |                           |   |
|     age six                              |                           |   |
|                                          |                           |   |
| -   Examinations, such as:               |                           |   |
|                                          |                           |   |
| ```{=html}                               |                           |   |
| <!-- -->                                 |                           |   |
| ```                                      |                           |   |
| -   Eye exams through age 17 to          |                           |   |
|     determine the need for vision        |                           |   |
|     correction                           |                           |   |
|                                          |                           |   |
| -   Ear exams through age 17 to          |                           |   |
|     determine the need for hearing       |                           |   |
|     correction                           |                           |   |
|                                          |                           |   |
| -   Examinations done on the day of      |                           |   |
|     immunizations (through age 22)       |                           |   |
+------------------------------------------+---------------------------+---+
| ######## Maternity care                  |                           |   |
+------------------------------------------+---------------------------+---+
| > Complete maternity (obstetrical) care, | > \$10 for the first      |   |
| > such as:                               | > office visit for        |   |
|                                          | > prenatal care, all      |   |
| -   Prenatal care                        | > other prenatal visits   |   |
|                                          | > covered in full;        |   |
| -   Delivery                             | >                         |   |
|                                          | > \$10 per office visit   |   |
| -   Postnatal care                       | > for postnatal care      |   |
|                                          | >                         |   |
| > Note: Here are some things to keep in  | > \$100 copay applies to  |   |
| > mind:                                  | > inpatient care.         |   |
|                                          |                           |   |
| -   You do not need pre-authorization    |                           |   |
|     for your normal delivery; see page   |                           |   |
|     15 for other circumstances.          |                           |   |
|                                          |                           |   |
| -   You may remain in the hospital up to |                           |   |
|     48 hours after a regular delivery    |                           |   |
|     and 96 hours after a Caesarean       |                           |   |
|     delivery. We will extend your        |                           |   |
|     inpatient stay if medically          |                           |   |
|     necessary. If you are discharged     |                           |   |
|     sooner (the mother must decide to    |                           |   |
|     accept an early discharge), you are  |                           |   |
|     covered for one home visit by a      |                           |   |
|     registered nurse, physician or       |                           |   |
|     certified nurse midwife.             |                           |   |
|                                          |                           |   |
| -   We cover routine nursery care,       |                           |   |
|     routine examination, newborn hearing |                           |   |
|     screening and circumcision 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)*.*             |                           |   |
+------------------------------------------+---------------------------+---+

Maternity care \-- continued on next page

+------------------------------------------+--------------------------+---+
| > *Not covered: Routine sonograms to     | > *All charges.*         |   |
| > determine fetal age, size or sex*      |                          |   |
+------------------------------------------+--------------------------+---+
| ######## Family planning                 | ##### You pay            |   |
+------------------------------------------+--------------------------+---+
| A range of voluntary family planning     | > \$10 per office visit  |   |
| services, limited to:                    |                          |   |
|                                          |                          |   |
| -   Consultations, examinations,         |                          |   |
|     procedures and medical services      |                          |   |
|     related to the use of all            |                          |   |
|     contraceptive methods                |                          |   |
|                                          |                          |   |
| -   Voluntary sterilization (See         |                          |   |
|     Surgical procedures Section 5 (b))   |                          |   |
|                                          |                          |   |
| -   Contraceptives that are furnished by |                          |   |
|     a provider during an office visit,   |                          |   |
|     such as:                             |                          |   |
|                                          |                          |   |
| ```{=html}                               |                          |   |
| <!-- -->                                 |                          |   |
| ```                                      |                          |   |
| -   Surgically implanted contraceptives  |                          |   |
|     (such as Norplant)                   |                          |   |
|                                          |                          |   |
| -   Intrauterine devices (IUDs)          |                          |   |
|                                          |                          |   |
| -   Diaphragms                           |                          |   |
|                                          |                          |   |
| -   Cervical caps                        |                          |   |
|                                          |                          |   |
| > NOTE: We cover oral contraceptives and |                          |   |
| > certain other contraceptives, such as  |                          |   |
| > Depo Provera and the contraceptive     |                          |   |
| > patch under the prescription drug      |                          |   |
| > benefit.                               |                          |   |
+------------------------------------------+--------------------------+---+
| > *Not covered: reversal of voluntary    | > *All charges.*         |   |
| > surgical sterilization, genetic        |                          |   |
| > counseling, over-the-counter           |                          |   |
| > contraceptive drugs or devices*        |                          |   |
+------------------------------------------+--------------------------+---+
| ######## Infertility services            |                          |   |
+------------------------------------------+--------------------------+---+
| > Diagnosis and treatment of             | > \$10 per office visit  |   |
| > infertility, such as:                  |                          |   |
|                                          |                          |   |
| -   Office visits for the evaluation and |                          |   |
|     diagnosis of infertility             |                          |   |
|                                          |                          |   |
| -   Artificial insemination (AI)         |                          |   |
|                                          |                          |   |
| -   In vitro fertilization and embryo    |                          |   |
|     placement (IVF-EP)                   |                          |   |
|                                          |                          |   |
| -   Gamete Intra fallopian transfer      |                          |   |
|     (GIFT)                               |                          |   |
|                                          |                          |   |
| -   Zygote Intra fallopian transfer      |                          |   |
|     (ZIFT)                               |                          |   |
|                                          |                          |   |
| -   Intracytoplasmic sperm injection     |                          |   |
|     (ICSI)                               |                          |   |
|                                          |                          |   |
| -   Sperm, egg and/or inseminated egg    |                          |   |
|     procurement and processing, and      |                          |   |
|     banking of sperm or inseminated eggs |                          |   |
|                                          |                          |   |
| To be eligible, you must be an           |                          |   |
| individual who:                          |                          |   |
|                                          |                          |   |
| (1) is unable to conceive or produce     |                          |   |
|     conception during a period of one    |                          |   |
|     year; and                            |                          |   |
|                                          |                          |   |
| (2) should expect fertility as a natural |                          |   |
|     state; or                            |                          |   |
|                                          |                          |   |
| (3) is a premenopausal female or a       |                          |   |
|     female who is experiencing menopause |                          |   |
|     at a premature age.                  |                          |   |
|                                          |                          |   |
| Approval for Assisted Reproductive       |                          |   |
| Technology (ART) is contingent upon      |                          |   |
| review of your medical history by the    |                          |   |
| Plan medical director. Initial approval  |                          |   |
| covers four ART cycles, if you wish to   |                          |   |
| continue beyond four cycles, further     |                          |   |
| medical review by the Plan medical       |                          |   |
| director is required.                    |                          |   |
|                                          |                          |   |
| A benefits pamphlet is available by      |                          |   |
| contacting Customer Service at           |                          |   |
| 1-800-868-5200 (TDD/TTY:                 |                          |   |
| 1-877-608-7677).                         |                          |   |
|                                          |                          |   |
| Note: We cover oral and injectable       |                          |   |
| fertility drugs that are                 |                          |   |
| self-administered under the prescription |                          |   |
| drug benefit.                            |                          |   |
+------------------------------------------+--------------------------+---+
| > *Not covered:*                         | > *All charges.*         |   |
|                                          |                          |   |
| -   *Treatments, services and supplies   |                          |   |
|     which have not been determined to be |                          |   |
|     medically necessary*                 |                          |   |
|                                          |                          |   |
| -   *Donor egg transfer for women who    |                          |   |
|     are menopausal, except as stated     |                          |   |
|     above*                               |                          |   |
|                                          |                          |   |
| -   *Chromosome studies of a donor       |                          |   |
|     (sperm or egg)*                      |                          |   |
|                                          |                          |   |
| -   *Charges for the storage of donor    |                          |   |
|     sperm, eggs or embryo that remain in |                          |   |
|     storage after the completion of an   |                          |   |
|     approved treatment cycle*            |                          |   |
|                                          |                          |   |
| -   *Compensation to a donor (this does  |                          |   |
|     not include charges related to the   |                          |   |
|     procurement and processing of sperm, |                          |   |
|     egg and inseminated egg, to the      |                          |   |
|     extent that the donor's insurance    |                          |   |
|     does not cover these costs.)*        |                          |   |
|                                          |                          |   |
| -   *Supplies that may be purchased      |                          |   |
|     without a physician's written order, |                          |   |
|     such as ovulation test kits*         |                          |   |
|                                          |                          |   |
| -   *Services which are necessary due to |                          |   |
|     a voluntary sterilization, or for    |                          |   |
|     which there is no diagnosis of       |                          |   |
|     infertility*                         |                          |   |
|                                          |                          |   |
| -   *Surrogacy or gestational carrier    |                          |   |
|     services*                            |                          |   |
|                                          |                          |   |
| -   *Transportation costs to or from the |                          |   |
|     medical facility*                    |                          |   |
+------------------------------------------+--------------------------+---+
| > **Allergy care**                       | **You pay**              |   |
+------------------------------------------+--------------------------+---+
| Testing and treatment                    | > \$10 per office visit  |   |
|                                          |                          |   |
| Allergy injections                       |                          |   |
+------------------------------------------+--------------------------+---+
| > Allergy serum                          | > Nothing                |   |
+------------------------------------------+--------------------------+---+
| > *Not covered: provocative food testing | > *All charges.*         |   |
| > and sublingual allergy                 |                          |   |
| > desensitization*                       |                          |   |
+------------------------------------------+--------------------------+---+
| ######## Treatment therapies             |                          |   |
+------------------------------------------+--------------------------+---+
| -   Chemotherapy                         | > Nothing                |   |
|                                          | >                        |   |
| > Note: High dose chemotherapy in        | > (If you receive these  |   |
| > association with autologous bone       | > services during an     |   |
| > marrow transplants is limited to those | > office visit a \$10    |   |
| > transplants listed under Organ/tissue  | > copay applies to the   |   |
| > transplants on page 30.                | > office visit only)     |   |
|                                          |                          |   |
| -   Radiation therapy                    |                          |   |
|                                          |                          |   |
| > Note: drug therapies for the treatment |                          |   |
| > of respiratory diseases are covered    |                          |   |
| > under the prescription drug benefit    |                          |   |
|                                          |                          |   |
| -   Respiratory and inhalation therapy   |                          |   |
|                                          |                          |   |
| ```{=html}                               |                          |   |
| <!-- -->                                 |                          |   |
| ```                                      |                          |   |
| -   Dialysis -- hemodialysis and         |                          |   |
|     continuous ambulatory peritoneal     |                          |   |
|     dialysis                             |                          |   |
|                                          |                          |   |
| ```{=html}                               |                          |   |
| <!-- -->                                 |                          |   |
| ```                                      |                          |   |
| -   Intravenous (IV)/Infusion Therapy -- |                          |   |
|     Home IV and antibiotic therapy       |                          |   |
|                                          |                          |   |
| -   Growth hormone therapy (GHT)         |                          |   |
|                                          |                          |   |
| Note: Growth hormone is covered under    |                          |   |
| the prescription drug benefit. We will   |                          |   |
| only provide coverage for GHT when we    |                          |   |
| preauthorize the treatment. Your Plan    |                          |   |
| provider will submit a request for       |                          |   |
| authorization before you begin           |                          |   |
| treatment. If your Plan provider does    |                          |   |
| 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.            |                          |   |
+------------------------------------------+--------------------------+---+
| > **Physical and occupational            | ####### You pay          |   |
| > therapies**                            |                          |   |
+------------------------------------------+--------------------------+---+
| -   Up to 60 consecutive visits or 20    | > \$10 per office visit  |   |
|     nonconsecutive visits (whichever is  | >                        |   |
|     greater) per illness or injury per   | > Nothing per visit      |   |
|     calendar year for:                   | > during covered         |   |
|                                          | > inpatient admission    |   |
| ```{=html}                               |                          |   |
| <!-- -->                                 |                          |   |
| ```                                      |                          |   |
| -   physical therapy                     |                          |   |
|                                          |                          |   |
| -   occupational therapy                 |                          |   |
|                                          |                          |   |
| > Note: We only cover therapy to restore |                          |   |
| > bodily function when there has been a  |                          |   |
| > total or partial loss of bodily        |                          |   |
| > function due to illness or injury.     |                          |   |
+------------------------------------------+--------------------------+---+
| -   Cardiac rehabilitation for persons   | > Nothing                |   |
|     with documented cardiovascular       |                          |   |
|     disease, initiated within 26 weeks   |                          |   |
|     after the diagnosis of               |                          |   |
|     cardiovascular disease.              |                          |   |
|                                          |                          |   |
| -   Early intervention services          |                          |   |
|     delivered by certified early         |                          |   |
|     intervention specialists according   |                          |   |
|     to operational standards developed   |                          |   |
|     by the Department of Public Health,  |                          |   |
|     for children from birth to their     |                          |   |
|     3^rd^ birthday. Benefits are limited |                          |   |
|     to a maximum of \$3,200 per year per |                          |   |
|     child and an aggregate of \$9,600    |                          |   |
|     over the term of the child's Plan    |                          |   |
|     membership.                          |                          |   |
+------------------------------------------+--------------------------+---+
| > *Not covered:*                         | > *All charges.*         |   |
|                                          |                          |   |
| -   *Long-term rehabilitative therapy*   |                          |   |
|                                          |                          |   |
| -   *Exercise programs*                  |                          |   |
|                                          |                          |   |
| -   *Acupuncture, aquatic therapy or     |                          |   |
|     massage therapy*                     |                          |   |
+------------------------------------------+--------------------------+---+
| > **Speech therapy**                     |                          |   |
+------------------------------------------+--------------------------+---+
| > Medically necessary services for the   | > \$10 per office visit  |   |
| > diagnosis and treatment of speech,     | >                        |   |
| > hearing and language disorders when    | > Nothing per visit      |   |
| > services are provided by a Plan        | > during covered         |   |
| > provider who is a speech-language      | > inpatient admission    |   |
| > pathologist or audiologist; at a Plan  |                          |   |
| > facility or provider's office.         |                          |   |
+------------------------------------------+--------------------------+---+
| > **Hearing services**                   |                          |   |
+------------------------------------------+--------------------------+---+
| > Hearing testing for children through   | > \$10 per office visit  |   |
| > age 17 (see *Preventive care,          |                          |   |
| > children*)                             |                          |   |
+------------------------------------------+--------------------------+---+
| > *Not covered:*                         | > *All charges.*         |   |
|                                          |                          |   |
| -   *All other hearing testing*          |                          |   |
|                                          |                          |   |
| -   *Hearing aids, testing and           |                          |   |
|     examinations for them*               |                          |   |
+------------------------------------------+--------------------------+---+
| > **Vision services**                    |                          |   |
+------------------------------------------+--------------------------+---+
| -   Diagnosis and treatment of diseases  | > \$10 per office visit  |   |
|     of the eye                           |                          |   |
|                                          |                          |   |
| -   Annual eye refractions               |                          |   |
+------------------------------------------+--------------------------+---+
| > *Not covered:*                         | > *All charges.*         |   |
|                                          |                          |   |
| -   *Eyeglasses or contact lenses*       |                          |   |
|                                          |                          |   |
| -   *Eye examinations for contact        |                          |   |
|     lenses*                              |                          |   |
|                                          |                          |   |
| -   *Eye exercises and orthoptics*       |                          |   |
|                                          |                          |   |
| -   *Radial keratotomy and other         |                          |   |
|     refractive surgery*                  |                          |   |
+------------------------------------------+--------------------------+---+
| ######## Foot care                       | **You pay**              |   |
+------------------------------------------+--------------------------+---+
| > 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*              |                          |   |
|                                          |                          |   |
| -   *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**  |                          |   |
+------------------------------------------+--------------------------+---+
| > Orthopedic devices (devices that       | > Nothing up to the      |   |
| > support part of the body and/or        | > benefit limit of       |   |
| > eliminate motion) such as neck collars | > \$1,500 per calendar   |   |
| > for cervical support, molded body      | > year. You pay all      |   |
| > jacket for curvature of the spine and  | > charges beyond the     |   |
| > braces with rigid support              | > benefit limit.         |   |
| >                                        | >                        |   |
| > Prosthetic devices (devices that       | > Orthopedic and         |   |
| > replace all or part of an organ or     | > prosthetic devices and |   |
| > body part, not including dental) such  | > durable medical        |   |
| > as artificial limbs and eyes,          | > equipment are subject  |   |
| > implanted corrective lenses following  | > to a combined benefit  |   |
| > cataract surgery and electric speech   | > limit.                 |   |
| > aids                                   |                          |   |
| >                                        |                          |   |
| > Corrective orthopedic appliances for   |                          |   |
| > nondental treatment of                 |                          |   |
| > temporomandibular joint (TMJ) pain     |                          |   |
| > dysfunction syndrome                   |                          |   |
| >                                        |                          |   |
| > Note: All orthopedic and prosthetic    |                          |   |
| > devices must be ordered by a Plan      |                          |   |
| > provider and authorized by the Plan.   |                          |   |
+------------------------------------------+--------------------------+---+
| > Scalp hair prosthesis (wigs) for       | > Nothing up to the      |   |
| > individuals who have suffered hair     | > benefit limit of \$350 |   |
| > loss as a result of the treatment of   | > per calendar year. You |   |
| > any form of cancer or leukemia         | > pay all charges beyond |   |
|                                          | > the benefit limit.     |   |
+------------------------------------------+--------------------------+---+
| > Externally worn breast prostheses and  | > Nothing                |   |
| > surgical bras, including necessary     |                          |   |
| > replacements, following a mastectomy   |                          |   |
| >                                        |                          |   |
| > Internal prosthetic devices, such as   |                          |   |
| > artificial joints, pacemakers,         |                          |   |
| > cochlear implants and surgically       |                          |   |
| > implanted breast implant following     |                          |   |
| > mastectomy. Note: We pay internal      |                          |   |
| > prosthetic devices as hospital         |                          |   |
| > benefits; see Section 5(c) for payment |                          |   |
| > information. See 5(b) for coverage of  |                          |   |
| > the surgery to insert the device.      |                          |   |
+------------------------------------------+--------------------------+---+
| > *Not covered:*                         | > *All charges.*         |   |
|                                          |                          |   |
| -   *Orthopedic and corrective shoes*    |                          |   |
|                                          |                          |   |
| -   *Arch supports*                      |                          |   |
|                                          |                          |   |
| -   *Foot orthotics*                     |                          |   |
|                                          |                          |   |
| -   *Heel pads and heel cups*            |                          |   |
|                                          |                          |   |
| -   *Lumbosacral supports*               |                          |   |
|                                          |                          |   |
| -   *Corsets, trusses, elastic           |                          |   |
|     stockings, support hose, and other   |                          |   |
|     supportive devices*                  |                          |   |
+------------------------------------------+--------------------------+---+
| ######## Durable medical equipment (DME) | **You pay**              |   |
+------------------------------------------+--------------------------+---+
| > The rental or purchase, at our option, | > Nothing up to the      |   |
| > including repair and adjustment, of    | > benefit limit of       |   |
| > durable medical equipment prescribed   | > \$1,500 per calendar   |   |
| > by your Plan provider, such as oxygen  | > year. You pay all      |   |
| > and dialysis equipment. Under this     | > charges beyond the     |   |
| > benefit, we also cover                 | > benefit limit.         |   |
|                                          | >                        |   |
| -   hospital beds                        | > Orthopedic and         |   |
|                                          | > prosthetic devices and |   |
| -   wheelchairs                          | > durable medical        |   |
|                                          | > equipment are subject  |   |
| -   crutches                             | > to a combined benefit  |   |
|                                          | > limit.                 |   |
| -   walkers                              |                          |   |
|                                          |                          |   |
| -   blood glucose monitors               |                          |   |
|                                          |                          |   |
| ```{=html}                               |                          |   |
| <!-- -->                                 |                          |   |
| ```                                      |                          |   |
| -   visual magnifying aids and voice     |                          |   |
|     synthesizers for blood glucose       |                          |   |
|     monitors for use by the legally      |                          |   |
|     blind                                |                          |   |
|                                          |                          |   |
| -   therapeutic/molded shoes and shoe    |                          |   |
|     inserts for the treatment of severe  |                          |   |
|     diabetic foot disease                |                          |   |
|                                          |                          |   |
| > Note: Insulin pumps and insulin pump   |                          |   |
| > supplies are covered under the         |                          |   |
| > prescription drug benefit. All durable |                          |   |
| > medical equipment must be ordered by a |                          |   |
| > Plan provider and authorized by the    |                          |   |
| > Plan.                                  |                          |   |
+------------------------------------------+--------------------------+---+
| > Oxygen and oxygen equipment            | > Nothing                |   |
+------------------------------------------+--------------------------+---+
| > *Not covered:*                         | > *All charges.*         |   |
|                                          |                          |   |
| -   *Items that are not covered include, |                          |   |
|     but are not limited to air           |                          |   |
|     conditioners, air purifiers, arch    |                          |   |
|     supports, ear plugs (to prevent      |                          |   |
|     fluid from entering the ear canal    |                          |   |
|     during water activities), foot       |                          |   |
|     orthotics, orthopedic shoes (except  |                          |   |
|     when part of a brace) or other       |                          |   |
|     supportive devices for the feet,     |                          |   |
|     articles of special clothing,        |                          |   |
|     compression garments (such as Jobst® |                          |   |
|     stockings), bed-pans, raised toilet  |                          |   |
|     seats, dehumidifiers, dentures,      |                          |   |
|     elevators, safety grab bars, car     |                          |   |
|     seats, seizure helmets, hearing      |                          |   |
|     aids, heating pads, hot water        |                          |   |
|     bottles, exercise equipment or       |                          |   |
|     similar equipment.*                  |                          |   |
|                                          |                          |   |
| -   *Oxygen and related equipment when   |                          |   |
|     received from a non-Plan provider.   |                          |   |
|     This includes oxygen and related     |                          |   |
|     equipment that you are supplied with |                          |   |
|     while you are out of our service     |                          |   |
|     area.*                               |                          |   |
+------------------------------------------+--------------------------+---+
| ######## Home health services            | **You pay**              |   |
+------------------------------------------+--------------------------+---+
| > Home health care ordered by a Plan     | > Nothing                |   |
| > physician and authorized by the Plan.  |                          |   |
| > Services include:                      |                          |   |
|                                          |                          |   |
| -   skilled nursing care                 |                          |   |
|                                          |                          |   |
| -   physical, occupational and speech    |                          |   |
|     therapy                              |                          |   |
|                                          |                          |   |
| -   oxygen and intravenous therapy       |                          |   |
|                                          |                          |   |
| -   medical social services              |                          |   |
|                                          |                          |   |
| -   home health aide services            |                          |   |
|                                          |                          |   |
| -   medical and surgical supplies and    |                          |   |
|     durable medical equipment            |                          |   |
|                                          |                          |   |
| -   nutritional consultation             |                          |   |
|                                          |                          |   |
| > Note: Durable medical equipment and    |                          |   |
| > physical and occupational therapy      |                          |   |
| > provided as a medically necessary      |                          |   |
| > component of home health care are not  |                          |   |
| > subject to the benefit limits.         |                          |   |
+------------------------------------------+--------------------------+---+
| > 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                    |                          |   |
+------------------------------------------+--------------------------+---+
| > Chiropractic services for acute        | > \$10 per office visit  |   |
| > musculoskeletal conditions. The        |                          |   |
| > condition must be new or an            |                          |   |
| > exacerbation of a previous condition.  |                          |   |
| > Treatment must be provided by a Plan   |                          |   |
| > chiropractor and requires a referral   |                          |   |
| > from your primary care physician.      |                          |   |
| > Coverage is provided for up to 20      |                          |   |
| > visits in each calendar year.          |                          |   |
+------------------------------------------+--------------------------+---+
| ######## Alternative treatments          |                          |   |
+------------------------------------------+--------------------------+---+
| ## Not covered:                          | > *All charges.*         |   |
|                                          |                          |   |
| -   *Naturopathic services*              |                          |   |
|                                          |                          |   |
| -   *Hypnotherapy*                       |                          |   |
|                                          |                          |   |
| -   *Biofeedback*                        |                          |   |
+------------------------------------------+--------------------------+---+
| #                                        |                          |   |
| ### **Educational classes and programs** |                          |   |
+------------------------------------------+--------------------------+---+
| > Smoking Cessation -- Up to \$100 for   | > Nothing                |   |
| > one smoking cessation program per      |                          |   |
| > member per lifetime, including all     |                          |   |
| > related expenses such as drugs         |                          |   |
+------------------------------------------+--------------------------+---+
| > Diabetes self-management training and  | > \$10 per office visit  |   |
| > education, including medical nutrition |                          |   |
| > therapy, provided by a certified       |                          |   |
| > diabetes health care provider          |                          |   |
+------------------------------------------+--------------------------+---+

+---+---+-----------------------------------+-------------------+---+---+
| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
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| f |   |                                   |                   |   |   |
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| s |   |                                   |                   |   |   |
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| 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  |                   | * |   |
|   | * |     your care.                    |                   | * |   |
|   | P |                                   |                   | P |   |
|   | * | -   Be sure to read Section 4,    |                   | * |   |
|   | * |     *Your costs for covered       |                   | * |   |
|   |   |     services,* for valuable       |                   |   |   |
|   | * |     information about how cost    |                   | * |   |
|   | * |     sharing works. Also read      |                   | * |   |
|   | O |     Section 9 about coordinating  |                   | O |   |
|   | * |     benefits with other coverage, |                   | * |   |
|   | * |     including with Medicare.      |                   | * |   |
|   |   |                                   |                   |   |   |
|   | * | -   The amounts listed below are  |                   | * |   |
|   | * |     for the charges billed by a   |                   | * |   |
|   | R |     physician or other health     |                   | R |   |
|   | * |     care professional for your    |                   | * |   |
|   | * |     surgical care. Look in        |                   | * |   |
|   |   |     Section 5(c) for charges      |                   |   |   |
|   | * |     associated with the facility  |                   | * |   |
|   | * |     (i.e. hospital, surgical      |                   | * |   |
|   | T |     center, etc.).                |                   | T |   |
|   | * |                                   |                   | * |   |
|   | * | ```{=html}                        |                   | * |   |
|   |   | <!-- -->                          |                   |   |   |
|   | * | ```                               |                   | * |   |
|   | * | -   YOUR PHYSICIAN MUST GET       |                   | * |   |
|   | A |     PRE-AUTHORIZATION FOR SOME    |                   | A |   |
|   | * |     SURGICAL PROCEDURES. Please   |                   | * |   |
|   | * |     refer to the                  |                   | * |   |
|   |   |     pre-authorization information |                   |   |   |
|   | * |     shown in Section 3 to be sure |                   | * |   |
|   | * |     which services require        |                   | * |   |
|   | N |     pre-authorization.            |                   | N |   |
|   | * |                                   |                   | * |   |
|   | * |                                   |                   | * |   |
|   |   |                                   |                   |   |   |
|   | * |                                   |                   | * |   |
|   | * |                                   |                   | * |   |
|   | T |                                   |                   | T |   |
|   | * |                                   |                   | * |   |
|   | * |                                   |                   | * |   |
+---+---+-----------------------------------+-------------------+---+---+
| > |   |                                   | **You pay**       |   |   |
|   |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
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| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
+---+---+-----------------------------------+-------------------+---+---+
| > |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
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| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
+---+---+-----------------------------------+-------------------+---+---+
| > |   |                                   | > \$10 per office |   |   |
|   |   |                                   | > visit           |   |   |
| A |   |                                   | >                 |   |   |
| > |   |                                   | > \$100 per       |   |   |
|   |   |                                   | > admission for   |   |   |
| c |   |                                   | > inpatient       |   |   |
| o |   |                                   | > surgical        |   |   |
| m |   |                                   | > procedures      |   |   |
| p |   |                                   | >                 |   |   |
| r |   |                                   | > Nothing for     |   |   |
| e |   |                                   | > surgical        |   |   |
| h |   |                                   | > procedures in a |   |   |
| e |   |                                   | > hospital        |   |   |
| n |   |                                   | > outpatient, day |   |   |
| s |   |                                   | > surgery or      |   |   |
| i |   |                                   | > ambulatory      |   |   |
| v |   |                                   | > surgical center |   |   |
| e |   |                                   |                   |   |   |
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| > |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
| o |   |                                   |                   |   |   |
| f |   |                                   |                   |   |   |
| > |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
| t |   |                                   |                   |   |   |
| h |   |                                   |                   |   |   |
| e |   |                                   |                   |   |   |
| > |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
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| e |   |                                   |                   |   |   |
| r |   |                                   |                   |   |   |
| . |   |                                   |                   |   |   |
+---+---+-----------------------------------+-------------------+---+---+
| > |   |                                   | > *All charges.*  |   |   |
|   |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
| N |   |                                   |                   |   |   |
| o |   |                                   |                   |   |   |
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|   |   |                                   |                   |   |   |
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| s |   |                                   |                   |   |   |
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|   |   |                                   |                   |   |   |
| F |   |                                   |                   |   |   |
| o |   |                                   |                   |   |   |
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|   |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
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| c |   |                                   |                   |   |   |
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| . |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
+---+---+-----------------------------------+-------------------+---+---+

+------------------------------------------+---------------------------+
| > **Reconstructive surgery**             | > **You pay**             |
+------------------------------------------+---------------------------+
| > The Plan covers reconstructive surgery | > \$10 per office visit   |
| > to repair a condition resulting from:  | >                         |
|                                          | > \$100 per admission for |
| -   Surgery to correct a functional      | > inpatient surgical      |
|     defect                               | > procedures              |
|                                          | >                         |
| -   Surgery to correct a condition       | > Nothing for surgical    |
|     caused by injury or illness if:      | > procedures in a         |
|                                          | > hospital outpatient,    |
| ```{=html}                               | > day surgery or          |
| <!-- -->                                 | > ambulatory surgical     |
| ```                                      | > center                  |
| -   the condition produced a major       |                           |
|     effect on the member's appearance    |                           |
|     and                                  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   the condition can reasonably be      |                           |
|     expected to be corrected by such     |                           |
|     surgery                              |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Surgery to correct a condition that  |                           |
|     existed at or from birth and is a    |                           |
|     significant deviation from the       |                           |
|     common form or norm. Examples of     |                           |
|     congenital anomalies are: protruding |                           |
|     ear deformities; cleft lip; cleft    |                           |
|     palate; birth marks; webbed fingers; |                           |
|     and webbed toes.                     |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   All stages of breast reconstruction  |                           |
|     surgery following a mastectomy, such |                           |
|     as:                                  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   reconstruction of the breast on      |                           |
|     which the mastectomy was performed;  |                           |
|                                          |                           |
| -   surgery to produce a symmetrical     |                           |
|     appearance on the other breast;      |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   treatment of any physical            |                           |
|     complications, such as lymphedemas;  |                           |
|                                          |                           |
| > Note: If you need a mastectomy, you    |                           |
| > may choose to have the procedure       |                           |
| > performed on an inpatient basis and    |                           |
| > remain in the hospital up to 48 hours  |                           |
| > after the procedure.                   |                           |
+------------------------------------------+---------------------------+
| > Breast prostheses and surgical bras    | > Nothing                 |
| > and replacements (see Prosthetic       |                           |
| > devices)                               |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *Cosmetic surgery -- any surgical    |                           |
|     procedure (or any portion of a       |                           |
|     procedure) performed primarily to    |                           |
|     improve physical appearance through  |                           |
|     change in bodily form, except repair |                           |
|     of accidental injury*                |                           |
|                                          |                           |
| -   *Surgeries related to sex            |                           |
|     transformation*                      |                           |
+------------------------------------------+---------------------------+
| > **Oral and maxillofacial surgery**     |                           |
+------------------------------------------+---------------------------+
| > Oral surgical procedures, limited to:  | > \$10 per office visit   |
|                                          |                           |
| -   Reduction of fractures of the jaws   |                           |
|     or facial bones;                     |                           |
|                                          |                           |
| -   Surgical correction of cleft lip,    |                           |
|     cleft palate or severe functional    |                           |
|     malocclusion;                        |                           |
|                                          |                           |
| -   Removal of stones from salivary      |                           |
|     ducts;                               |                           |
|                                          |                           |
| -   Excision of leukoplakia or           |                           |
|     malignancies;                        |                           |
|                                          |                           |
| -   Excision of cysts and incision of    |                           |
|     abscesses when done as independent   |                           |
|     procedures; and                      |                           |
|                                          |                           |
| -   Other surgical procedures that do    |                           |
|     not involve the teeth or their       |                           |
|     supporting structures.               |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *Oral implants and transplants*      |                           |
|                                          |                           |
| -   *Procedures that involve the teeth   |                           |
|     or their supporting structures (such |                           |
|     as the periodontal membrane,         |                           |
|     gingiva, and alveolar bone)*         |                           |
+------------------------------------------+---------------------------+
| > **Organ/tissue transplants**           | > **You pay**             |
+------------------------------------------+---------------------------+
| > Transplant services must be provided   | > \$10 per office visit   |
| > at a Plan-affiliated facility, subject | >                         |
| > to your acceptance into the facility's | > \$100 per admission for |
| > transplant program. The transplant     | > inpatient surgical      |
| > facility makes the final determination | > procedures              |
| > on eligibility for transplant          | >                         |
| > coverage. The Plan may require that    | > Nothing for surgical    |
| > members receive their transplant at a  | > procedures in a         |
| > specified facility. If a covered       | > hospital outpatient,    |
| > transplant is not available from a     | > day surgery or          |
| > Plan provider, benefits will be paid   | > ambulatory surgical     |
| > at the same benefit level for services | > center                  |
| > rendered by a non-Plan provider.       |                           |
| >                                        |                           |
| > Limited to:                            |                           |
|                                          |                           |
| -   Cornea                               |                           |
|                                          |                           |
| -   Heart                                |                           |
|                                          |                           |
| -   Heart/lung for patients under age 60 |                           |
|     with end-stage primary or secondary  |                           |
|     pulmonary hypertension               |                           |
|                                          |                           |
| -   Kidney                               |                           |
|                                          |                           |
| -   Liver                                |                           |
|                                          |                           |
| -   Lung transplant for patients under   |                           |
|     age 60 with end-stage obstructive or |                           |
|     restrictive pulmonary disease        |                           |
|                                          |                           |
| -   Allogenic (donor) bone marrow        |                           |
|     transplants for leukemia, aplastic   |                           |
|     anemia, severe combined              |                           |
|     immunodeficiency disease, or         |                           |
|     Wiskott-Aldrich Syndrome; for        |                           |
|     patients with high-risk              |                           |
|     lymphoblastic lymphoma in remission; |                           |
|     or for patients under age 60 with    |                           |
|     myelodysplasia                       |                           |
|                                          |                           |
| -   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; resistant or    |                           |
|     advanced non-Hodgkin\'s lymphoma;    |                           |
|     recurrent or refractory              |                           |
|     neuroblastoma; for patients          |                           |
|     diagnosed with breast cancer that    |                           |
|     has progressed to metastatic         |                           |
|     disease; for patients under age 65   |                           |
|     with chemo-responsive multiple       |                           |
|     myeloma; epithelial ovarian cancer;  |                           |
|     and testicular, mediastinal,         |                           |
|     retroperitoneal and ovarian germ     |                           |
|     cell tumors                          |                           |
|                                          |                           |
| -   Intestinal transplants (small        |                           |
|     intestine) and the small intestine   |                           |
|     with the liver or small intestine    |                           |
|     with multiple organs such as the     |                           |
|     liver, stomach, and pancreas         |                           |
|                                          |                           |
| -   Human Leukocyte Antigen (HLA) or     |                           |
|     histocompatibility locus antigen     |                           |
|     testing for A, B, or DR antigens, or |                           |
|     any combination thereof, to          |                           |
|     establish bone marrow transplant     |                           |
|     donor suitability                    |                           |
|                                          |                           |
| > Limited Benefits - Treatment for       |                           |
| > breast cancer, multiple myeloma, and   |                           |
| > epithelial ovarian cancer may be       |                           |
| > provided in an NCI- or NIH-approved    |                           |
| > clinical trial at a Plan-designated    |                           |
| > center of excellence and if approved   |                           |
| > by the Plan's medical director in      |                           |
| > accordance with the Plan's protocols.  |                           |
| >                                        |                           |
| > Note: We cover related medical and     |                           |
| > hospital expenses of the donor when we |                           |
| > cover the recipient                    |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *Transplants not listed as covered*  |                           |
|                                          |                           |
| -   *Donor screening tests and donor     |                           |
|     search expenses, except those        |                           |
|     performed for the actual donor*      |                           |
|                                          |                           |
| -   *Implants of artificial organs*      |                           |
|                                          |                           |
| -   *Services for the organ donor that   |                           |
|     are covered by another insurance     |                           |
|     plan*                                |                           |
+------------------------------------------+---------------------------+

Organ/tissue transplants --continued on next page

+------------------------------------------+---------------------------+
| > *Not covered continued:*               |                           |
|                                          |                           |
| -   *Services of the organ donor if the  |                           |
|     recipient is not a Plan member*      |                           |
|                                          |                           |
| -   *Transportation, housing or home     |                           |
|     cleaning services incurred by either |                           |
|     the donor or the recipient*          |                           |
+------------------------------------------+---------------------------+
| > **Anesthesia**                         | > **You pay**             |
+------------------------------------------+---------------------------+
| > Professional services provided in --   | > Nothing                 |
|                                          |                           |
| -   Hospital (inpatient)                 |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Skilled nursing facility             |                           |
|                                          |                           |
| -   Hospital outpatient department or    |                           |
|     day surgery                          |                           |
|                                          |                           |
| -   Ambulatory surgical center           |                           |
+------------------------------------------+---------------------------+
| > Professional services provided in --   | > \$10 per office visit   |
|                                          |                           |
| -   Office                               |                           |
+------------------------------------------+---------------------------+

+---+---+-----------------------------------+-------------------+---+---+
| > |   |                                   |                   |   |   |
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| e |   |                                   |                   |   |   |
| 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  |                   | * |   |
|   | * |     your care and you must be     |                   | * |   |
|   | P |     hospitalized in a Plan        |                   | P |   |
|   | * |     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).                          |                   |   |   |
|   | * |                                   |                   | * |   |
|   | * | ```{=html}                        |                   | * |   |
|   | A | <!-- -->                          |                   | A |   |
|   | * | ```                               |                   | * |   |
|   | * | -   **YOUR PHYSICIAN MUST GET     |                   | * |   |
|   |   |     PRE-AUTHORIZATION OF HOSPITAL |                   |   |   |
|   | * |     STAYS.** Please refer to      |                   | * |   |
|   | * |     Section 3 to be sure which    |                   | * |   |
|   | N |     services require              |                   | N |   |
|   | * |     pre-authorization.            |                   | * |   |
|   | * |                                   |                   | * |   |
|   |   |                                   |                   |   |   |
|   | * |                                   |                   | * |   |
|   | * |                                   |                   | * |   |
|   | T |                                   |                   | T |   |
|   | * |                                   |                   | * |   |
|   | * |                                   |                   | * |   |
+---+---+-----------------------------------+-------------------+---+---+
| > |   |                                   | **You pay**       |   |   |
|   |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
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+---+---+-----------------------------------+-------------------+---+---+
| # |   |                                   | ########          |   |   |
| # |   |                                   |                   |   |   |
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+---+---+-----------------------------------+-------------------+---+---+
| > |   |                                   | > \$100 per       |   |   |
|   |   |                                   | > admission       |   |   |
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+---+---+-----------------------------------+-------------------+---+---+
| # |   |                                   | ########          |   |   |
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|   |   |                                   | > admission       |   |   |
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+---+---+-----------------------------------+-------------------+---+---+
| # |   |                                   | ####              |   |   |
| # |   |                                   |                   |   |   |
| # |   |                                   |                   |   |   |
| # |   |                                   |                   |   |   |
|   |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
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| e |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
| * |   |                                   |                   |   |   |
+---+---+-----------------------------------+-------------------+---+---+
| > |   |                                   | > Nothing for     |   |   |
|   |   |                                   | > hospice care    |   |   |
| H |   |                                   | > provided in     |   |   |
| o |   |                                   | > your home       |   |   |
| s |   |                                   | >                 |   |   |
| p |   |                                   | > Note: \$100     |   |   |
| i |   |                                   | > copay applies   |   |   |
| c |   |                                   | > to inpatient    |   |   |
| e |   |                                   | > respite care    |   |   |
| > |   |                                   | > provided in a   |   |   |
|   |   |                                   | > skilled nursing |   |   |
| c |   |                                   | > or hospice      |   |   |
| a |   |                                   | > facility        |   |   |
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|   | * | > Here are some important things to keep in mind about     | * | # |
|   | * | > these benefits:                                          | * | # |
|   | I |                                                            | I | # |
|   | * | -   Please remember that all benefits are subject to the   | * | # |
|   | * |     definitions, limitations, and exclusions in this       | * | # |
|   |   |     brochure and are payable only when we determine they   |   |   |
|   | * |     are medically necessary.                               | * |   |
|   | * |                                                            | * |   |
|   | M | ```{=html}                                                 | M |   |
|   | * | <!-- -->                                                   | * |   |
|   | * | ```                                                        | * |   |
|   |   | -   Be sure to read Section 4, *Your costs for covered     |   |   |
|   | * |     services,* for valuable information about how cost     | * |   |
|   | * |     sharing works. Also read Section 9 about coordinating  | * |   |
|   | P |     benefits with other coverage, including with Medicare. | P |   |
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| r |   |                                                            |   |   |
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|   |   |                                                            |   |   |
| p |   |                                                            |   |   |
| h |   |                                                            |   |   |
| y |   |                                                            |   |   |
| s |   |                                                            |   |   |
| i |   |                                                            |   |   |
| c |   |                                                            |   |   |
| i |   |                                                            |   |   |
| a |   |                                                            |   |   |
| n |   |                                                            |   |   |
| > |   |                                                            |   |   |
|   |   |                                                            |   |   |
| i |   |                                                            |   |   |
| f |   |                                                            |   |   |
| > |   |                                                            |   |   |
|   |   |                                                            |   |   |
| y |   |                                                            |   |   |
| o |   |                                                            |   |   |
| u |   |                                                            |   |   |
| > |   |                                                            |   |   |
|   |   |                                                            |   |   |
| n |   |                                                            |   |   |
| e |   |                                                            |   |   |
| e |   |                                                            |   |   |
| d |   |                                                            |   |   |
| > |   |                                                            |   |   |
|   |   |                                                            |   |   |
| f |   |                                                            |   |   |
| o |   |                                                            |   |   |
| l |   |                                                            |   |   |
| l |   |                                                            |   |   |
| o |   |                                                            |   |   |
| w |   |                                                            |   |   |
| - |   |                                                            |   |   |
| u |   |                                                            |   |   |
| p |   |                                                            |   |   |
| > |   |                                                            |   |   |
|   |   |                                                            |   |   |
| c |   |                                                            |   |   |
| a |   |                                                            |   |   |
| r |   |                                                            |   |   |
| e |   |                                                            |   |   |
| . |   |                                                            |   |   |
+---+---+------------------------------------------------------------+---+---+

+------------------------------------------+---------------------------+
| > **Benefit Description**                | **You pay**               |
+------------------------------------------+---------------------------+
| > **Emergency within our service area**  |                           |
+------------------------------------------+---------------------------+
| -   Care for a minor emergency in a      | > \$10 per visit          |
|     doctor's office or urgent care       |                           |
|     center                               |                           |
+------------------------------------------+---------------------------+
| -   Emergency care as an outpatient or   | > \$50 per visit (waived  |
|     inpatient at a hospital, including   | > if admitted)            |
|     doctors\' services                   |                           |
+------------------------------------------+---------------------------+
| ###                                      |                           |
| ##### Emergency outside our service area |                           |
+------------------------------------------+---------------------------+
| -   Care for a minor emergency in a      | > \$10 per visit          |
|     doctor's office or urgent care       |                           |
|     center                               |                           |
+------------------------------------------+---------------------------+
| -   Emergency care as an outpatient or   | > \$50 per visit (waived  |
|     inpatient at a hospital, including   | > if admitted)            |
|     doctors\' services                   |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *Elective care or non-emergency      |                           |
|     care*                                |                           |
|                                          |                           |
| -   *Emergency care provided outside the |                           |
|     service area if the need for care    |                           |
|     could have been foreseen before      |                           |
|     leaving the service area*            |                           |
|                                          |                           |
| -   *Medical and hospital costs          |                           |
|     resulting from a normal full-term    |                           |
|     delivery of a baby outside the       |                           |
|     service area*                        |                           |
+------------------------------------------+---------------------------+
| > **Ambulance**                          |                           |
+------------------------------------------+---------------------------+
| > Emergency ambulance service when       | > Nothing                 |
| > medically appropriate.                 |                           |
| >                                        |                           |
| > See 5(c) for non-emergency service.    |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges.*          |
|                                          |                           |
| -   *Air ambulance when not appropriate  |                           |
|     to medical condition or geographic   |                           |
|     location*                            |                           |
|                                          |                           |
| -   *Transfers between hospitals when    |                           |
|     the patient's medical condition does |                           |
|     not warrant that he or she be        |                           |
|     transported to another facility*     |                           |
|                                          |                           |
| -   *Commercial airline transportation*  |                           |
+------------------------------------------+---------------------------+

+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| S |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| 5 |   |                                     |                     |   |   |
| ( |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| ) |   |                                     |                     |   |   |
| . |   |                                     |                     |   |   |
| M |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
|   | * | > When you get our approval for     |                     | * |   |
|   | * | > services and follow a treatment   |                     | * |   |
|   | 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:**                       |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   | P |     benefits are subject to the     |                     | P |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   |   |     are payable only when we        |                     |   |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   | O |                                     |                     | O |   |
|   | * | > • Be sure to read Section 4,      |                     | * |   |
|   | * | > *Your costs for covered           |                     | * |   |
|   |   | > services*, for valuable           |                     |   |   |
|   | * | > information about how cost        |                     | * |   |
|   | * | > sharing works. Also read Section  |                     | * |   |
|   | R | > 9 about coordinating benef4its    |                     | R |   |
|   | * | > with other coverage, including    |                     | * |   |
|   | * | > with Medicare.                    |                     | * |   |
|   |   | >                                   |                     |   |   |
|   | * | > • **YOU MUST GET                  |                     | * |   |
|   | * | > PRE-AUTHORIZATION INPATIENT       |                     | * |   |
|   | T | > MENTAL HEALTH AND SUBSTANCE ABUSE |                     | T |   |
|   | * | > CARE.** See the instructions      |                     | * |   |
|   | * | > after the benefits description    |                     | * |   |
|   |   | > below.                            |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | N |                                     |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| > |   |                                     | **You pay**         |   |   |
|   |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| B |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| > |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     | ###                 |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| M |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| b |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
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| s |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| > |   |                                     | > Your cost sharing |   |   |
|   |   |                                     | > responsibilities  |   |   |
| A |   |                                     | > are no greater    |   |   |
| l |   |                                     | > than for other    |   |   |
| l |   |                                     | > illness or        |   |   |
| > |   |                                     | > conditions.       |   |   |
|   |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
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| - |   |                                     | > Nothing           |   |   |
|   |   |                                     | >                   |   |   |
|   |   |                                     | > (If you receive   |   |   |
|   |   |                                     | > these services    |   |   |
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| i |   |                                     | > visit a \$10      |   |   |
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| g |   |                                     | > the office visit  |   |   |
| n |   |                                     | > only)             |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | > \$100 per         |   |   |
|   |   |                                     | > admission         |   |   |
|   |   |                                     | >                   |   |   |
|   |   |                                     | > Nothing for       |   |   |
| S |   |                                     | > services in       |   |   |
| e |   |                                     | > alternative care  |   |   |
| r |   |                                     | > settings          |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     | > *All charges.*    |   |   |
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| r |   |                                     |                     |   |   |
| . |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

Mental health and substance abuse benefits -- continued on next page

+-----------------------------------------------------------------------+
| **Pre-authorization** To be eligible to receive these benefits you    |
| must obtain a treatment plan and follow all of the following          |
| authorization processes*:*                                            |
|                                                                       |
| You may self-refer for outpatient mental health and substance abuse   |
| services with a Plan provider. For assistance in finding a Plan       |
| provider, call 1-888-421-8861 (TDD/TTY: 1-781-994-7660).              |
|                                                                       |
| > Inpatient mental health and substance abuse services require        |
| > pre-authorization, call 1- 888-421-8861 (TDD/TTY: 1-781-994-7660).  |
| >                                                                     |
| > For mental health and substance abuse emergencies, follow the same  |
| > procedures as for any other medical emergency. See Section 5(d)     |
| > Emergency services.                                                 |
+-----------------------------------------------------------------------+
| ## **Limitation                                                       |
| ** We may limit your benefits if you do not obtain a treatment plan.  |
+-----------------------------------------------------------------------+

+---+---+----------------------------------------------------------+---+---+
| * |   |                                                          |   |   |
| * |   |                                                          |   |   |
| S |   |                                                          |   |   |
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| c |   |                                                          |   |   |
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| n |   |                                                          |   |   |
| 5 |   |                                                          |   |   |
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| c |   |                                                          |   |   |
| r |   |                                                          |   |   |
| i |   |                                                          |   |   |
| p |   |                                                          |   |   |
| t |   |                                                          |   |   |
| i |   |                                                          |   |   |
| o |   |                                                          |   |   |
| n |   |                                                          |   |   |
| d |   |                                                          |   |   |
| r |   |                                                          |   |   |
| u |   |                                                          |   |   |
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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.                                           | * |   |
|   | * |                                                          | * |   |
|   |   | ```{=html}                                               |   |   |
|   | * | <!-- -->                                                 | * |   |
|   | * | ```                                                      | * |   |
|   | P | -   Be sure to read Section 4, *Your costs for covered   | P |   |
|   | * |     services,* for valuable information about how cost   | * |   |
|   | * |     sharing works. Also read Section 9 about             | * |   |
|   |   |     coordinating benefits with other coverage, including |   |   |
|   | * |     with Medicare.                                       | * |   |
|   | * |                                                          | * |   |
|   | O |                                                          | O |   |
|   | * |                                                          | * |   |
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+---+---+----------------------------------------------------------+---+---+
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| t |   |                                                          |   |   |
| , |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
| P |   |                                                          |   |   |
| . |   |                                                          |   |   |
| O |   |                                                          |   |   |
| . |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
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| o |   |                                                          |   |   |
| x |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
| 1 |   |                                                          |   |   |
| 5 |   |                                                          |   |   |
| 1 |   |                                                          |   |   |
| 2 |   |                                                          |   |   |
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| e |   |                                                          |   |   |
| r |   |                                                          |   |   |
| , |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
| M |   |                                                          |   |   |
| A |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
|   |   |                                                          |   |   |
| 0 |   |                                                          |   |   |
| 1 |   |                                                          |   |   |
| 6 |   |                                                          |   |   |
| 1 |   |                                                          |   |   |
| 5 |   |                                                          |   |   |
| - |   |                                                          |   |   |
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| 1 |   |                                                          |   |   |
| . |   |                                                          |   |   |
+---+---+----------------------------------------------------------+---+---+

+------------------------------------------+---------------------------+
| > **Benefit Description**                | **You pay**               |
+------------------------------------------+---------------------------+
| > **Covered medications and supplies**   |                           |
+------------------------------------------+---------------------------+
| > We cover the following medications and | > At a Plan pharmacy:     |
| > supplies prescribed by a Plan provider | >                         |
| > and obtained from a Plan pharmacy or   | > Tier 1: \$5 copay for   |
| > through our mail order program:        | > up to a 30-day supply   |
|                                          | >                         |
| -   Drugs and medicines that by Federal  | > Tier 2: \$20 copay for  |
|     law of the United States require a   | > up to a 30-day supply   |
|     physician's prescription for their   | >                         |
|     purchase except those listed as *not | > Tier 3: \$40 copay for  |
|     covered*                             | > up to a 30-day supply   |
|                                          | >                         |
| -   Diabetic supplies and medications    | > Mail order:             |
|     limited to insulin, insulin          | >                         |
|     syringes, blood glucose monitoring   | > Tier 1: \$10 copay for  |
|     strips, urine glucose strips, ketone | > up to a 90-day supply   |
|     strips, lancets, insulin pumps,      | >                         |
|     insulin pump supplies and insulin    | > Tier 2: \$40 copay for  |
|     pens                                 | > up to a 90-day supply   |
|                                          | >                         |
| -   Oral medications that influence      | > Tier 3: \$120 copay for |
|     blood sugar levels                   | > up to a 90-day supply   |
|                                          | >                         |
| -   Self-administered injectable agents  | > Note: If there is no    |
|                                          | > generic equivalent      |
| -   Hormone replacement therapy          | > available, you will     |
|                                          | > still have to pay the   |
| -   Disposable needles and syringes for  | > brand name copay.       |
|     the administration of covered        |                           |
|     medications                          |                           |
|                                          |                           |
| -   Fertility drugs                      |                           |
|                                          |                           |
| -   Drugs for sexual dysfunction         |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Contraceptive drugs and devices      |                           |
|                                          |                           |
| -   Off-label use of covered drugs in    |                           |
|     the treatment of HIV, AIDS or cancer |                           |
|                                          |                           |
| > Note: injectables furnished and        |                           |
| > administered in a provider's office or |                           |
| > under professional supervision are     |                           |
| > generally covered under the medical    |                           |
| > benefit.                               |                           |
+------------------------------------------+---------------------------+
| > The Plan covers the special medical    | > Nothing                 |
| > formulas and food products limited to  |                           |
| > those listed below. Prior              |                           |
| > authorization is required.             |                           |
|                                          |                           |
| -   Special medical formulas for the     |                           |
|     treatment of phenylketonuria,        |                           |
|     tyrosinemia, homocystinuria, maple   |                           |
|     syrup urine disease, propionic       |                           |
|     acidemia, or methylmalonic acidemia  |                           |
|     in infants and children or to        |                           |
|     protect the unborn fetuses of        |                           |
|     pregnant women with phenylketonuria  |                           |
|                                          |                           |
| -   Enteral formulas for home use for    |                           |
|     which a physician has issued a       |                           |
|     written order and which are          |                           |
|     necessary for the treatment of       |                           |
|     malabsorption caused by Crohn's      |                           |
|     disease, ulcerative colitis,         |                           |
|     gastroesophageal reflux,             |                           |
|     gastrointestinal motility, chronic   |                           |
|     intestinal pseudo-obstruction and    |                           |
|     inherited diseases of amino acids    |                           |
|     and organic acids                    |                           |
+------------------------------------------+---------------------------+
| -   Food products modified to be low in  | > Nothing up to a maximum |
|     protein for individuals that have    | > of \$2,500 per calendar |
|     been diagnosed with phenylketonuria  | > year                    |
|     and other inherited diseases of      |                           |
|     amino acids and organic acids.       |                           |
|     Coverage is provided for up to       |                           |
|     \$2,500 per calendar year. You may   |                           |
|     be required to purchase these        |                           |
|     products over-the-counter and submit |                           |
|     claims to the Plan for reimbursement |                           |
+------------------------------------------+---------------------------+

Covered medications and supplies -- continued on next page

+------------------------------------------+---------------------------+
| > *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 even if a physician      |                           |
|     prescribes or administers them*      |                           |
|                                          |                           |
| -   *Nonprescription medicines,          |                           |
|     over-the-counter preparations and    |                           |
|     devices and medical supplies such as |                           |
|     dressings and antiseptics*           |                           |
|                                          |                           |
| -   *Drugs that are investigational or   |                           |
|     that have not been approved for      |                           |
|     general sale and distribution by the |                           |
|     U.S. Food and Drug Administration*   |                           |
|                                          |                           |
| -   *Nicotine patches and gum or other   |                           |
|     smoking cessation products unless    |                           |
|     supplied to you as part of an        |                           |
|     approved smoking cessation program*  |                           |
+------------------------------------------+---------------------------+

+----------------------+-----------------------------------------------+
| > Section 5 (g).     |                                               |
| > Special features   |                                               |
+======================+===============================================+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| > **Flexible         | > Under the flexible benefits option, we      |
| > benefits option**  | > determine the most effective way to provide |
|                      | > services.                                   |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| > **Out-of-area      | Students attending school outside the Plan    |
| > student coverage** | service area may not have easy access to a    |
|                      | Plan provider. They are covered for a limited |
|                      | number of services while out-of-area, if      |
|                      | authorized in advance by the Plan. These      |
|                      | services include:                             |
|                      |                                               |
|                      | -   Non-routine medical office visits         |
|                      |                                               |
|                      | -   Diagnostic lab and X-ray connected with a |
|                      |     non-routine office visits                 |
|                      |                                               |
|                      | -   Non-elective inpatient services if the    |
|                      |     Plan is notified within 48 hours of       |
|                      |     admission                                 |
|                      |                                               |
|                      | -   Outpatient services to treat the abuse of |
|                      |     or addiction to alcohol or drugs, while   |
|                      |     out of the Plan service area              |
|                      |                                               |
|                      | -   Outpatient services to diagnose and/or    |
|                      |     treat mental conditions                   |
|                      |                                               |
|                      | -   Short-term rehabilitation services,       |
|                      |     including physical, occupational and      |
|                      |     speech therapy. Coverage for physical and |
|                      |     occupational therapy is provided for up   |
|                      |     to 60 consecutive days or 20              |
|                      |     nonconsecutive visits (whichever is       |
|                      |     greater) per illness or injury in each    |
|                      |     calendar year (combined with any in-area  |
|                      |     visits). Coverage for speech therapy is   |
|                      |     determined by medically necessary         |
|                      |                                               |
|                      |     *Aside from emergency care, the services  |
|                      |     listed above are the only services that   |
|                      |     are covered for students on an            |
|                      |     out-of-network basis. To be covered, all  |
|                      |     other services must be obtained when they |
|                      |     return to the Plan service area.*         |
|                      |                                               |
|                      |     Services that are **not** covered for     |
|                      |     students while out of the Plan service    |
|                      |     area include:                             |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Routine physical, gynecological exams,    |
|                      |     vision screening and hearing screening    |
|                      |                                               |
|                      | -   Routine preventive care                   |
|                      |                                               |
|                      | -   Non-emergency prescription medication.    |
|                      |     You may use the prescription medication   |
|                      |     mail order program to fill medication     |
|                      |     refills. (See pages 38-41.)               |
|                      |                                               |
|                      | -   Second opinion                            |
|                      |                                               |
|                      | -   Preventive dental care or minor           |
|                      |     restorative care (e.g., fillings)         |
|                      |                                               |
|                      | -   Chiropractic care services                |
|                      |                                               |
|                      | -   Home health care                          |
|                      |                                               |
|                      | -   Outpatient surgical procedures that could |
|                      |     be delayed until return to the Plan       |
|                      |     service area                              |
|                      |                                               |
|                      | -   Maternity care or delivery                |
|                      |                                               |
|                      | -   Durable medical equipment (e.g.,          |
|                      |     wheelchairs), including maintenance or    |
|                      |     replacement                               |
+----------------------+-----------------------------------------------+
| > **Services for     | You may access our TDD/TTY equipment at       |
| > deaf and hearing   | 1-877-608-7677.                               |
| > impaired**         |                                               |
+----------------------+-----------------------------------------------+
| > **Interpreter      | We will, upon request, provide members with   |
| > services**         | interpreters and translation services related |
|                      | to our administrative procedures.             |
+----------------------+-----------------------------------------------+
| > **Peace of Mind    | Our Peace of Mind Program™ provides access to |
| > Program^™^**       | specialty services at specified Boston area   |
|                      | medical centers. You may access Peace of Mind |
|                      | Program™ providers if you meet the following  |
|                      | conditions:                                   |
|                      |                                               |
|                      | -   Care is for covered services as described |
|                      |     in this brochure. The same copayments and |
|                      |     benefit limits apply.                     |
|                      |                                               |
|                      | -   You have seen a Plan specialist for this  |
|                      |     condition within the past three months.   |
|                      |                                               |
|                      | -   A referral to a specific Peace of Mind    |
|                      |     Program^™^ physician is made by your      |
|                      |     primary care provider and notification is |
|                      |     given to the Plan that you are accessing  |
|                      |     that specialist through the Peace of Mind |
|                      |     Program. ™                                |
|                      |                                               |
|                      | -   The physician to whom you are referred is |
|                      |     on staff at one of the six medical        |
|                      |     centers listed below:                     |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Massachusetts General Hospital            |
|                      |                                               |
|                      | -   Brigham and Women's Hospital              |
|                      |                                               |
|                      | -   Children's Hospital (Boston)              |
|                      |                                               |
|                      | -   Dana-Farber Cancer Institute              |
|                      |                                               |
|                      | -   New England Medical Center                |
|                      |                                               |
|                      | -   Boston IVF (for infertility services      |
|                      |     only)                                     |
|                      |                                               |
|                      | > Once the Plan has been notified of the      |
|                      | > Peace of Mind Program™ referral to a        |
|                      | > specific physician, you may arrange an      |
|                      | > appointment to see this specialist for a    |
|                      | > consultation. You may continue treatment    |
|                      | > with this specialist or you may return to a |
|                      | > Plan provider for care at any time, so long |
|                      | > as you obtain appropriate authorization. If |
|                      | > you wish to see any other Peace of Mind     |
|                      | > Program™ provider, you must request a       |
|                      | > separate referral from your primary care    |
|                      | > physician and the Plan must be notified of  |
|                      | > your request, and the request must meet the |
|                      | > conditions listed above.                    |
|                      | >                                             |
|                      | > You should advise your Peace of Mind        |
|                      | > Program™ provider that all laboratory,      |
|                      | > X-ray services and tests must be authorized |
|                      | > in advance by the Plan. To ensure coverage, |
|                      | > the Peace of Mind Program™ provider should  |
|                      | > work with the Plan's Peace of Mind Program™ |
|                      | > coordinator to make arrangements for these  |
|                      | > services. Whenever practical, arrangements  |
|                      | > will be made for these services to be       |
|                      | > performed by Plan providers. Unauthorized   |
|                      | > services will not be covered. You should    |
|                      | > not rely on an assurance from the Peace of  |
|                      | > Mind Program™ provider that a service will  |
|                      | > be covered by the Plan. Services must be    |
|                      | > authorized by the Plan to be covered.       |
|                      | >                                             |
|                      | > You may use the Peace of Mind Program™ for  |
|                      | > all specialty care except mental health,    |
|                      | > substance abuse, chiropractic services,     |
|                      | > obstetrics or dental care. You may not use  |
|                      | > the Peace of Mind Program™ for any primary  |
|                      | > care services, including internal medicine, |
|                      | > family practice or pediatrics. If you have  |
|                      | > not met the conditions listed above, or if  |
|                      | > you or your physician have not obtained     |
|                      | > Plan authorization for a Peace of Mind      |
|                      | > Program™ service, the service will not be   |
|                      | > covered by the Plan and the Peace of Mind   |
|                      | > Program™ provider may hold you financially  |
|                      | > responsible.                                |
+----------------------+-----------------------------------------------+

+---+---+------------------------------------+--------------------+---+---+
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| S |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| o |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| 5 |   |                                    |                    |   |   |
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| ( |   |                                    |                    |   |   |
| h |   |                                    |                    |   |   |
| ) |   |                                    |                    |   |   |
| . |   |                                    |                    |   |   |
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| D |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| a |   |                                    |                    |   |   |
| l |   |                                    |                    |   |   |
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| b |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| f |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| s |   |                                    |                    |   |   |
+===+===+====================================+====================+===+===+
|   | * | **Here are some important things   |                    | * |   |
|   | * | to keep in mind about these        |                    | * |   |
|   | 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     |                    | * |   |
|   | * |     your care.                     |                    | * |   |
|   | P |                                    |                    | P |   |
|   | * | -   We cover hospitalization for   |                    | * |   |
|   | * |     dental procedures only when a  |                    | * |   |
|   |   |     nondental physical impairment  |                    |   |   |
|   | * |     exists which makes             |                    | * |   |
|   | * |     hospitalization necessary to   |                    | * |   |
|   | O |     safeguard the health of the    |                    | O |   |
|   | * |     patient. See Section 5 (c) for |                    | * |   |
|   | * |     inpatient hospital benefits.   |                    | * |   |
|   |   |     We do not cover the dental     |                    |   |   |
|   | * |     procedure unless it is         |                    | * |   |
|   | * |     described below.               |                    | * |   |
|   | R |                                    |                    | R |   |
|   | * | ```{=html}                         |                    | * |   |
|   | * | <!-- -->                           |                    | * |   |
|   |   | ```                                |                    |   |   |
|   | * | -   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**      |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| * |   |                                    |                    |   |   |
| * |   |                                    |                    |   |   |
| A |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| d |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| a |   |                                    |                    |   |   |
| l |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| j |   |                                    |                    |   |   |
| u |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| y |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| b |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| f |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| * |   |                                    |                    |   |   |
| * |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| > |   |                                    | > \$10 per office  |   |   |
|   |   |                                    | > visit            |   |   |
| W |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| o |   |                                    |                    |   |   |
| v |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| m |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| g |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| y |   |                                    |                    |   |   |
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
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| c |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| s |   |                                    |                    |   |   |
| . |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| > |   |                                    | > **You pay**      |   |   |
|   |   |                                    |                    |   |   |
| * |   |                                    |                    |   |   |
| * |   |                                    |                    |   |   |
| O |   |                                    |                    |   |   |
| u |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| - |   |                                    |                    |   |   |
| o |   |                                    |                    |   |   |
| f |   |                                    |                    |   |   |
| - |   |                                    |                    |   |   |
| a |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| a |   |                                    |                    |   |   |
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| d |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| a |   |                                    |                    |   |   |
| l |   |                                    |                    |   |   |
| > |   |                                    |                    |   |   |
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| c |   |                                    |                    |   |   |
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| * |   |                                    |                    |   |   |
| * |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| > |   |                                    | > \$10 per office  |   |   |
|   |   |                                    | > visit            |   |   |
| W |   |                                    | >                  |   |   |
| h |   |                                    | > Coverage is      |   |   |
| i |   |                                    | > provided for up  |   |   |
| l |   |                                    | > to \$50 per      |   |   |
| e |   |                                    | > incident.        |   |   |
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+---+---+------------------------------------+--------------------+---+---+
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| d |   |                                    |                    |   |   |
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| n |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| a |   |                                    |                    |   |   |
| l |   |                                    |                    |   |   |
| > |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| s |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| v |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| s |   |                                    |                    |   |   |
| . |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+

+------------------------------------------+---------------------------+
| **Dental Benefits**                      |                           |
+------------------------------------------+---------------------------+
| ### **Service**                          | **You pay**               |
+------------------------------------------+---------------------------+
| **Diagnostic (exams)**                   | > \$10                    |
|                                          | >                         |
| 120. Periodic oral examination           | > \$10                    |
|                                          | >                         |
| ```{=html}                               | > \$10                    |
| <!-- -->                                 | >                         |
| ```                                      | > \$10                    |
| 140. Limited oral evaluation (problem    | >                         |
|      focused)                            | > \$10                    |
|                                          | >                         |
| ```{=html}                               | > \$10                    |
| <!-- -->                                 | >                         |
| ```                                      | > \$10                    |
| 150. Comprehensive oral evaluation       | >                         |
|                                          | > \$10                    |
| 170 Reevaluation limited (problem        | >                         |
| focused)                                 | > \$10                    |
|                                          | >                         |
| 220. Intraoral: (periapical, first film) | > \$10                    |
|                                          | >                         |
| ```{=html}                               | > \$10                    |
| <!-- -->                                 | >                         |
| ```                                      | > \$10                    |
| 230. Intraoral: (periapical, each        | >                         |
|      additional film)                    | > \$10                    |
|                                          | >                         |
| ```{=html}                               | > \$10                    |
| <!-- -->                                 | >                         |
| ```                                      | > \$10                    |
| 240. Intraoral: (occlusal film)          | >                         |
|                                          | > \$10                    |
| 270 Bitewing (single film)               | >                         |
|                                          | > \$10                    |
| 272. Bitewings (two films)               | >                         |
|                                          | > \$16                    |
| 274 Bitewings (four films)               | >                         |
|                                          | > \$22                    |
| 460. Pulp vitality tests                 | >                         |
|                                          | > \$26                    |
| 470 Diagnostic casts                     | >                         |
|                                          | > \$34                    |
| **Preventive (cleanings)**               | >                         |
|                                          | > \$18                    |
| 1110. Prophylaxis (adult, every six      | >                         |
|       months)                            | > \$24                    |
|                                          | >                         |
| ```{=html}                               | > \$26                    |
| <!-- -->                                 | >                         |
| ```                                      | > \$34                    |
| 1120. Prophylaxis (child, every six      | >                         |
|       months)                            | > \$23                    |
|                                          | >                         |
| ```{=html}                               | > \$26                    |
| <!-- -->                                 | >                         |
| ```                                      | > \$34                    |
| 1201. Topical application fluoride       | >                         |
|       (includes prophylaxis--under age   | > \$40                    |
|       14)                                | >                         |
|                                          | > \$22                    |
| 1203 Topical application fluoride        | >                         |
| (excludes prophylaxis--under age 14)     | > \$31                    |
|                                          | >                         |
| 1205. Topical application fluoride       | > \$38                    |
|       (includes prophylaxis--age 14 and  | >                         |
|       over)                              | > \$23                    |
|                                          | >                         |
| **Minor restorative (fillings)**         | > \$30                    |
|                                          | >                         |
| 2110. Amalgam (one surface, primary)     | > \$42                    |
|                                          | >                         |
| ```{=html}                               | > \$49                    |
| <!-- -->                                 |                           |
| ```                                      |                           |
| 2120. Amalgam (two surfaces, primary)    |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| 2130. Amalgam (three surfaces, primary)  |                           |
|                                          |                           |
| 2131. Amalgam (four or more surfaces,    |                           |
|       primary)                           |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| 2140. Amalgam (one surface, permanent)   |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| 2150. Amalgam (two surfaces, permanent)  |                           |
|                                          |                           |
| 2160 Amalgam (three surfaces, permanent) |                           |
|                                          |                           |
| 2161 Amalgam (four or more surfaces,     |                           |
| permanent)                               |                           |
|                                          |                           |
| 2330 Resin (one surface, anterior)       |                           |
|                                          |                           |
| 2331 Resin (two surfaces, anterior)      |                           |
|                                          |                           |
| 2332 Resin (three surfaces, anterior)    |                           |
|                                          |                           |
| 2335. Resin (more than three surfaces,   |                           |
|       or involving incisal angle --      |                           |
|       anterior)                          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| 2380. Resin (one surface, posterior      |                           |
|       primary)                           |                           |
|                                          |                           |
| 2381. Resin (two surfaces, posterior     |                           |
|       primary)                           |                           |
|                                          |                           |
| 2382. Resin (three or more surfaces,     |                           |
|       posterior primary)                 |                           |
|                                          |                           |
| 2385 Resin (one surface, posterior       |                           |
| permanent)                               |                           |
|                                          |                           |
| 2386 Resin (two surfaces, posterior      |                           |
| permanent)                               |                           |
|                                          |                           |
| 2387. Resin (three surfaces, posterior   |                           |
|       permanent)                         |                           |
|                                          |                           |
| 2388. Resin (four or more surfaces,      |                           |
|       posterior permanent)               |                           |
|                                          |                           |
| Note: Procedures not shown are not       |                           |
| covered by the Plan                      |                           |
+------------------------------------------+---------------------------+

+-----------------------------------------------------------------------+
| > 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 provider 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 15.**
>
> 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;

```{=html}
<!-- -->
```
-   Services, drugs, or supplies related to sex transformations;

```{=html}
<!-- -->
```
-   Services, drugs, or supplies you receive from a provider or facility
    barred from the FEHB Program; or

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

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

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

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

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

**Medical and hospital and drug** In most cases, providers and
facilities file claims for you. Physicians must file on the **benefits**
form HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form.

> For claims questions and assistance, call us at 1-800-868-5200
> (TDD/TTY: 1-877-608-7677).

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

-   Covered member's name and ID number;

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

-   Dates you received the services or supplies;

-   Diagnosis;

-   Type of each service or supply;

-   The charge for each service or supply;

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

-   Receipts, if you paid for your services.

    **Submit your claims to:** Fallon Community Health Plan

    Claims Department

    P. O. Box 15121

    Worcester, MA 01615-0121

**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
pre-authorization:

+---+------------------------------------------------------------------+
| * | **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) Mail your request to us at: Fallon Community Health Plan,    |
|   |     Consumer Affairs Department, 10 Chestnut St., Worcester, MA  |
|   |     01608; or fax it to us at: 1-508-755-7393; and               |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms. Be sure to |
|   |     include the member's name, membership ID number and the name |
|   |     of any Plan representatives you may have spoken with.        |
|   |                                                                  |
|   | (e) We will acknowledge your written or faxed request in writing |
|   |     within 15 business days from the date that we receive the    |
|   |     request. If you call or come in to our offices we will put   |
|   |     your request in writing and send the written statement to    |
|   |     you or your authorized representative within 48 hours of the |
|   |     time that we talked to you. If your request involves         |
|   |     termination of ongoing treatment, this treatment will        |
|   |     continue until we complete our review and send you a         |
|   |     response.                                                    |
+---+------------------------------------------------------------------+
| * | 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. A Plan administrator and/or Plan physicians |
| * | who are knowledgeable about the matters at issue will review     |
| * | your request. For certain types of review, we may ask you to     |
|   | participate in a conference.                                     |
|   |                                                                  |
|   | 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. In our written response  |
|   | we will describe the specific information considered.            |
|   |                                                                  |
|   | If we deny your request (we call this an adverse determination)  |
|   | you may ask for a reconsideration if any relevant information    |
|   | was received too late to review within the time limits described |
|   | above. If we agree to reconsider, we will inform you in writing  |
|   | of the new time period for review. This would be no longer than  |
|   | 30 days from the date we agree to reconsideration.               |
|   |                                                                  |
|   | If we fail to complete a review within the time limits specified |
|   | above, the decision will automatically be in favor of the        |
|   | member. Time limits include any extensions made by mutual        |
|   | written agreement between the member, or the member's authorized |
|   | representative, and the Plan.                                    |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us \-- if we did not       |
|   |     answer that request in some way within 30 days; or           |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: Office of Personnel Management, Insurance       |
|   | Services Programs, Health Insurance Group 3, 1900 E Street, NW,  |
|   | Washington, DC 20415-3630.                                       |
+---+------------------------------------------------------------------+
|   | **The Disputed Claims process *(Continued) ***                   |
|   |                                                                  |
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | 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 pre-authorization 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) If we haven\'t responded yet to your initial request for care or
    pre-authorization or prior approval, then call us at 1-800-868-5200
    (TDD/TTY: 1-877-608-7677) and we will expedite our review. In
    certain cases we may automatically reverse our decision if your
    provider certifies in writing that a denial of coverage would create
    a substantial risk of serious harm, and that this risk is so
    substantial that you cannot wait for the outcome of the normal
    review process. If you are an inpatient at the time you submit your
    request for review, we will respond before you are discharged from
    the hospital. In all other expedited reviews we will send you a
    written response within 72 hours of our receipt of your request. If
    you have a terminal illness, we will respond to you within five
    business days from our receipt of your request.

(b) We denied your initial request for care or pre-authorization/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 202/606-0755 between
    8 a.m. and 5 p.m. eastern time.

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

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

**When you have other health coverage** You must tell us if you or a
covered family member have coverage under another group health plan or
have automobile insurance that pays 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 National Association of Insurance Commissioner's guidelines in
determining secondary coverage.

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

-   People 65 years of age and older.

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

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

Medicare has two parts:

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

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

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

If you can get premium-free Part A coverage, we advise you to enroll in
it. Most Federal employees and annuitants are entitled to Medicare Part
A at age 65 **without cost**. When you don't have to pay premiums for
Medicare Part A, it makes good sense to obtain the coverage. It can
reduce your out-of-pocket expenses as well as costs to the FEHB, which
can help keep FEHB premiums down.

> Everyone is charged a premium for Medicare Part B coverage. The Social
> Security Administration can provide you with premium and benefit
> information. Review the information and decide if it makes sense for
> you to buy the Medicare Part B coverage.
>
> If you are eligible for Medicare, you may have choices in how you get
> your health care. Medicare + Choice is the term used to describe the
> various health plan choices available to Medicare beneficiaries. The
> information in the next few pages shows how we coordinate benefits
> with Medicare, depending on the type of Medicare + Choice plan you
> have.

The Original Medicare Plan (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.

> **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.

```{=html}
<!-- -->
```
-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In most cases, your claim will be coordinated
    automatically and we will then provide secondary benefits for
    covered charges. You will not need to do anything. To find out if
    you need to do something to file your claim, call us at
    1-800-868-5200 (TDD/TTY: 1-877-608-7677).

> **We do not waive any costs if the Original Medicare Plan is your
> primary payer.**
>
> ***(Primary payer chart begins on next page)***
>
> Medicare always makes the final determination as to whether they are
> the primary payer. The following chart illustrates whether Medicare or
> this Plan should be the primary payer for you according to your
> employment status and other factors determined by Medicare. It is
> critical that you tell us if you or a covered family member has
> Medicare coverage so we can administer these requirements correctly.

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

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

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

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

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

> **This Plan and 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 not waive cost-sharing for your FEHB coverage.

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

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

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

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

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

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

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

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

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

**Suspended FEHB coverage to enroll in Medicaid or a similar
State-sponsored program of medical assistance:** If you are an annuitant
or former spouse, you can suspend your FEHB coverage to enroll in 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          | We do not cover services and supplies when a |
| Government agencies** | local, State, or Federal Government agency   |
| **are responsible for | directly or indirectly pays for them.        |
| your care**           |                                              |
+-----------------------+----------------------------------------------+
| **When others are     | When you receive money to compensate you for |
| responsible**         | 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.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 65.

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

**Custodial care** Care furnished to meet non-medically necessary needs
such as assistance in mobility, dressing, bathing, eating, preparation
of special diets and taking medications. Custodial care that lasts 90
days or more is sometimes known as long-term care. Custodial care is not
covered by the Plan.

+----------------------+-----------------------------------------------+
| **Experimental or**  | Our Benefits & Technology Assessment          |
|                      | Committee determines what procedures, devices |
| **investigational    | and services are experimental or              |
| services**           | investigational use FDA guidelines and        |
|                      | long-term clinical studies. Clinical studies  |
|                      | are used to ensure that the procedure, device |
|                      | or service has proven to be more effective    |
|                      | than currently accepted procedures, devices   |
|                      | or services.                                  |
+----------------------+-----------------------------------------------+

**Group health coverage** Health care coverage through a partnership,
association, or corporation that has an agreement to pay the Plan, or
its agent, the Plan premium for a group of subscribers. FEHB is an
example of a group.

**Medical necessity** A medical or hospital service, which is rendered
for treatment or diagnosis of an injury or illness, not furnished
primarily for the convenience of the member, physician or provider, and
is in accordance with professionally recognized medical standards and
Plan medical criteria.

**Provider** A person, agency or facility that may furnish health care
to you under the terms of this contract. This includes doctors of
medicine, osteopathy and podiatry; registered nurse anesthetists and
nurse practitioners.

**Us/We** Us and we refer to Fallon Community Health Plan (FCHP).

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

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

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

**Coverage information**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

**premiums start** 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

-   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      | If you are divorced from a Federal employee or   |
|     equity        | annuitant, you may not continue to get benefits  |
|     coverage**    | 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]{.underline}.                |
+-------------------+--------------------------------------------------+

+-------------------+--------------------------------------------------+
| -   **Temporary   | If you leave Federal service, or if you lose     |
|     continuation  | coverage because you no longer qualify as a      |
|     of coverage   | family member, you may be eligible for Temporary |
|     (TCC)**       | 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  | You may convert to a non-FEHB individual policy  |
|     to individual | if:                                              |
|     coverage**    |                                                  |
|                   | -   Your coverage under TCC or the spouse equity |
|                   |     law ends (If you canceled your coverage or   |
|                   |     did not pay your premium, you cannot         |
|                   |     convert);                                    |
|                   |                                                  |
|                   | -   You decided not to receive coverage under    |
|                   |     TCC or the spouse equity law; or             |
|                   |                                                  |
|                   | -   You are not eligible for coverage under TCC  |
|                   |     or the spouse equity law.                    |
|                   |                                                  |
|                   | If you leave Federal service, your employing     |
|                   | office will notify you of your right to convert. |
|                   | You must apply in writing to us within 31 days   |
|                   | after you receive this notice. However, if you   |
|                   | are a family member who is losing coverage, the  |
|                   | employing or retirement office will **not**      |
|                   | notify you. You must apply in writing to us      |
|                   | within 31 days after you are no longer eligible  |
|                   | for coverage.                                    |
|                   |                                                  |
|                   | Your benefits and rates will differ from those   |
|                   | under the FEHB Program; however, you will not    |
|                   | have to answer questions about your health, and  |
|                   | we will not impose a waiting period or limit     |
|                   | your coverage due to pre-existing conditions.    |
+-------------------+--------------------------------------------------+

+-------------------+--------------------------------------------------+
| -   **Getting a   | The Health Insurance Portability and             |
|     Certificate   | Accountability Act of 1996 (HIPAA) is a Federal  |
|     of Group      | law that offers limited Federal protections for  |
|     Health Plan   | health coverage availability and continuity to   |
|     Coverage**    | 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 website                                 |
|                   | ([www.opm.gov/insu                               |
|                   | re/health);](http://www.opm.gov/insure/health);) |
|                   | refer to the \"TCC and HIPAA\" frequently asked  |
|                   | questions. These highlight HIPAA rules, such as  |
|                   | the requirement that Federal employees must      |
|                   | exhaust any TCC eligibility as one condition for |
|                   | guaranteed access to individual health coverage  |
|                   | under HIPAA, and 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 childcare
    subsidy you may receive.

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

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

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

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

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

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

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

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

+-------------------+--------------------------------------------------+
| -   **What can my | Every FEHB health plan includes cost sharing     |
|     HCFSA pay     | features, such as deductibles you must meet      |
|     for?**        | 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 65 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    |
|                   | are NOT covered by this FEHB Plan or any other   |
|                   | coverage that you have.                          |
|                   |                                                  |
|                   | Under This Plan, typical out-of-pocket expenses  |
|                   | include: office visit, prescription and          |
|                   | inpatient hospital copays, hearing aids,         |
|                   | eyeglasses and orthodontia.                      |
|                   |                                                  |
|                   | 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 Website at                   |
|                   | <http://www.irs.gov/pub/irs-pdf/p502.pdf>. If    |
|                   | you do not see your service or expense listed in |
|                   | Publication 502, please call a FSAFEDS Benefit   |
|                   | Counselor at 1-877-FSAFEDS (372-3337), who will  |
|                   | be able to answer your specific questions.       |
+-------------------+--------------------------------------------------+

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

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

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

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

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

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

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

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

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

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

+-----------------+----------------------------------------------------+
| -   **Tax       | > You *cannot* claim expenses on your Federal      |
|     credits and | > income tax return if you receive reimbursement   |
|                 | > for them from your HCFSA or DCFSA. Below are     |
|    deductions** | > 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]{.underline} is not available on your Federal income tax
> return.
>
> **Dependent care expenses** The DCFSA generally allows many families
> to save more than they would with the Federal tax credit for dependent
> care expenses. Note that you may only be reimbursed from the DCFSA up
> to your current account balance. If you file a claim for more than
> your current balance, it will be held until additional payroll
> allotments have been added to your account.
>
> Visit [www.fsafeds.com](http://www.fsafeds.com/) and download the
> Dependent Care Tax Credit Worksheet from the Quick Links box to help
> you determine what is best for your situation. You may also wish to
> consult a tax professional for more details.

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

> **to participate in FSAFEDS?** and 1.5% of the annual election for a
> DCFSA, most agencies have elected to pay these fees out of their share
> of employment tax savings. To be sure, check the FSAFEDS.com website
> 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 Website** 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 44

Allergy tests 23

Alternative treatment 27

Allogenetic (donor) bone marrow transplant 23, 30

Ambulance 16 ,32 ,34 ,36

Anesthesia 7,28,31,33

Autologous bone marrow transplant 23, 30

**B**lood and blood plasma 32, 33

Breast cancer screening 13, 18, 20

Casts 28, 32, 33, 45

Catastrophic protection out-of-pocket maximum 17, 65

Changes for 2004 11

Chemotherapy 23

Childbirth 13, 21, 32, 42, 57

Chiropractic 11, 14, 37

Cholesterol tests 20

Circumcision 21

Claims 6, 8, 12, 18, 39,40,42,48-50, 52-54, 58, 60-62

Coinsurance 8, 17, 61

Colorectal cancer screening 20

Congenital anomalies 28, 29

Contraceptive devices and drugs 11, 22, 40

Coordination of benefits 53

Covered charges 52

Covered providers 8, 12, 19, 37, 43, 55

Crutches 26

**D**eductible 8, 17, 61

Definitions 56

Dental care 11, 13, 25, 33,41, 42, 44-46, 65

Diagnostic services 18, 19, 27, 32, 33, 37, 42, 44, 45, 65

Disputed claims review 42, 49, 50

Donor expenses (transplants) 23, 30, 31

Dressings 32, 33, 41

Durable medical equipment (DME) 16, 25-27, 42

**E**ducational classes and programs 27

Effective date of enrollment 5, 12, 15, 56, 58

Emergency 8, 10, 16, 35, 36, 38, 39, 42, 44, 47, 48

Experimental or investigational 47, 56

Eyeglasses 24, 61

**F**amily planning 22

Fecal occult blood test 20

Fraud 5, 6, 13

General Exclusions 47

**H**earing services 21, 24, 26, 42, 43, 46, 61, 63

Home health services 27

Hospice care 16, 33

Home nursing care 16, 27, 31, 33, 42

Hospital 8, 11,15, 21, 35, 26, 28-33, 35-37, 43, 44,46, 48, 50-52,54-56,
61, 65

**I**mmunizations 20, 21

Infertility 13, 15, 22, 23, 43

In-hospital physician care 28, 32

Inpatient Hospital Benefits 11, 15, 21, 24, 28-33, 36-38, 42, 44, 50,
61, 65

Insulin 26, 40

**L**aboratory and pathological services 32, 33, 43

**M**agnetic Resonance Imaging (MRIs) 19

Mail Order Prescription Drugs 39, 40, 42

Mammograms 13, 18, 20

Maternity Benefits 13, 21, 32, 42, 57

Medicaid 55

Medically necessary 11, 15, 19, 21, 23, 24, 27, 28, 32, 33, 35, 37, 39,
42, 44, 42, 56

Medicare 11, 19, 28, 32, 35, 37, 39, 44, 48, 51, 52-54

Members 8, 12, 57

Mental Conditions/Substance Abuse Benefits 13, 37, 38, 43, 65

Non-FEHB Benefits 46

Nurse

Nurse Anesthetist 32

Nurse Midwife 11, 13

Nurse Practitioner 13, 56

Registered Nurse 11

Nursery charges 21

**O**bstetrical care 21

Occupational therapy 11, 24, 27, 33, 42

Ocular injury 24

Office visits 8, 13, 14, 17, 19-31, 37, 42, 44, 61, 65

Oral and maxillofacial surgery 29

Orthopedic devices 25

Out-of-pocket expenses 17, 51, 60, 61, 65

Outpatient facility care 13, 18, 28-31, 33, 36-38, 42, 65

Oxygen 26, 27, 32, 33

**P**ap test 13, 19, 20

Physical examination 8, 20, 21, 42

Physical therapy 11, 14, 24, 27, 33, 42

Pre-authorization 15, 16, 21, 28, 32, 37, 38-50

Preventive care, adult 8, 18, 20,44, 65

Preventive care, children 8, 18, 21, 24, 42, 44, 65

Prescription drugs 11, 22, 23, 26, 39, 48, 52, 54, 65

Prior approval 8, 15, 23, 47, 50

Prostate cancer screening 20

Prosthetic devices 16, 18, 25, 26, 28, 29

**R**adiation therapy 23

Renal dialysis 23, 26, 51

Room and board 32, 33

**S**econd surgical opinion 19

Skilled nursing facility care 19, 31, 33

Smoking cessation 27, 41

Speech therapy 14, 18, 24, 25, 27, 33, 42

Splints 32

Sterilization procedures 22, 23, 28

Subrogation 55

Substance abuse 13, 18, 37, 38, 43, 65

Surgery 7, 13, 15, 18, 21, 24, 25, 28-32

-   Anesthesia 7, 28,31,33

```{=html}
<!-- -->
```
-   Oral 13, 15

-   Outpatient 18, 28-31, 33, 36, 65

-   Reconstructive 15, 18, 28, 29

    Syringes 40

    **T**emporary continuation of coverage 58, 59

    Transplants 15, 18, 23, 29, 30, 51

Treatment therapies 18, 23

**V**ision services 18, 21, 24, 42, 60, 65

**W**ell child care 21

Wheelchairs 26, 42

Workers' compensation 53, 54

**X**-rays 18, 19, 32, 33, 42, 43, 44

  -----------------------------------------------------------------------
  **Summary of benefits for Fallon Community Health Plan 2004**

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

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

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

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

+-------------------------------------+--------------------------+----+
| **Benefits**                        | **You Pay**              | ** |
|                                     |                          | Pa |
|                                     |                          | ge |
|                                     |                          | ** |
+-------------------------------------+--------------------------+----+
| Medical services provided by        | Office visit copay: \$10 | >  |
| physicians:                         |                          | 19 |
|                                     |                          |    |
| -   Diagnostic and treatment        |                          |    |
|     services provided in the office |                          |    |
+-------------------------------------+--------------------------+----+
| Services provided by a hospital:    | > \$100 per admission    | >  |
|                                     | > copay                  | 28 |
| -   Inpatient                       | >                        | >  |
|                                     | > Nothing                | >  |
| -   Outpatient                      |                          | 33 |
+-------------------------------------+--------------------------+----+
| Emergency benefits:                 | > \$50 per visit         | >  |
|                                     | >                        | 35 |
| -   In-area                         | > \$50 per visit         | >  |
|                                     |                          | >  |
| -   Out-of-area                     |                          | 35 |
+-------------------------------------+--------------------------+----+
| > Mental health and substance abuse | > Regular cost sharing   | >  |
| > treatment                         |                          | 37 |
+-------------------------------------+--------------------------+----+
| Prescription drugs                  | > Tier 1: \$5 copay for  | >  |
|                                     | > up to a 30-day supply  | 39 |
|                                     | >                        |    |
|                                     | > Tier 2: \$20 copay for |    |
|                                     | > up to a 30-day supply  |    |
|                                     | >                        |    |
|                                     | > Tier 3: \$40 copay for |    |
|                                     | > up to a 30-day supply  |    |
+-------------------------------------+--------------------------+----+
| Dental Care                         | > \$10 per office visit  | >  |
|                                     | > for preventive care;   | 44 |
|                                     | > copayments vary from   |    |
|                                     | > \$16 to \$49 for minor |    |
|                                     | > restorative care       |    |
+-------------------------------------+--------------------------+----+
| Vision Care                         | > \$10 per visit         | >  |
|                                     |                          | 24 |
+-------------------------------------+--------------------------+----+
| > Special features:                 | > Flexible benefits      | >  |
|                                     | > option                 | 43 |
|                                     | >                        |    |
|                                     | > Out-of-area student    |    |
|                                     | > benefits               |    |
|                                     | >                        |    |
|                                     | > Services for the       |    |
|                                     | > hearing impaired       |    |
|                                     | >                        |    |
|                                     | > Interpreter services   |    |
|                                     | >                        |    |
|                                     | > Peace of Mind          |    |
|                                     | > Program^™^             |    |
+-------------------------------------+--------------------------+----+
| Protection against catastrophic     | We do not have a         | >  |
| costs                               | catastrophic             | 17 |
|                                     | out-of-pocket maximum.   |    |
| (your catastrophic protection       |                          |    |
| out-of-pocket maximum)              |                          |    |
+-------------------------------------+--------------------------+----+

**2004 Rate Information for**

**Fallon Community 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.

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

# Location Information: Central and Eastern Massachusetts, Including the Worcester metropolitan area

+------------+---------+--------------------------+-------------------+
| ### **Hig  | **JV1** | **\$121.40 \$57.26       | **\$143.32        |
| h Option** |         | \$263.03 \$124.07**      | \$35.34**         |
|            | **JV2** |                          |                   |
| **Self     |         | **\$277.09 \$157.14      | **\$327.12        |
| Only**     |         | \$600.36 \$340.47**      | \$107.11**        |
|            |         |                          |                   |
| **High     |         |                          |                   |
| Option**   |         |                          |                   |
|            |         |                          |                   |
| **Self &   |         |                          |                   |
| Family**   |         |                          |                   |
+------------+---------+--------------------------+-------------------+