**Humana Health Plans\
of Puerto Rico, Inc.**

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A Health Maintenance Organization\
with a point of service product

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#### 

**Enrollment codes for this Plan:**

######## 

########  ZJ1 Self Only

########  ZJ2 Self and Family

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

**OFFICE OF PERSONNEL MANAGEMENT**

**WASHINGTON, DC 20415-0001**

**OFFICE OF THE DIRECTOR**

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

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Sincerely,

> Kay Cole James
>
> Director

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# Notice of the Office of Personnel Management's

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

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  Table of Contents
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Introduction 4

Plain Language 4

Stop Health Care Fraud! 4-5

Preventing medical mistakes 5-6

Section 1. Facts about this HMO plan 7

We also have point-of-service (POS) benefits 7

How we pay providers 7

Your Rights 7

Service Area 7

Section 2. How we change for 2004 8

Section 3. How you get care ............\... 9-11

Identification cards 9

Where you get covered care 9

-   Plan providers 9

-   Plan facilities 9

What you must do to get covered care 9-10

-   Primary care 9

-   Specialty care 9-10

-   Hospital care 10

Circumstances beyond our control 11

Services requiring our prior approval 11

Section 4. Your costs for covered services 12

-   Copayments 12

-   Deductible 12

-   Coinsurance 12

Your catastrophic protection out-of-pocket maximum 12

Section 5.
Benefits..................................................................
13-37

Overview 13

(a) Medical services and supplies provided by physicians and other
    health care professionals 14-21

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 22-25

(c) Services provided by a hospital or other facility, and ambulance
    services 26-27

(d) Emergency services/accidents 28-29

(e) Mental health and substance abuse benefits 30-31

(f) Prescription drug benefits 32-33

(g) Special features 34

-   Flexible benefits option

-   Services for deaf and hearing impaired

-   High risk pregnancies

-   Centers of excellence

-   24-hour nurse line

(h) Dental benefits 35

(i) Point of service product 36

(j) Non-FEHB benefits available to Plan members 37

Section 6. General exclusions -- things we don\'t cover 38

Section 7. Filing a claim for covered services 39

Section 8. The disputed claims process 40-41

Section 9. Coordinating benefits with other coverage 42-46

When you have other health coverage 42-46

-   What is Medicare? 42

-   Should I enroll in Medicare? 42

-   Medicare + Choice 45

-   TRICARE and CHAMPVA 45

-   Workers\' Compensation 45

-   Medicaid 46

-   Other Government agencies 46

-   When others are responsible for injuries 46

Section 10. Definitions of terms we use in this brochure 47-48

Section 11. FEHB facts 49-52

Coverage information 49-50

-   No pre-existing condition limitation 49

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

-   Types of coverage available for you and your family 49

-   Children's Equity Act 49-50

-   When benefits and premiums start 50

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-   When you retire 50

    When you lose benefits 50-52

-   When FEHB coverage ends 50

-   Spouse equity coverage 51

-   Temporary Continuation of Coverage (TCC) 51

-   Converting to individual coverage 51

-   Getting a Certificate of Group Health Plan Coverage 51-52

Two new Federal Programs complement FEHB benefits 53-56

> The Federal Flexible Spending Account Program -- *FSAFEDS* 53-56
>
> The Federal Long Term Care Insurance Program 56

Index 57

Summary of benefits 60

Rates Back cover

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  Introduction

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This brochure describes the benefits of Humana Health Plans of Puerto
Rico, Inc. under our contract (CS 2872) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits
law. The address for Humana Health Plans of Puerto Rico, Inc.
administrative offices is:

Humana Health Plans of Puerto Rico, Inc.

383 F.D. Roosevelt Avenue

San Juan, Puerto Rico 00918-2131

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

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

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and changes are summarized on
page 8. Rates are shown at the end of this brochure.

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

-   Except for necessary technical terms, we use common words. For
    instance, "you" means the enrollee or family member; "we" means
    Humana Health Plans of Puerto Rico, Inc.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   If we do not resolve the issue:

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

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

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

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

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

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

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

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

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

Want more information on patient safety?

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

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

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

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

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

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

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  **Section 1. Facts about this 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 and
coinsurance described in this brochure. When you receive emergency
services from non-Plan providers, you may have to submit reimbursement
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.**

**We also have Point-of-Service (POS) benefits:**

Our HMO offers Point-of-Service (POS) benefits. This means you can
receive covered services from a participating provider without a
required referral, or from a non-participating provider. These
out-of-network benefits have higher out-of-pocket costs than our
in-network benefits. Out of the service area, we pay benefits only when
the services are due to an emergency or have been preauthorized by us.
When services are rendered by non-participating providers, the applicant
will pay for all the services and request reimbursement from Humana.

How we pay providers

We contract with individual physicians, medical groups, and hospitals to
provide the benefits in this brochure. These Plan providers accept a
negotiated payment from us, and you will only be responsible for your
copayments or coinsurance. When you get services out of the network, you
will be responsible for your copayment or coinsurance and all costs
above the rate contracted by Humana for those services.

**Your Rights**

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

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

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

If you want more information about us, call 1-800/314-3121 or
787/282-7900 ext. 5500, or write to the Plan at 383 F.D. Roosevelt
Avenue, San Juan, Puerto Rico 00918-2131. You may also contact us by fax
at 787/622-5713 or visit our website at www.pr.humana.com.

**Service Area**

To enroll in this Plan, you must live in or work in our Service Area.
This is where our providers practice. Our Service Area is:

The entire island of Puerto Rico.

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

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

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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 pages 53-56.

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

-   We added information regarding enrolling in Medicare. See pages
    42-43.

-   We revised the Medicare Primary Payer Chart. See page 44.

**Changes to this Plan**

-   Your share of the non-Postal premium will increase 10% for Self Only
    and 10% for Self and Family.

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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\
1-800/314-3121 or 787/282-7900 ext. 5500 or write to use at Humana
Health Plans of Puerto Rico, 383 F.D. Roosevelt Avenue, San Juan, Puerto
Rico 00918-2131. You may also request replacement cards through our web
site: www.pr.humana.com at the *My*Humana portal.

**Where you get covered care** You get care from "Plan providers" and
"Plan facilities." You will only pay copayments or coinsurance, and you
will not have to file claims. You can also use our point-of-service
program, you can also get care from non-Plan providers, or from
participating providers without a required referral, but it will cost
you more. You may have to file a request for reimbursement for non-Plan
providers.

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

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website at www.pr.humana.com, at
the Physician Finder portal.

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

**What you must do**

**to get covered care** It depends on the type of care you need. First,
you and each family member must choose a primary care physician. This
decision is important since your primary care physician provides or
arranges for most of your health care. You may choose your primary care
physician from our Provider Directory or our website, or you may call us
for assistance.

**• Primary care** Your primary care physician can be a general
practitioner, internist or pediatrician. Your primary care physician
will provide most of your health care, or give you a referral to see a
specialist. However, a woman may see her plan gynecologist without a
referral.

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

> **• Specialty care** Your primary care physician will refer you to a
> specialist for needed care. However, you may see any specialist
> without a referral.
>
> Here are other things you should know about specialty care:

• If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician will
develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals. Your primary care
physician will use our criteria when creating your treatment plan.

• If you are seeing a specialist when you enroll in our Plan, talk to
your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a
specialist, you can see your current specialist. If your current
specialist does not participate with us, you will pay for the service
and file a reimbursement form.

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

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

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

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

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

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

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

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

If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 1-800/314-3121 or
787/282-7900 ext. 5500. If you are new to the FEHB Program, we will
arrange for you to receive care.

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

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

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

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

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

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

**Services requiring our** Your primary care physician has authority to
refer you for most services.

**prior approval** For certain services, however, your physician must
obtain approval from us. Before giving approval, we consider if the
service is covered, medically necessary, and follows generally accepted
medical practice.

We call this review and approval process precertification. Your
physician must obtain precertification for the following services, such
as:

-   Services outside the service area -- not emergencies

-   Growth hormone therapy

-   Ambulatory surgery

-   Stereotactic biopsy

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-   Physical therapy (after 15 treatments)

-   Home health care (after 60 days)

-   Organ/tissue transplants

Your physician must obtain our approval by calling 800/314-3121 or
787/282-7900 ext. 5550.

  -----------------------------------------------------------------------
  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 a primary care physician you pay a copayment of
\$5 per office visit.

> **• Deductible** A deductible applies only if you access the Point of
> Service Option -- see Section 5i.

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

Example: In our Plan, you pay 50% of our negotiated fee for durable
medical equipment.

**Your catastrophic protection**

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

+-----------------------------------------------------------------------+
| **Section 5. Benefits -- OVERVIEW**                                   |
|                                                                       |
| ***(See page 8 for how our benefits changed this year and page 60 for |
| a benefits summary.)***                                               |
+-----------------------------------------------------------------------+

**NOTE**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claims forms,
claims filing advice, or more information about our benefits, contact us
at 1-800/314-3121 or 787/282-7900 ext. 5500 or at our website at
www.pr.humana.com*.*

(a) Medical services and supplies provided by physicians and other
    health care professionals 14-21

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 22-25

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

(c) Services provided by a hospital or other facility, and ambulance
    services 26-27

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

(d) Emergency services/accidents 28-29

> • Medical emergency • Ambulance

(e) Mental health and substance abuse benefits 30-31

(f) Prescription drug benefits 32-33

(g) Special features 34

    -   Flexible benefits option

    -   Services for deaf and hearing impaired

    -   High risk pregnancies

    -   Centers of excellence for transplants

    -   24-hour nurse line

(h) Dental benefits 35

(i) Point of Service benefits 36

(j) Non-FEHB benefits available to Plan members 37

Summary of benefits 60

+---+----+----+------------------------------+---+---------------+----+---+---+
|   | *  |    |                              |   |               |    |   |   |
|   | *S |    |                              |   |               |    |   |   |
|   | ec |    |                              |   |               |    |   |   |
|   | ti |    |                              |   |               |    |   |   |
|   | on |    |                              |   |               |    |   |   |
|   | 5  |    |                              |   |               |    |   |   |
|   | (a |    |                              |   |               |    |   |   |
|   | ). |    |                              |   |               |    |   |   |
|   | M  |    |                              |   |               |    |   |   |
|   | ed |    |                              |   |               |    |   |   |
|   | ic |    |                              |   |               |    |   |   |
|   | al |    |                              |   |               |    |   |   |
|   | se |    |                              |   |               |    |   |   |
|   | rv |    |                              |   |               |    |   |   |
|   | ic |    |                              |   |               |    |   |   |
|   | es |    |                              |   |               |    |   |   |
|   | a  |    |                              |   |               |    |   |   |
|   | nd |    |                              |   |               |    |   |   |
|   | su |    |                              |   |               |    |   |   |
|   | pp |    |                              |   |               |    |   |   |
|   | li |    |                              |   |               |    |   |   |
|   | es |    |                              |   |               |    |   |   |
|   | pr |    |                              |   |               |    |   |   |
|   | ov |    |                              |   |               |    |   |   |
|   | id |    |                              |   |               |    |   |   |
|   | ed |    |                              |   |               |    |   |   |
|   | by |    |                              |   |               |    |   |   |
|   | p  |    |                              |   |               |    |   |   |
|   | hy |    |                              |   |               |    |   |   |
|   | si |    |                              |   |               |    |   |   |
|   | ci |    |                              |   |               |    |   |   |
|   | an |    |                              |   |               |    |   |   |
|   | s\ |    |                              |   |               |    |   |   |
|   | a  |    |                              |   |               |    |   |   |
|   | nd |    |                              |   |               |    |   |   |
|   | o  |    |                              |   |               |    |   |   |
|   | th |    |                              |   |               |    |   |   |
|   | er |    |                              |   |               |    |   |   |
|   | he |    |                              |   |               |    |   |   |
|   | al |    |                              |   |               |    |   |   |
|   | th |    |                              |   |               |    |   |   |
|   | ca |    |                              |   |               |    |   |   |
|   | re |    |                              |   |               |    |   |   |
|   | p  |    |                              |   |               |    |   |   |
|   | ro |    |                              |   |               |    |   |   |
|   | fe |    |                              |   |               |    |   |   |
|   | ss |    |                              |   |               |    |   |   |
|   | io |    |                              |   |               |    |   |   |
|   | na |    |                              |   |               |    |   |   |
|   | ls |    |                              |   |               |    |   |   |
|   | ** |    |                              |   |               |    |   |   |
+---+----+----+------------------------------+---+---------------+----+---+---+
|   |    | *  | > **Here are some important  |   |               | *  |   |   |
|   |    | *I | > things to keep in mind     |   |               | *I |   |   |
|   |    | ** | > about these benefits:**    |   |               | ** |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    | *  | -   Please remember that all |   |               | *  |   |   |
|   |    | *M |     benefits are subject to  |   |               | *M |   |   |
|   |    | ** |     the definitions,         |   |               | ** |   |   |
|   |    |    |     limitations, and         |   |               |    |   |   |
|   |    | *  |     exclusions in this       |   |               | *  |   |   |
|   |    | *P |     brochure and are payable |   |               | *P |   |   |
|   |    | ** |     only when we determine   |   |               | ** |   |   |
|   |    |    |     they are medically       |   |               |    |   |   |
|   |    | *  |     necessary.               |   |               | *  |   |   |
|   |    | *O |                              |   |               | *O |   |   |
|   |    | ** | -   Plan physicians must     |   |               | ** |   |   |
|   |    |    |     provide or arrange your  |   |               |    |   |   |
|   |    | *  |     care.                    |   |               | *  |   |   |
|   |    | *R |                              |   |               | *R |   |   |
|   |    | ** | ```{=html}                   |   |               | ** |   |   |
|   |    |    | <!-- -->                     |   |               |    |   |   |
|   |    | *  | ```                          |   |               | *  |   |   |
|   |    | *T | -   Be sure to read Section  |   |               | *T |   |   |
|   |    | ** |     4, *Your costs for       |   |               | ** |   |   |
|   |    |    |     covered services* for    |   |               |    |   |   |
|   |    | *  |     valuable information     |   |               | *  |   |   |
|   |    | *A |     about how cost sharing   |   |               | *A |   |   |
|   |    | ** |     works. Also read Section |   |               | ** |   |   |
|   |    |    |     9 about coordinating     |   |               |    |   |   |
|   |    | *  |     benefits with other      |   |               | *  |   |   |
|   |    | *N |     coverage, including with |   |               | *N |   |   |
|   |    | ** |     Medicare.                |   |               | ** |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    | *  |                              |   |               | *  |   |   |
|   |    | *T |                              |   |               | *T |   |   |
|   |    | ** |                              |   |               | ** |   |   |
+---+----+----+------------------------------+---+---------------+----+---+---+
|   | >  |    |                              |   | > **You pay** |    |   |   |
|   |  * |    |                              |   |               |    |   |   |
|   | *B |    |                              |   |               |    |   |   |
|   | en |    |                              |   |               |    |   |   |
|   | ef |    |                              |   |               |    |   |   |
|   | it |    |                              |   |               |    |   |   |
|   | >  |    |                              |   |               |    |   |   |
|   |  D |    |                              |   |               |    |   |   |
|   | es |    |                              |   |               |    |   |   |
|   | cr |    |                              |   |               |    |   |   |
|   | ip |    |                              |   |               |    |   |   |
|   | ti |    |                              |   |               |    |   |   |
|   | on |    |                              |   |               |    |   |   |
|   | ** |    |                              |   |               |    |   |   |
+---+----+----+------------------------------+---+---------------+----+---+---+
|   | #  |    |                              |   |               |    |   |   |
|   | ## |    |                              |   |               |    |   |   |
|   |  * |    |                              |   |               |    |   |   |
|   | *D |    |                              |   |               |    |   |   |
|   | ia |    |                              |   |               |    |   |   |
|   | gn |    |                              |   |               |    |   |   |
|   | os |    |                              |   |               |    |   |   |
|   | ti |    |                              |   |               |    |   |   |
|   | c  |    |                              |   |               |    |   |   |
|   | an |    |                              |   |               |    |   |   |
|   | d  |    |                              |   |               |    |   |   |
|   | tr |    |                              |   |               |    |   |   |
|   | ea |    |                              |   |               |    |   |   |
|   | tm |    |                              |   |               |    |   |   |
|   | en |    |                              |   |               |    |   |   |
|   | t  |    |                              |   |               |    |   |   |
|   | se |    |                              |   |               |    |   |   |
|   | rv |    |                              |   |               |    |   |   |
|   | ic |    |                              |   |               |    |   |   |
|   | es |    |                              |   |               |    |   |   |
|   | ** |    |                              |   |               |    |   |   |
+---+----+----+------------------------------+---+---------------+----+---+---+
|   | >  |    |                              |   | > \$5 per     |    |   |   |
|   | Pr |    |                              |   | > office      |    |   |   |
|   | of |    |                              |   | > visit       |    |   |   |
|   | es |    |                              |   |               |    |   |   |
|   | si |    |                              |   |               |    |   |   |
|   | on |    |                              |   |               |    |   |   |
|   | al |    |                              |   |               |    |   |   |
|   | >  |    |                              |   |               |    |   |   |
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|   | es |    |                              |   |               |    |   |   |
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|   |    |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | In |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  p |    |                              |   |               |    |   |   |
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|   | `` |    |                              |   |               |    |   |   |
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|   | ns |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
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|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | su |    |                              |   |               |    |   |   |
|   | rg |    |                              |   |               |    |   |   |
|   | ic |    |                              |   |               |    |   |   |
|   | al |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  o |    |                              |   |               |    |   |   |
|   | pi |    |                              |   |               |    |   |   |
|   | ni |    |                              |   |               |    |   |   |
|   | on |    |                              |   |               |    |   |   |
+---+----+----+------------------------------+---+---------------+----+---+---+
|   | -  |    |                              |   | > Nothing     |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | Du |    |                              |   |               |    |   |   |
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|   |    |    |                              |   |               |    |   |   |
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|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | st |    |                              |   |               |    |   |   |
|   | ay |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | `` |    |                              |   |               |    |   |   |
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|   | -> |    |                              |   |               |    |   |   |
|   | `  |    |                              |   |               |    |   |   |
|   | `` |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | In |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  a |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  s |    |                              |   |               |    |   |   |
|   | ki |    |                              |   |               |    |   |   |
|   | ll |    |                              |   |               |    |   |   |
|   | ed |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  n |    |                              |   |               |    |   |   |
|   | ur |    |                              |   |               |    |   |   |
|   | si |    |                              |   |               |    |   |   |
|   | ng |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | fa |    |                              |   |               |    |   |   |
|   | ci |    |                              |   |               |    |   |   |
|   | li |    |                              |   |               |    |   |   |
|   | ty |    |                              |   |               |    |   |   |
+---+----+----+------------------------------+---+---------------+----+---+---+
|   | #  |    |                              |   | \$15 per      |    |   |   |
|   |  A |    |                              |   | visit         |    |   |   |
|   | t  |    |                              |   |               |    |   |   |
|   | ho |    |                              |   |               |    |   |   |
|   | me |    |                              |   |               |    |   |   |
+---+----+----+------------------------------+---+---------------+----+---+---+
|   | #  |    |                              |   |               |    |   |   |
|   |  L |    |                              |   |               |    |   |   |
|   | ab |    |                              |   |               |    |   |   |
|   | ,  |    |                              |   |               |    |   |   |
|   | x- |    |                              |   |               |    |   |   |
|   | ra |    |                              |   |               |    |   |   |
|   | y  |    |                              |   |               |    |   |   |
|   | an |    |                              |   |               |    |   |   |
|   | d  |    |                              |   |               |    |   |   |
|   | ot |    |                              |   |               |    |   |   |
|   | he |    |                              |   |               |    |   |   |
|   | r  |    |                              |   |               |    |   |   |
|   | di |    |                              |   |               |    |   |   |
|   | ag |    |                              |   |               |    |   |   |
|   | no |    |                              |   |               |    |   |   |
|   | st |    |                              |   |               |    |   |   |
|   | ic |    |                              |   |               |    |   |   |
|   |  t |    |                              |   |               |    |   |   |
|   | es |    |                              |   |               |    |   |   |
|   | ts |    |                              |   |               |    |   |   |
+---+----+----+------------------------------+---+---------------+----+---+---+
|   | >  |    |                              |   | > Nothing     |    |   |   |
|   | Su |    |                              |   |               |    |   |   |
|   | ch |    |                              |   |               |    |   |   |
|   | >  |    |                              |   |               |    |   |   |
|   |  a |    |                              |   |               |    |   |   |
|   | s: |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  B |    |                              |   |               |    |   |   |
|   | lo |    |                              |   |               |    |   |   |
|   | od |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  t |    |                              |   |               |    |   |   |
|   | es |    |                              |   |               |    |   |   |
|   | ts |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | Ur |    |                              |   |               |    |   |   |
|   | in |    |                              |   |               |    |   |   |
|   | al |    |                              |   |               |    |   |   |
|   | ys |    |                              |   |               |    |   |   |
|   | is |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  N |    |                              |   |               |    |   |   |
|   | on |    |                              |   |               |    |   |   |
|   | -r |    |                              |   |               |    |   |   |
|   | ou |    |                              |   |               |    |   |   |
|   | ti |    |                              |   |               |    |   |   |
|   | ne |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  P |    |                              |   |               |    |   |   |
|   | ap |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  t |    |                              |   |               |    |   |   |
|   | es |    |                              |   |               |    |   |   |
|   | ts |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  P |    |                              |   |               |    |   |   |
|   | at |    |                              |   |               |    |   |   |
|   | ho |    |                              |   |               |    |   |   |
|   | lo |    |                              |   |               |    |   |   |
|   | gy |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | X- |    |                              |   |               |    |   |   |
|   | ra |    |                              |   |               |    |   |   |
|   | ys |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  N |    |                              |   |               |    |   |   |
|   | on |    |                              |   |               |    |   |   |
|   | -r |    |                              |   |               |    |   |   |
|   | ou |    |                              |   |               |    |   |   |
|   | ti |    |                              |   |               |    |   |   |
|   | ne |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | Ma |    |                              |   |               |    |   |   |
|   | mm |    |                              |   |               |    |   |   |
|   | og |    |                              |   |               |    |   |   |
|   | ra |    |                              |   |               |    |   |   |
|   | ms |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  C |    |                              |   |               |    |   |   |
|   | AT |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  S |    |                              |   |               |    |   |   |
|   | ca |    |                              |   |               |    |   |   |
|   | ns |    |                              |   |               |    |   |   |
|   | /M |    |                              |   |               |    |   |   |
|   | RI |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | Ul |    |                              |   |               |    |   |   |
|   | tr |    |                              |   |               |    |   |   |
|   | as |    |                              |   |               |    |   |   |
|   | ou |    |                              |   |               |    |   |   |
|   | nd |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   | -  |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  E |    |                              |   |               |    |   |   |
|   | le |    |                              |   |               |    |   |   |
|   | ct |    |                              |   |               |    |   |   |
|   | ro |    |                              |   |               |    |   |   |
|   | ca |    |                              |   |               |    |   |   |
|   | rd |    |                              |   |               |    |   |   |
|   | io |    |                              |   |               |    |   |   |
|   | gr |    |                              |   |               |    |   |   |
|   | am |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  a |    |                              |   |               |    |   |   |
|   | nd |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |  E |    |                              |   |               |    |   |   |
|   | EG |    |                              |   |               |    |   |   |
+---+----+----+------------------------------+---+---------------+----+---+---+
| # |    |    |                              | * |               |    |   |   |
| # |    |    |                              | * |               |    |   |   |
| # |    |    |                              | Y |               |    |   |   |
| # |    |    |                              | o |               |    |   |   |
| # |    |    |                              | u |               |    |   |   |
|   |    |    |                              | p |               |    |   |   |
| P |    |    |                              | a |               |    |   |   |
| r |    |    |                              | y |               |    |   |   |
| e |    |    |                              | * |               |    |   |   |
| v |    |    |                              | * |               |    |   |   |
| e |    |    |                              |   |               |    |   |   |
| n |    |    |                              |   |               |    |   |   |
| t |    |    |                              |   |               |    |   |   |
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|   |    |    |                              |   |               |    |   |   |
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+---+----+----+------------------------------+---+---------------+----+---+---+
| > |    |    |                              | > |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
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| n |    |    |                              |   |               |    |   |   |
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|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
|   |    |    |                              |   |               |    |   |   |
| c |    |    |                              |   |               |    |   |   |
| o |    |    |                              |   |               |    |   |   |
| n |    |    |                              |   |               |    |   |   |
| d |    |    |                              |   |               |    |   |   |
| i |    |    |                              |   |               |    |   |   |
| t |    |    |                              |   |               |    |   |   |
| i |    |    |                              |   |               |    |   |   |
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| n |    |    |                              |   |               |    |   |   |
| s |    |    |                              |   |               |    |   |   |
+---+----+----+------------------------------+---+---------------+----+---+---+

+--------------------------------------------+-------------------------+
| ##### Preventive care, children            | **You pay**             |
+--------------------------------------------+-------------------------+
| -   Childhood immunizations recommended by | > \$5 per office visit  |
|     the American Academy of Pediatrics     |                         |
+--------------------------------------------+-------------------------+
| -   Well-child care charges for routine    | > \$5 per office visit  |
|     examinations, immunizations and care   |                         |
|     (through age 22)                       |                         |
|                                            |                         |
| -   Examinations, such as:                 |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Eye exams to determine the need for    |                         |
|     vision correction.                     |                         |
|                                            |                         |
| -   Ear exams to determine the need for    |                         |
|     hearing correction                     |                         |
|                                            |                         |
| -   Examinations done on the day of        |                         |
|     immunizations (through age 22)         |                         |
+--------------------------------------------+-------------------------+
| ######## Maternity care                    |                         |
+--------------------------------------------+-------------------------+
| > Complete maternity (obstetrical) care,   | > \$5 per office visit  |
| > such as:                                 |                         |
|                                            |                         |
| -   Prenatal care                          |                         |
|                                            |                         |
| -   Delivery                               |                         |
|                                            |                         |
| -   Postnatal care                         |                         |
|                                            |                         |
| > Note: Here are some things to keep in    |                         |
| > mind:                                    |                         |
|                                            |                         |
| -   You may remain in the hospital up to   |                         |
|     48 hours after a regular delivery and  |                         |
|     96 hours after a cesarean delivery. We |                         |
|     will extend your inpatient stay if     |                         |
|     medically necessary.                   |                         |
|                                            |                         |
| -   We cover routine nursery care of the   |                         |
|     newborn child during the covered       |                         |
|     portion of the mother's maternity      |                         |
|     stay. We will cover other care of an   |                         |
|     infant who requires non-routine        |                         |
|     treatment only if we cover the infant  |                         |
|     under a Self and Family enrollment.    |                         |
|                                            |                         |
| -   We pay hospitalization and surgeon     |                         |
|     services (delivery)\                   |                         |
|     the same as for illness and injury.    |                         |
|     See Section 5(c) and Section 5(b)*.*   |                         |
+--------------------------------------------+-------------------------+

+-------------------------------------------+--------------------------+
| ######## Family planning                  | **You pay**              |
+-------------------------------------------+--------------------------+
| A range of voluntary family planning      | > \$5 per office visit   |
| services, limited to:                     |                          |
|                                           |                          |
| -   Surgically implanted contraceptives   |                          |
|     (such as Norplant)                    |                          |
|                                           |                          |
| -   Injectable contraceptive drugs (such  |                          |
|     as Depo Provera)                      |                          |
|                                           |                          |
| -   Intrauterine devices (IUD's)          |                          |
|                                           |                          |
| -   Diaphragms                            |                          |
|                                           |                          |
| -   Voluntary sterilization (See          |                          |
|     *Surgical Procedures*, Section 5b)    |                          |
|                                           |                          |
| > Note: We cover oral contraceptives      |                          |
| > under the prescription drug benefit.    |                          |
+-------------------------------------------+--------------------------+
| > *Not covered: Reversal of voluntary     | > *All charges*          |
| > surgical sterilization, genetic         |                          |
| > counseling*                             |                          |
+-------------------------------------------+--------------------------+
| ######## Infertility services             |                          |
+-------------------------------------------+--------------------------+
| > Diagnosis and treatment of infertility, | > \$5 per office visit   |
| > such as:                                |                          |
|                                           |                          |
| -   Artificial insemination:              |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   intravaginal insemination (IVI)       |                          |
|                                           |                          |
| -   intra­cervical insemination (ICI)      |                          |
|                                           |                          |
| -   intrauterine insemina­tion (IUI)       |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *Infertility services after voluntary |                          |
|     sterilization*                        |                          |
|                                           |                          |
| -   *Assisted reproductive technology     |                          |
|     (ART) procedures, such as:*           |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   *In vitro fertilization*              |                          |
|                                           |                          |
| -   *Embryo transfer, gamete GIFT and     |                          |
|     zygote ZIFT*                          |                          |
|                                           |                          |
| -   *Zygote transfer*                     |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   *Services and supplies related to     |                          |
|     excluded ART procedures*              |                          |
|                                           |                          |
| -   *Cost of donor sperm*                 |                          |
|                                           |                          |
| -   *Cost of donor egg*                   |                          |
|                                           |                          |
| -   *Fertility drugs*                     |                          |
+-------------------------------------------+--------------------------+
| > **Allergy care**                        |                          |
+-------------------------------------------+--------------------------+
| -   Testing and treatment                 | > \$5 per office visit   |
+-------------------------------------------+--------------------------+
| -   Allergy serum                         | > Nothing                |
|                                           |                          |
| -   Allergy injections                    |                          |
+-------------------------------------------+--------------------------+
| > *Not covered: Provocative food testing  | > *All charges*          |
| > and sublingual allergy desensitization* |                          |
+-------------------------------------------+--------------------------+

+--------------------------------------------+-------------------------+
| ######## Treatment therapies               | **You pay**             |
+--------------------------------------------+-------------------------+
| -   Chemotherapy and radiation therapy     | > Nothing               |
|                                            |                         |
| > Note: High dose chemotherapy in          |                         |
| > association with autologous bone marrow  |                         |
| > transplants is limited to those          |                         |
| > transplants listed under Organ/Tissue    |                         |
| > Transplants on page 25.                  |                         |
|                                            |                         |
| -   Respiratory and inhalation therapy     |                         |
|                                            |                         |
| -   Dialysis -- hemodialysis and           |                         |
|     peritoneal dialysis                    |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Intravenous (IV)/Infusion therapy --   |                         |
|     Home IV and antibiotic therapy         |                         |
|                                            |                         |
| -   Growth hormone therapy (GHT)           |                         |
|                                            |                         |
| > Note: We will only cover GHT when we     |                         |
| > preauthorize the treatment. Call         |                         |
| > 800/314-3121 or 787/282-7900 ext. 5550   |                         |
| > for preauthorization. We will ask you to |                         |
| > submit information that establishes that |                         |
| > the GHT is medically necessary. Ask us   |                         |
| > to authorize GHT before you begin        |                         |
| > treatment; otherwise, we will only cover |                         |
| > GHT services from the date you submit    |                         |
| > the information. If you do not ask or if |                         |
| > we determine GHT is not medically        |                         |
| > necessary, we will not cover the GHT or  |                         |
| > related services and supplies. See       |                         |
| > *Services requiring our prior approval*  |                         |
| > in Section 3.                            |                         |
+--------------------------------------------+-------------------------+
| > **Physical, occupational and cardiac     |                         |
| > therapies**                              |                         |
+--------------------------------------------+-------------------------+
| -   60 visits per year per condition for   | > Nothing               |
|     the services of each of the following: |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   qualified physical therapists and      |                         |
|                                            |                         |
| -   occupational therapists.               |                         |
|                                            |                         |
| > Note: We only cover therapy to restore   |                         |
| > bodily function when there has been a    |                         |
| > total or partial loss of bodily function |                         |
| > due to illness or injury.                |                         |
| >                                          |                         |
| > Physical and occupational therapy        |                         |
| > require authorization in advance after   |                         |
| > the first fifteen (15) sessions.         |                         |
|                                            |                         |
| -   Cardiac rehabilitation following a     |                         |
|     heart transplant, bypass surgery or a  |                         |
|     myocardial infarction                  |                         |
+--------------------------------------------+-------------------------+
| > *Not covered:*                           | > *All charges*         |
|                                            |                         |
| -   *Long-term rehabilitative therapy*     |                         |
|                                            |                         |
| -   *Exercise programs*                    |                         |
+--------------------------------------------+-------------------------+
| > **Speech therapy**                       |                         |
+--------------------------------------------+-------------------------+
| -   60 visits per year                     | > Nothing               |
+--------------------------------------------+-------------------------+

+-------------------------------------------+--------------------------+
| > **Hearing services (testing, treatment, | **You pay**              |
| > and supplies)**                         |                          |
+-------------------------------------------+--------------------------+
| -   First hearing aid and testing only    | > \$5 per office visit   |
|     when necessitated by accidental       |                          |
|     injury                                |                          |
|                                           |                          |
| -   Hearing testing for children (see     |                          |
|     *Preventive care, children*)          |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *All other hearing testing*           |                          |
|                                           |                          |
| -   *Hearing aids, testing and            |                          |
|     examinations for them*                |                          |
+-------------------------------------------+--------------------------+
| > **Vision services (testing, treatment,  |                          |
| > and supplies)**                         |                          |
+-------------------------------------------+--------------------------+
| -   One pair of eyeglasses or contact     | > \$5 per office visit   |
|     lenses to correct an impairment       |                          |
|     directly caused by accidental ocular  |                          |
|     injury or intraocular surgery (such   |                          |
|     as for cataracts)                     |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   Eye exam to determine the need for    |                          |
|     vision correction                     |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *Eyeglasses or contact lenses, except |                          |
|     as shown above*                       |                          |
|                                           |                          |
| -   *Eye exercises and orthoptics*        |                          |
|                                           |                          |
| -   *Radial keratotomy and other          |                          |
|     refractive surgery*                   |                          |
+-------------------------------------------+--------------------------+
| ######## Foot care                        |                          |
+-------------------------------------------+--------------------------+
| -   Routine foot care when you are under  | > \$5 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**   | **You pay**             |   |   |
+-------------------------------------------+-------------------------+---+---+
| -   Artificial limbs and eyes             | > 50% of charges        |   |   |
|                                           |                         |   |   |
| -   Externally worn breast prostheses and |                         |   |   |
|     surgical bras, including necessary    |                         |   |   |
|     replacements, following a mastectomy  |                         |   |   |
|                                           |                         |   |   |
| ```{=html}                                |                         |   |   |
| <!-- -->                                  |                         |   |   |
| ```                                       |                         |   |   |
| -   Internal prosthetic devices, such as  |                         |   |   |
|     artificial joints, pacemakers,        |                         |   |   |
|     cochlear implants, and surgically     |                         |   |   |
|     implanted breast implant following    |                         |   |   |
|     mastectomy. Note: See 5(b) for        |                         |   |   |
|     coverage of the surgery to insert the |                         |   |   |
|     device.                               |                         |   |   |
|                                           |                         |   |   |
| ```{=html}                                |                         |   |   |
| <!-- -->                                  |                         |   |   |
| ```                                       |                         |   |   |
| -   Corrective orthopedic appliances for  |                         |   |   |
|     non-dental treatment of               |                         |   |   |
|     temporomandibular joint (TMJ) pain    |                         |   |   |
|     dysfunction syndrome.                 |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| > *Not covered:*                          | > *All charges*         |   |   |
|                                           |                         |   |   |
| -   *Foot orthotics*                      |                         |   |   |
|                                           |                         |   |   |
| -   *Orthopedic and corrective shoes*     |                         |   |   |
|                                           |                         |   |   |
| -   *Arch supports*                       |                         |   |   |
|                                           |                         |   |   |
| -   *Heel pads and heel cups*             |                         |   |   |
|                                           |                         |   |   |
| -   *Lumbosacral supports*                |                         |   |   |
|                                           |                         |   |   |
| -   *Corsets, trusses, elastic stockings, |                         |   |   |
|     support hose, and other supportive    |                         |   |   |
|     devices*                              |                         |   |   |
|                                           |                         |   |   |
| -   *Prosthetic replacements due to       |                         |   |   |
|     normal use and wear and tear*         |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| ######## Durable medical equipment (DME)  |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| > Rental or purchase, at our option,      | > 50% of covered        |   |   |
| > including repair and adjustment, of     | > services              |   |   |
| > durable medical equipment prescribed by |                         |   |   |
| > your Plan physician, such as oxygen and |                         |   |   |
| > dialysis equipment. Under this benefit, |                         |   |   |
| > we also cover:                          |                         |   |   |
|                                           |                         |   |   |
| -   Hospital beds                         |                         |   |   |
|                                           |                         |   |   |
| ```{=html}                                |                         |   |   |
| <!-- -->                                  |                         |   |   |
| ```                                       |                         |   |   |
| -   Wheelchairs                           |                         |   |   |
|                                           |                         |   |   |
| -   Crutches                              |                         |   |   |
|                                           |                         |   |   |
| -   Walkers                               |                         |   |   |
|                                           |                         |   |   |
| > Note: Call us at 800/314-3121 or        |                         |   |   |
| > 787/282-7900 ext. 5550 as soon as your  |                         |   |   |
| > Plan physician prescribes this          |                         |   |   |
| > equipment. We will arrange with a       |                         |   |   |
| > health care provider to rent or sell    |                         |   |   |
| > you durable medical equipment at        |                         |   |   |
| > discounted rates and will tell you more |                         |   |   |
| > about this service when you call.       |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| > *Not covered: Electric wheelchairs*     | > *All charges*         |   |   |
+-------------------------------------------+-------------------------+---+---+
| ######## Home health services             |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| -   Home health care ordered by a Plan    | > Nothing               |   |   |
|     physician and provided by a           |                         |   |   |
|     registered nurse (R.N.), licensed     |                         |   |   |
|     practical nurse (L.P.N.), licensed    |                         |   |   |
|     vocational nurse (L.V.N.), or home    |                         |   |   |
|     health aide.                          |                         |   |   |
|                                           |                         |   |   |
| -   Services include oxygen therapy,      |                         |   |   |
|     intravenous therapy and medications.  |                         |   |   |
|                                           |                         |   |   |
| > Authorization must be renewed at the    |                         |   |   |
| > ending period of sixty (60) days.       |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| ##                                        | **You pay**             |   |   |
| ###### Home health services *(continued)* |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| > 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                     |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| -   Manipulation of the spine and         | > \$5 per office visit  |   |   |
|     extremities                           |                         |   |   |
|                                           |                         |   |   |
| ```{=html}                                |                         |   |   |
| <!-- -->                                  |                         |   |   |
| ```                                       |                         |   |   |
| -   Adjunctive procedures such as         |                         |   |   |
|     ultrasound, electrical muscle         |                         |   |   |
|     stimulation, vibratory therapy, and   |                         |   |   |
|     cold pack application.                |                         |   |   |
|                                           |                         |   |   |
| ######## Limited to 1                     |                         |   |   |
| 5 visits per subscriber per calendar year |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| ######## Alternative treatments           |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| ## No benefit                             | > *All charges*         |   |   |
+-------------------------------------------+-------------------------+---+---+
| ## **Educational classes and programs**   |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| ## Coverage is limited to:                | > Nothing               |   |   |
|                                           |                         |   |   |
| ## Smoking cessa                          |                         |   |   |
| tion - Up to \$100 for one smoking cessat |                         |   |   |
| ion program per member per lifetime, incl |                         |   |   |
| uding all related expenses such as drugs. |                         |   |   |
+-------------------------------------------+-------------------------+---+---+
| ## Diabetes self management               | > \$5 per office visit  |   |   |
+-------------------------------------------+-------------------------+---+---+

+----+----+---------------------------------+---------------+----+----+
| *  |    |                                 |               |    |    |
| *S |    |                                 |               |    |    |
| ec |    |                                 |               |    |    |
| ti |    |                                 |               |    |    |
| on |    |                                 |               |    |    |
| 5  |    |                                 |               |    |    |
| (b |    |                                 |               |    |    |
| ). |    |                                 |               |    |    |
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| rg |    |                                 |               |    |    |
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| al |    |                                 |               |    |    |
| a  |    |                                 |               |    |    |
| nd |    |                                 |               |    |    |
| an |    |                                 |               |    |    |
| es |    |                                 |               |    |    |
| th |    |                                 |               |    |    |
| es |    |                                 |               |    |    |
| ia |    |                                 |               |    |    |
| se |    |                                 |               |    |    |
| rv |    |                                 |               |    |    |
| ic |    |                                 |               |    |    |
| es |    |                                 |               |    |    |
| pr |    |                                 |               |    |    |
| ov |    |                                 |               |    |    |
| id |    |                                 |               |    |    |
| ed |    |                                 |               |    |    |
| by |    |                                 |               |    |    |
| p  |    |                                 |               |    |    |
| hy |    |                                 |               |    |    |
| si |    |                                 |               |    |    |
| ci |    |                                 |               |    |    |
| an |    |                                 |               |    |    |
| s\ |    |                                 |               |    |    |
| a  |    |                                 |               |    |    |
| nd |    |                                 |               |    |    |
| o  |    |                                 |               |    |    |
| th |    |                                 |               |    |    |
| er |    |                                 |               |    |    |
| he |    |                                 |               |    |    |
| al |    |                                 |               |    |    |
| th |    |                                 |               |    |    |
| ca |    |                                 |               |    |    |
| re |    |                                 |               |    |    |
| p  |    |                                 |               |    |    |
| ro |    |                                 |               |    |    |
| fe |    |                                 |               |    |    |
| ss |    |                                 |               |    |    |
| io |    |                                 |               |    |    |
| na |    |                                 |               |    |    |
| ls |    |                                 |               |    |    |
| ** |    |                                 |               |    |    |
+----+----+---------------------------------+---------------+----+----+
|    | *  | > **Here are some important     |               | *  |    |
|    | *I | > things to keep in mind about  |               | *I |    |
|    | ** | > these benefits:**             |               | ** |    |
|    |    |                                 |               |    |    |
|    | *  | -   Please remember that all    |               | *  |    |
|    | *M |     benefits are subject to the |               | *M |    |
|    | ** |     definitions, limitations,   |               | ** |    |
|    |    |     and exclusions in this      |               |    |    |
|    | *  |     brochure and are payable    |               | *  |    |
|    | *P |     only when we determine they |               | *P |    |
|    | ** |     are medically necessary.    |               | ** |    |
|    |    |                                 |               |    |    |
|    | *  | -   Plan physicians must        |               | *  |    |
|    | *O |     provide or arrange your     |               | *O |    |
|    | ** |     care.                       |               | ** |    |
|    |    |                                 |               |    |    |
|    | *  | -   Be sure to read Section 4,  |               | *  |    |
|    | *R |     *Your costs for covered     |               | *R |    |
|    | ** |     services* for valuable      |               | ** |    |
|    |    |     information about how cost  |               |    |    |
|    | *  |     sharing works. Also read    |               | *  |    |
|    | *T |     Section 9 about             |               | *T |    |
|    | ** |     coordinating benefits with  |               | ** |    |
|    |    |     other coverage, including   |               |    |    |
|    | *  |     with Medicare.              |               | *  |    |
|    | *A |                                 |               | *A |    |
|    | ** | -   The amounts listed below    |               | ** |    |
|    |    |     are for the charges billed  |               |    |    |
|    | *  |     by a physician or other     |               | *  |    |
|    | *N |     health care professional    |               | *N |    |
|    | ** |     for your surgical care.     |               | ** |    |
|    |    |     Look in Section 5(c) for    |               |    |    |
|    | *  |     charges associated with the |               | *  |    |
|    | *T |     facility (i.e. hospital,    |               | *T |    |
|    | ** |     surgical center, etc.).     |               | ** |    |
|    |    |                                 |               |    |    |
|    |    | -   YOUR PHYSICIAN MUST GET     |               |    |    |
|    |    |     PRECERTIFICATION OF SOME    |               |    |    |
|    |    |     SURGICAL PROCEDURES. Please |               |    |    |
|    |    |     refer to the                |               |    |    |
|    |    |     precertification            |               |    |    |
|    |    |     information shown in        |               |    |    |
|    |    |     Section 3 to be sure which  |               |    |    |
|    |    |     services require            |               |    |    |
|    |    |     precertification and        |               |    |    |
|    |    |     identify which surgeries    |               |    |    |
|    |    |     require precertification.   |               |    |    |
+----+----+---------------------------------+---------------+----+----+
| >  |    |                                 | > **You pay** |    |    |
|  * |    |                                 |               |    |    |
| *B |    |                                 |               |    |    |
| en |    |                                 |               |    |    |
| ef |    |                                 |               |    |    |
| it |    |                                 |               |    |    |
| >  |    |                                 |               |    |    |
|  D |    |                                 |               |    |    |
| es |    |                                 |               |    |    |
| cr |    |                                 |               |    |    |
| ip |    |                                 |               |    |    |
| ti |    |                                 |               |    |    |
| on |    |                                 |               |    |    |
| ** |    |                                 |               |    |    |
+----+----+---------------------------------+---------------+----+----+
| >  |    |                                 |               |    |    |
| ** |    |                                 |               |    |    |
| Su |    |                                 |               |    |    |
| rg |    |                                 |               |    |    |
| ic |    |                                 |               |    |    |
| al |    |                                 |               |    |    |
| >  |    |                                 |               |    |    |
| pr |    |                                 |               |    |    |
| oc |    |                                 |               |    |    |
| ed |    |                                 |               |    |    |
| ur |    |                                 |               |    |    |
| es |    |                                 |               |    |    |
| ** |    |                                 |               |    |    |
+----+----+---------------------------------+---------------+----+----+
| A  |    |                                 | > \$5 per     |    |    |
| c  |    |                                 | > office      |    |    |
| om |    |                                 | > visit       |    |    |
| pr |    |                                 | >             |    |    |
| eh |    |                                 | > Nothing for |    |    |
| en |    |                                 | > hospital    |    |    |
| si |    |                                 | > visits      |    |    |
| ve |    |                                 |               |    |    |
| r  |    |                                 |               |    |    |
| an |    |                                 |               |    |    |
| ge |    |                                 |               |    |    |
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+----+----+---------------------------------+---------------+----+----+

+--------------------------------------------+------------------------+---+---+
| > **Surgical procedures** *(continued)*    | **You pay**            |   |   |
+--------------------------------------------+------------------------+---+---+
| > *Not covered:*                           | > *All charges*        |   |   |
|                                            |                        |   |   |
| -   *Reversal of voluntary sterilization*  |                        |   |   |
|                                            |                        |   |   |
| -   *Routine treatment of conditions of    |                        |   |   |
|     the feet; see Foot care*               |                        |   |   |
+--------------------------------------------+------------------------+---+---+
| > **Reconstructive surgery**               |                        |   |   |
+--------------------------------------------+------------------------+---+---+
| -   Surgery to correct a functional defect | > \$5 per office visit |   |   |
|                                            | >                      |   |   |
| -   Surgery to correct a condition caused  | > Nothing for hospital |   |   |
|     by injury or illness if:               | > visits               |   |   |
|                                            |                        |   |   |
| ```{=html}                                 |                        |   |   |
| <!-- -->                                   |                        |   |   |
| ```                                        |                        |   |   |
| -   the condition produced a major effect  |                        |   |   |
|     on the member's appearance and         |                        |   |   |
|                                            |                        |   |   |
| -   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 that is a |                        |   |   |
|     significant deviation from the common  |                        |   |   |
|     form or norm. Examples of congenital   |                        |   |   |
|     anomalies are: protruding ear          |                        |   |   |
|     deformities; cleft lip; cleft palate;  |                        |   |   |
|     birth marks; webbed fingers; and       |                        |   |   |
|     webbed toes.                           |                        |   |   |
|                                            |                        |   |   |
| -   All stages of breast reconstruction    |                        |   |   |
|     surgery following a mastectomy, such   |                        |   |   |
|     as:                                    |                        |   |   |
|                                            |                        |   |   |
| ```{=html}                                 |                        |   |   |
| <!-- -->                                   |                        |   |   |
| ```                                        |                        |   |   |
| -   surgery to produce a symmetrical       |                        |   |   |
|     appearance on the other breast;        |                        |   |   |
|                                            |                        |   |   |
| -   treatment of any physical              |                        |   |   |
|     complications, such as lymphedemas;    |                        |   |   |
|                                            |                        |   |   |
| -   breast prostheses and surgical bras    |                        |   |   |
|     and replacements (see *Prosthetic      |                        |   |   |
|     devices*)                              |                        |   |   |
|                                            |                        |   |   |
| > Note: If you need a mastectomy, you may  |                        |   |   |
| > choose to have the procedure performed   |                        |   |   |
| > on an inpatient basis and remain in the  |                        |   |   |
| > hospital up to 48 hours after the        |                        |   |   |
| > procedure.                               |                        |   |   |
+--------------------------------------------+------------------------+---+---+
| > *Not covered:*                           | > *All charges*        |   |   |
|                                            |                        |   |   |
| -   *Cosmetic surgery -- any surgical      |                        |   |   |
|     procedure (or any portion of a         |                        |   |   |
|     procedure) performed primarily to      |                        |   |   |
|     improve physical appearance through    |                        |   |   |
|     change in bodily form, except repair   |                        |   |   |
|     of accidental injury*                  |                        |   |   |
|                                            |                        |   |   |
| -   *Surgeries related to sex              |                        |   |   |
|     transformation*                        |                        |   |   |
+--------------------------------------------+------------------------+---+---+

+--------------------------------------------+-------------------------+
| > **Oral and maxillofacial surgery**       | **You pay**             |
+--------------------------------------------+-------------------------+
| > Oral surgical procedures, limited to:    | > \$5 per office visit  |
|                                            | >                       |
| -   Reduction of fractures of the jaws or  | > Nothing for hospital  |
|     facial bones;                          | > visits                |
|                                            |                         |
| -   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**              |
+-------------------------------------------+--------------------------+
| > Limited to:                             | > Nothing                |
|                                           |                          |
| -   Cornea                                |                          |
|                                           |                          |
| -   Heart                                 |                          |
|                                           |                          |
| -   Heart/lung                            |                          |
|                                           |                          |
| -   Kidney                                |                          |
|                                           |                          |
| -   Kidney/Pancreas                       |                          |
|                                           |                          |
| -   Liver                                 |                          |
|                                           |                          |
| -   Lung: Single - Double                 |                          |
|                                           |                          |
| -   Pancreas                              |                          |
|                                           |                          |
| -   Allogeneic (donor) bone marrow        |                          |
|     transplants                           |                          |
|                                           |                          |
| -   Autologous bone marrow transplants    |                          |
|     (autologous stem cell and peripheral  |                          |
|     stem cell support) for the following  |                          |
|     conditions: acute lymphocytic or      |                          |
|     non-lymphocytic leukemia; advanced    |                          |
|     Hodgkin\'s lymphoma; advanced         |                          |
|     non-Hodgkin\'s lymphoma; advanced     |                          |
|     neuroblastoma; breast cancer;         |                          |
|     multiple myeloma; epithelial ovarian  |                          |
|     cancer; and testicular, mediastinal,  |                          |
|     retroperitoneal and ovarian germ cell |                          |
|     tumors.                               |                          |
|                                           |                          |
| -   Intestinal transplants (small         |                          |
|     intestine) and the small intestine    |                          |
|     with the liver or small intestine     |                          |
|     with multiple organs such as the      |                          |
|     liver, stomach, and pancreas.         |                          |
|                                           |                          |
| -   National Transplant Program (NTP) -   |                          |
|                                           |                          |
| > Limited Benefits -- Treatment for       |                          |
| > breast cancer, multiple myeloma, and    |                          |
| > epithelial ovarian cancer may be        |                          |
| > provided in an NCI- or NIH-approved     |                          |
| > clinical trial at a Plan-designated     |                          |
| > center of excellence if approved by the |                          |
| > Plan's medical director in accordance   |                          |
| > with the Plan's protocols.              |                          |
| >                                         |                          |
| > Note: We cover related medical and      |                          |
| > hospital expenses of the donor when we  |                          |
| > cover the recipient. All transplants    |                          |
| > must be precertified.                   |                          |
+-------------------------------------------+--------------------------+
| > *Not covered:*                          | > *All charges*          |
|                                           |                          |
| -   *Donor screening tests and donor      |                          |
|     search expenses, except those         |                          |
|     performed for the actual donor*       |                          |
|                                           |                          |
| -   *Implants of artificial organs*       |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   *Transplants not listed as covered*   |                          |
+-------------------------------------------+--------------------------+
| > **Anesthesia**                          |                          |
+-------------------------------------------+--------------------------+
| > Professional services provided in       | > \$5 per office visit   |
| > office                                  |                          |
+-------------------------------------------+--------------------------+
| > Professional services provided in --    | > Nothing                |
|                                           |                          |
| -   Hospital (inpatient)                  |                          |
|                                           |                          |
| ```{=html}                                |                          |
| <!-- -->                                  |                          |
| ```                                       |                          |
| -   Hospital outpatient department        |                          |
|                                           |                          |
| -   Skilled nursing facility              |                          |
|                                           |                          |
| -   Ambulatory surgical center            |                          |
+-------------------------------------------+--------------------------+

+----+----+--------------------------------+---------------+----+----+
| *  |    |                                |               |    |    |
| *S |    |                                |               |    |    |
| ec |    |                                |               |    |    |
| ti |    |                                |               |    |    |
| on |    |                                |               |    |    |
| 5  |    |                                |               |    |    |
| (c |    |                                |               |    |    |
| ). |    |                                |               |    |    |
| Se |    |                                |               |    |    |
| rv |    |                                |               |    |    |
| ic |    |                                |               |    |    |
| es |    |                                |               |    |    |
| pr |    |                                |               |    |    |
| ov |    |                                |               |    |    |
| id |    |                                |               |    |    |
| ed |    |                                |               |    |    |
| by |    |                                |               |    |    |
| a  |    |                                |               |    |    |
| ho |    |                                |               |    |    |
| sp |    |                                |               |    |    |
| it |    |                                |               |    |    |
| al |    |                                |               |    |    |
| or |    |                                |               |    |    |
| o  |    |                                |               |    |    |
| th |    |                                |               |    |    |
| er |    |                                |               |    |    |
| fa |    |                                |               |    |    |
| ci |    |                                |               |    |    |
| li |    |                                |               |    |    |
| ty |    |                                |               |    |    |
| ,\ |    |                                |               |    |    |
| a  |    |                                |               |    |    |
| nd |    |                                |               |    |    |
| a  |    |                                |               |    |    |
| mb |    |                                |               |    |    |
| ul |    |                                |               |    |    |
| an |    |                                |               |    |    |
| ce |    |                                |               |    |    |
| se |    |                                |               |    |    |
| rv |    |                                |               |    |    |
| ic |    |                                |               |    |    |
| es |    |                                |               |    |    |
| ** |    |                                |               |    |    |
+----+----+--------------------------------+---------------+----+----+
|    | *  | > **Here are some important    |               | *  |    |
|    | *I | > things to remember about     |               | *I |    |
|    | ** | > these benefits:**            |               | ** |    |
|    |    |                                |               |    |    |
|    | *  | -   Please remember that all   |               | *  |    |
|    | *M |     benefits are subject to    |               | *M |    |
|    | ** |     the definitions,           |               | ** |    |
|    |    |     limitations, and           |               |    |    |
|    | *  |     exclusions in this         |               | *  |    |
|    | *P |     brochure and are payable   |               | *P |    |
|    | ** |     only when we determine     |               | ** |    |
|    |    |     they are medically         |               |    |    |
|    | *  |     necessary.                 |               | *  |    |
|    | *O |                                |               | *O |    |
|    | ** | -   Plan physicians must       |               | ** |    |
|    |    |     provide or arrange your    |               |    |    |
|    | *  |     care and you must be       |               | *  |    |
|    | *R |     hospitalized in a Plan     |               | *R |    |
|    | ** |     facility.                  |               | ** |    |
|    |    |                                |               |    |    |
|    | *  | -   Be sure to read Section 4, |               | *  |    |
|    | *T |     *Your costs for covered    |               | *T |    |
|    | ** |     services* for valuable     |               | ** |    |
|    |    |     information about how cost |               |    |    |
|    | *  |     sharing works. Also read   |               | *  |    |
|    | *A |     Section 9 about            |               | *A |    |
|    | ** |     coordinating benefits with |               | ** |    |
|    |    |     other coverage, including  |               |    |    |
|    | *  |     with Medicare.             |               | *  |    |
|    | *N |                                |               | *N |    |
|    | ** | -   The amounts listed below   |               | ** |    |
|    |    |     are for the charges billed |               |    |    |
|    | *  |     by the facility (i.e.,     |               | *  |    |
|    | *T |     hospital or surgical       |               | *T |    |
|    | ** |     center) or ambulance       |               | ** |    |
|    |    |     service for your surgery   |               |    |    |
|    |    |     or care. Any costs         |               |    |    |
|    |    |     associated with the        |               |    |    |
|    |    |     professional charge (i.e., |               |    |    |
|    |    |     physicians, etc.) are      |               |    |    |
|    |    |     covered in Section 5(a) or |               |    |    |
|    |    |     (b).                       |               |    |    |
|    |    |                                |               |    |    |
|    |    | -   **YOUR PHYSICIAN MUST GET  |               |    |    |
|    |    |     PRECERTIFICATION OF        |               |    |    |
|    |    |     HOSPITAL STAYS.** Please   |               |    |    |
|    |    |     refer to Section 3 to be   |               |    |    |
|    |    |     sure which services        |               |    |    |
|    |    |     require precertification.  |               |    |    |
+----+----+--------------------------------+---------------+----+----+
| >  |    |                                | > **You pay** |    |    |
|  * |    |                                |               |    |    |
| *B |    |                                |               |    |    |
| en |    |                                |               |    |    |
| ef |    |                                |               |    |    |
| it |    |                                |               |    |    |
| >  |    |                                |               |    |    |
|  D |    |                                |               |    |    |
| es |    |                                |               |    |    |
| cr |    |                                |               |    |    |
| ip |    |                                |               |    |    |
| ti |    |                                |               |    |    |
| on |    |                                |               |    |    |
| ** |    |                                |               |    |    |
+----+----+--------------------------------+---------------+----+----+
| #  |    |                                |               |    |    |
| ## |    |                                |               |    |    |
| ## |    |                                |               |    |    |
| ## |    |                                |               |    |    |
| #  |    |                                |               |    |    |
| In |    |                                |               |    |    |
| pa |    |                                |               |    |    |
| ti |    |                                |               |    |    |
| en |    |                                |               |    |    |
| t  |    |                                |               |    |    |
| ho |    |                                |               |    |    |
| sp |    |                                |               |    |    |
| it |    |                                |               |    |    |
| al |    |                                |               |    |    |
+----+----+--------------------------------+---------------+----+----+
| >  |    |                                | > Nothing     |    |    |
| Ro |    |                                |               |    |    |
| om |    |                                |               |    |    |
| >  |    |                                |               |    |    |
|  a |    |                                |               |    |    |
| nd |    |                                |               |    |    |
| >  |    |                                |               |    |    |
| bo |    |                                |               |    |    |
| ar |    |                                |               |    |    |
| d, |    |                                |               |    |    |
| >  |    |                                |               |    |    |
| su |    |                                |               |    |    |
| ch |    |                                |               |    |    |
| >  |    |                                |               |    |    |
| as |    |                                |               |    |    |
|    |    |                                |               |    |    |
| -  |    |                                |               |    |    |
|    |    |                                |               |    |    |
|  W |    |                                |               |    |    |
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| d, |    |                                |               |    |    |
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|    |    |                                |               |    |    |
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|    |    |                                |               |    |    |
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|    |    |                                |               |    |    |
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|    |    |                                |               |    |    |
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| at |    |                                |               |    |    |
|    |    |                                |               |    |    |
|    |    |                                |               |    |    |
| ho |    |                                |               |    |    |
| me |    |                                |               |    |    |
+----+----+--------------------------------+---------------+----+----+

*Inpatient hospital services -- continued on next page*

+--------------------------------------------+---+-------------------------+
| #### **Inpatient hospital** *(continued)*  |   | **You pay**             |
+--------------------------------------------+---+-------------------------+
| > *Not covered:*                           |   | > *All charges*         |
|                                            |   |                         |
| -   *Custodial care*                       |   |                         |
|                                            |   |                         |
| ```{=html}                                 |   |                         |
| <!-- -->                                   |   |                         |
| ```                                        |   |                         |
| -   *Non-covered facilities, such as       |   |                         |
|     nursing homes, schools*                |   |                         |
|                                            |   |                         |
| -   *Personal comfort items, such as       |   |                         |
|     telephone, television, barber          |   |                         |
|     services, guest meals and beds*        |   |                         |
|                                            |   |                         |
| -   *Private nursing care*                 |   |                         |
+--------------------------------------------+---+-------------------------+
| #### **Outpatien                           |   |                         |
| t hospital or ambulatory surgical center** |   |                         |
+--------------------------------------------+---+-------------------------+
| -   Operating, recovery, and other         |   | > Nothing               |
|     treatment rooms                        |   |                         |
|                                            |   |                         |
| -   Prescribed drugs and medicines         |   |                         |
|                                            |   |                         |
| ```{=html}                                 |   |                         |
| <!-- -->                                   |   |                         |
| ```                                        |   |                         |
| -   Laboratory tests, x-rays, and          |   |                         |
|     pathology services                     |   |                         |
|                                            |   |                         |
| -   Administration of blood, blood plasma, |   |                         |
|     and other biologicals                  |   |                         |
|                                            |   |                         |
| -   Blood and blood plasma if not donated  |   |                         |
|     or replaced                            |   |                         |
|                                            |   |                         |
| -   Pre-surgical testing                   |   |                         |
|                                            |   |                         |
| -   Dressings, casts, and sterile tray     |   |                         |
|     services                               |   |                         |
|                                            |   |                         |
| -   Medical supplies, including oxygen     |   |                         |
|                                            |   |                         |
| -   Anesthetics and anesthesia service     |   |                         |
|                                            |   |                         |
| -   Note: We cover hospital services and   |   |                         |
|     supplies related to dental procedures  |   |                         |
|     when necessitated by a non-dental      |   |                         |
|     physical impairment. We do not cover   |   |                         |
|     the dental procedures.                 |   |                         |
+--------------------------------------------+---+-------------------------+
| ######## Extended care benef               |   | ########                |
| its/skilled nursing care facility benefits |   |                         |
+--------------------------------------------+---+-------------------------+
| > Skilled nursing facility (SNF): maximum  |   | > Nothing               |
| > sixty (60) days during member's lifetime |   |                         |
+--------------------------------------------+---+-------------------------+
| > Not covered: custodial care              |   | > *All charges*         |
+--------------------------------------------+---+-------------------------+
| #### **Hospice care**                      | # |                         |
|                                            | # |                         |
|                                            | # |                         |
|                                            | # |                         |
|                                            |   |                         |
+--------------------------------------------+---+-------------------------+
| #### Supportive and palliativ              | # |                         |
| e care for a terminally ill member is cove | # |                         |
| red in the home or hospice facility. Servi | # |                         |
| ces include inpatient and outpatient care. | # |                         |
|                                            |   |                         |
| #### The length of hospice c               | N |                         |
| overed services will not exceed 180 days.  | o |                         |
|                                            | t |                         |
|                                            | h |                         |
|                                            | i |                         |
|                                            | n |                         |
|                                            | g |                         |
+--------------------------------------------+---+-------------------------+
| #### *Not covered                          | # |                         |
| : Independent nursing, homemaker services* | # |                         |
|                                            | # |                         |
|                                            | # |                         |
|                                            |   |                         |
|                                            | * |                         |
|                                            | A |                         |
|                                            | l |                         |
|                                            | l |                         |
|                                            |   |                         |
|                                            | c |                         |
|                                            | h |                         |
|                                            | a |                         |
|                                            | r |                         |
|                                            | g |                         |
|                                            | e |                         |
|                                            | s |                         |
|                                            | * |                         |
+--------------------------------------------+---+-------------------------+
| #### **Ambulance**                         | # |                         |
|                                            | # |                         |
|                                            | # |                         |
|                                            | # |                         |
|                                            |   |                         |
+--------------------------------------------+---+-------------------------+
| #### Local professional amb                | # |                         |
| ulance service when medically appropriate. | # |                         |
|                                            | # |                         |
|                                            | # |                         |
|                                            |   |                         |
|                                            | \ |                         |
|                                            | $ |                         |
|                                            | 2 |                         |
|                                            | 5 |                         |
|                                            |   |                         |
|                                            | c |                         |
|                                            | o |                         |
|                                            | p |                         |
|                                            | a |                         |
|                                            | y |                         |
|                                            | m |                         |
|                                            | e |                         |
|                                            | n |                         |
|                                            | t |                         |
|                                            |   |                         |
+--------------------------------------------+---+-------------------------+
| #### Between hospital facilities           | # |                         |
|                                            | # |                         |
|                                            | # |                         |
|                                            | # |                         |
|                                            |   |                         |
|                                            | N |                         |
|                                            | o |                         |
|                                            | t |                         |
|                                            | h |                         |
|                                            | i |                         |
|                                            | n |                         |
|                                            | g |                         |
+--------------------------------------------+---+-------------------------+
| #### Air ambulance                         | # |                         |
|                                            | # |                         |
|                                            | # |                         |
|                                            | # |                         |
|                                            |   |                         |
|                                            | 5 |                         |
|                                            | 0 |                         |
|                                            | % |                         |
|                                            |   |                         |
|                                            | o |                         |
|                                            | f |                         |
|                                            |   |                         |
|                                            | c |                         |
|                                            | h |                         |
|                                            | a |                         |
|                                            | r |                         |
|                                            | g |                         |
|                                            | e |                         |
|                                            | s |                         |
+--------------------------------------------+---+-------------------------+

+----+----+-------------------------------------------------+----+----+
| #  |    |                                                 |    |    |
| ## |    |                                                 |    |    |
| ## |    |                                                 |    |    |
|  S |    |                                                 |    |    |
| ec |    |                                                 |    |    |
| ti |    |                                                 |    |    |
| on |    |                                                 |    |    |
|  5 |    |                                                 |    |    |
|  ( |    |                                                 |    |    |
| d) |    |                                                 |    |    |
| .  |    |                                                 |    |    |
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| er |    |                                                 |    |    |
| ge |    |                                                 |    |    |
| nc |    |                                                 |    |    |
| y  |    |                                                 |    |    |
| se |    |                                                 |    |    |
| rv |    |                                                 |    |    |
| ic |    |                                                 |    |    |
| es |    |                                                 |    |    |
| /a |    |                                                 |    |    |
| cc |    |                                                 |    |    |
| id |    |                                                 |    |    |
| en |    |                                                 |    |    |
| ts |    |                                                 |    |    |
+----+----+-------------------------------------------------+----+----+
|    | *  | > **Here are some important things to keep in   | *  | ## |
|    | *I | > mind about these benefits:**                  | *I | ## |
|    | ** |                                                 | ** | #  |
|    |    | -   Please remember that all benefits are       |    |    |
|    | *  |     subject to the definitions, limitations,    | *  |    |
|    | *M |     and exclusions in this brochure and are     | *M |    |
|    | ** |     payable only when we determine they are     | ** |    |
|    |    |     medically necessary.                        |    |    |
|    | *  |                                                 | *  |    |
|    | *P | -   Be sure to read Section 4, *Your costs for  | *P |    |
|    | ** |     covered services* for valuable information  | ** |    |
|    |    |     about how cost sharing works. Also read     |    |    |
|    | *  |     Section 9 about coordinating benefits with  | *  |    |
|    | *O |     other coverage, including with Medicare.    | *O |    |
|    | ** |                                                 | ** |    |
|    |    | #####                                           |    |    |
|    | *  |                                                 | *  |    |
|    | *R |                                                 | *R |    |
|    | ** |                                                 | ** |    |
|    |    |                                                 |    |    |
|    | *  |                                                 | *  |    |
|    | *T |                                                 | *T |    |
|    | ** |                                                 | ** |    |
|    |    |                                                 |    |    |
|    | *  |                                                 | *  |    |
|    | *A |                                                 | *A |    |
|    | ** |                                                 | ** |    |
|    |    |                                                 |    |    |
|    | *  |                                                 | *  |    |
|    | *N |                                                 | *N |    |
|    | ** |                                                 | ** |    |
|    |    |                                                 |    |    |
|    | *  |                                                 | *  |    |
|    | *T |                                                 | *T |    |
|    | ** |                                                 | ** |    |
+----+----+-------------------------------------------------+----+----+
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+----+----+-------------------------------------------------+----+----+

*Emergency services/accidents -- continued on next page*

+--------------------------------------------+-------------------------+
| > **Benefit Description**                  | > **You pay**           |
+--------------------------------------------+-------------------------+
| > **Emergency within our service area**    |                         |
+--------------------------------------------+-------------------------+
| -   Emergency care at a doctor's office    | > \$5 per office visit  |
+--------------------------------------------+-------------------------+
| -   Emergency care at an urgent care       | > \$20 per visit        |
|     center                                 |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Emergency care as an outpatient at a   |                         |
|     hospital, including doctors' services  |                         |
+--------------------------------------------+-------------------------+
| > *Not covered: Elective care or           | > *All charges*         |
| > non-emergency care*                      |                         |
+--------------------------------------------+-------------------------+
| #                                          |                         |
| ####### Emergency outside our service area |                         |
+--------------------------------------------+-------------------------+
| -   Emergency care at a doctor's office    | > \$8 per office visit  |
+--------------------------------------------+-------------------------+
| -   Emergency care at an urgent care       | > \$30 per visit        |
|     center                                 |                         |
|                                            |                         |
| -   Emergency care as an outpatient at a   |                         |
|     hospital, including doctor's 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**                            |                         |
+--------------------------------------------+-------------------------+
| -   Professional ambulance service when    | > \$25 copayment        |
|     medically appropriate                  |                         |
|                                            |                         |
| > See Section 5(c) for non-emergency       |                         |
| > service                                  |                         |
+--------------------------------------------+-------------------------+
| -   Between hospitals                      | > Nothing               |
+--------------------------------------------+-------------------------+
| -   Air ambulance                          | > 50% of charges        |
+--------------------------------------------+-------------------------+

+----+----+---------------------------------+--------------+----+----+
| *  |    |                                 |              |    |    |
| *S |    |                                 |              |    |    |
| ec |    |                                 |              |    |    |
| ti |    |                                 |              |    |    |
| on |    |                                 |              |    |    |
| 5  |    |                                 |              |    |    |
| (e |    |                                 |              |    |    |
| ). |    |                                 |              |    |    |
| Me |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
| he |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
| th |    |                                 |              |    |    |
| a  |    |                                 |              |    |    |
| nd |    |                                 |              |    |    |
| s  |    |                                 |              |    |    |
| ub |    |                                 |              |    |    |
| st |    |                                 |              |    |    |
| an |    |                                 |              |    |    |
| ce |    |                                 |              |    |    |
| a  |    |                                 |              |    |    |
| bu |    |                                 |              |    |    |
| se |    |                                 |              |    |    |
| be |    |                                 |              |    |    |
| ne |    |                                 |              |    |    |
| fi |    |                                 |              |    |    |
| ts |    |                                 |              |    |    |
| ** |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
|    | *  | > When you get our approval for |              | *  |    |
|    | *I | > services and follow a         |              | *I |    |
|    | ** | > treatment plan we approve,    |              | ** |    |
|    |    | > cost-sharing and limitations  |              |    |    |
|    | *  | > for Plan mental health and    |              | *  |    |
|    | *M | > substance abuse benefits will |              | *M |    |
|    | ** | > be no greater than for        |              | ** |    |
|    |    | > similar benefits for other    |              |    |    |
|    | *  | > illnesses and conditions.     |              | *  |    |
|    | *P | >                               |              | *P |    |
|    | ** | > **Here are some important     |              | ** |    |
|    |    | > things to keep in mind about  |              |    |    |
|    | *  | > these benefits:**             |              | *  |    |
|    | *O |                                 |              | *O |    |
|    | ** | -   Please remember that all    |              | ** |    |
|    |    |     benefits are subject to the |              |    |    |
|    | *  |     definitions, limitations,   |              | *  |    |
|    | *R |     and exclusions in this      |              | *R |    |
|    | ** |     brochure and are payable    |              | ** |    |
|    |    |     only when we determine they |              |    |    |
|    | *  |     are medically necessary.    |              | *  |    |
|    | *T |                                 |              | *T |    |
|    | ** | ```{=html}                      |              | ** |    |
|    |    | <!-- -->                        |              |    |    |
|    | *  | ```                             |              | *  |    |
|    | *A | -   Be sure to read Section 4,  |              | *A |    |
|    | ** |     *Your costs for covered     |              | ** |    |
|    |    |     services* for valuable      |              |    |    |
|    | *  |     information about how cost  |              | *  |    |
|    | *N |     sharing works. Also read    |              | *N |    |
|    | ** |     Section 9 about             |              | ** |    |
|    |    |     coordinating benefits with  |              |    |    |
|    | *  |     other coverage, including   |              | *  |    |
|    | *T |     with Medicare.              |              | *T |    |
|    | ** |                                 |              | ** |    |
|    |    | ```{=html}                      |              |    |    |
|    |    | <!-- -->                        |              |    |    |
|    |    | ```                             |              |    |    |
|    |    | -   **YOU MUST GET              |              |    |    |
|    |    |     PREAUTHORIZATION OF THESE   |              |    |    |
|    |    |     SERVICES.** See the         |              |    |    |
|    |    |     instructions after the      |              |    |    |
|    |    |     benefits description below. |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| #  |    |                                 | ###          |    |    |
| ## |    |                                 | #### You pay |    |    |
| ## |    |                                 |              |    |    |
| ## |    |                                 |              |    |    |
|  D |    |                                 |              |    |    |
| es |    |                                 |              |    |    |
| cr |    |                                 |              |    |    |
| ip |    |                                 |              |    |    |
| ti |    |                                 |              |    |    |
| on |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| ## |    |                                 |              |    |    |
| #  |    |                                 |              |    |    |
| ** |    |                                 |              |    |    |
| Me |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
|  h |    |                                 |              |    |    |
| ea |    |                                 |              |    |    |
| lt |    |                                 |              |    |    |
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| an |    |                                 |              |    |    |
| d  |    |                                 |              |    |    |
| su |    |                                 |              |    |    |
| bs |    |                                 |              |    |    |
| ta |    |                                 |              |    |    |
| nc |    |                                 |              |    |    |
| e  |    |                                 |              |    |    |
| ab |    |                                 |              |    |    |
| us |    |                                 |              |    |    |
| e  |    |                                 |              |    |    |
| be |    |                                 |              |    |    |
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| fi |    |                                 |              |    |    |
| ts |    |                                 |              |    |    |
| ** |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| >  |    |                                 | > Your cost  |    |    |
|  A |    |                                 | > sharing    |    |    |
| ll |    |                                 | > resp       |    |    |
| >  |    |                                 | onsibilities |    |    |
| di |    |                                 | > are no     |    |    |
| ag |    |                                 | > greater    |    |    |
| no |    |                                 | > than for   |    |    |
| st |    |                                 | > other      |    |    |
| ic |    |                                 | > illnesses  |    |    |
| >  |    |                                 | > or         |    |    |
|  a |    |                                 | > conditions |    |    |
| nd |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
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| >  |    |                                 |              |    |    |
| ap |    |                                 |              |    |    |
| pr |    |                                 |              |    |    |
| ov |    |                                 |              |    |    |
| e. |    |                                 |              |    |    |
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| he |    |                                 |              |    |    |
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|  t |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
| at |    |                                 |              |    |    |
| me |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| pl |    |                                 |              |    |    |
| an |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  m |    |                                 |              |    |    |
| ay |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  i |    |                                 |              |    |    |
| nc |    |                                 |              |    |    |
| lu |    |                                 |              |    |    |
| de |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  s |    |                                 |              |    |    |
| er |    |                                 |              |    |    |
| vi |    |                                 |              |    |    |
| ce |    |                                 |              |    |    |
| s, |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| dr |    |                                 |              |    |    |
| ug |    |                                 |              |    |    |
| s, |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  a |    |                                 |              |    |    |
| nd |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| su |    |                                 |              |    |    |
| pp |    |                                 |              |    |    |
| li |    |                                 |              |    |    |
| es |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  d |    |                                 |              |    |    |
| es |    |                                 |              |    |    |
| cr |    |                                 |              |    |    |
| ib |    |                                 |              |    |    |
| ed |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  e |    |                                 |              |    |    |
| ls |    |                                 |              |    |    |
| ew |    |                                 |              |    |    |
| he |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| in |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| th |    |                                 |              |    |    |
| is |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  b |    |                                 |              |    |    |
| ro |    |                                 |              |    |    |
| ch |    |                                 |              |    |    |
| ur |    |                                 |              |    |    |
| e. |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  N |    |                                 |              |    |    |
| ot |    |                                 |              |    |    |
| e: |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| Pl |    |                                 |              |    |    |
| an |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| be |    |                                 |              |    |    |
| ne |    |                                 |              |    |    |
| fi |    |                                 |              |    |    |
| ts |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  a |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  p |    |                                 |              |    |    |
| ay |    |                                 |              |    |    |
| ab |    |                                 |              |    |    |
| le |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| on |    |                                 |              |    |    |
| ly |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| wh |    |                                 |              |    |    |
| en |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| we |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  d |    |                                 |              |    |    |
| et |    |                                 |              |    |    |
| er |    |                                 |              |    |    |
| mi |    |                                 |              |    |    |
| ne |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  t |    |                                 |              |    |    |
| he |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| ca |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| is |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| cl |    |                                 |              |    |    |
| in |    |                                 |              |    |    |
| ic |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
| ly |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  a |    |                                 |              |    |    |
| pp |    |                                 |              |    |    |
| ro |    |                                 |              |    |    |
| pr |    |                                 |              |    |    |
| ia |    |                                 |              |    |    |
| te |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| to |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  t |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
| at |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| yo |    |                                 |              |    |    |
| ur |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  c |    |                                 |              |    |    |
| on |    |                                 |              |    |    |
| di |    |                                 |              |    |    |
| ti |    |                                 |              |    |    |
| on |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  a |    |                                 |              |    |    |
| nd |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| on |    |                                 |              |    |    |
| ly |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| wh |    |                                 |              |    |    |
| en |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  y |    |                                 |              |    |    |
| ou |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  r |    |                                 |              |    |    |
| ec |    |                                 |              |    |    |
| ei |    |                                 |              |    |    |
| ve |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  t |    |                                 |              |    |    |
| he |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| ca |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| as |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| pa |    |                                 |              |    |    |
| rt |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| of |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  a |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
|  t |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
| at |    |                                 |              |    |    |
| me |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| pl |    |                                 |              |    |    |
| an |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| th |    |                                 |              |    |    |
| at |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| we |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
| ap |    |                                 |              |    |    |
| pr |    |                                 |              |    |    |
| ov |    |                                 |              |    |    |
| e. |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| -  |    |                                 | > \$5 per    |    |    |
|    |    |                                 | > office     |    |    |
| Pr |    |                                 | > visit      |    |    |
| of |    |                                 |              |    |    |
| es |    |                                 |              |    |    |
| si |    |                                 |              |    |    |
| on |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  s |    |                                 |              |    |    |
| er |    |                                 |              |    |    |
| vi |    |                                 |              |    |    |
| ce |    |                                 |              |    |    |
| s, |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  i |    |                                 |              |    |    |
| nc |    |                                 |              |    |    |
| lu |    |                                 |              |    |    |
| di |    |                                 |              |    |    |
| ng |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| in |    |                                 |              |    |    |
| di |    |                                 |              |    |    |
| vi |    |                                 |              |    |    |
| du |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| or |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  g |    |                                 |              |    |    |
| ro |    |                                 |              |    |    |
| up |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  t |    |                                 |              |    |    |
| he |    |                                 |              |    |    |
| ra |    |                                 |              |    |    |
| py |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| by |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  p |    |                                 |              |    |    |
| ro |    |                                 |              |    |    |
| vi |    |                                 |              |    |    |
| de |    |                                 |              |    |    |
| rs |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
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| ch |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| as |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| ps |    |                                 |              |    |    |
| yc |    |                                 |              |    |    |
| hi |    |                                 |              |    |    |
| at |    |                                 |              |    |    |
| ri |    |                                 |              |    |    |
| st |    |                                 |              |    |    |
| s, |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| ps |    |                                 |              |    |    |
| yc |    |                                 |              |    |    |
| ho |    |                                 |              |    |    |
| lo |    |                                 |              |    |    |
| gi |    |                                 |              |    |    |
| st |    |                                 |              |    |    |
| s, |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| or |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| cl |    |                                 |              |    |    |
| in |    |                                 |              |    |    |
| ic |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| so |    |                                 |              |    |    |
| ci |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  w |    |                                 |              |    |    |
| or |    |                                 |              |    |    |
| ke |    |                                 |              |    |    |
| rs |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| -  |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| Me |    |                                 |              |    |    |
| di |    |                                 |              |    |    |
| ca |    |                                 |              |    |    |
| ti |    |                                 |              |    |    |
| on |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| ma |    |                                 |              |    |    |
| na |    |                                 |              |    |    |
| ge |    |                                 |              |    |    |
| me |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| -  |    |                                 | > Nothing if |    |    |
|    |    |                                 | > you        |    |    |
| Di |    |                                 | > receive    |    |    |
| ag |    |                                 | > these      |    |    |
| no |    |                                 | > services   |    |    |
| st |    |                                 | > during     |    |    |
| ic |    |                                 | > your       |    |    |
|    |    |                                 | > office     |    |    |
|    |    |                                 | > visit;     |    |    |
|  t |    |                                 | > otherwise, |    |    |
| es |    |                                 | > \$5 per    |    |    |
| ts |    |                                 | > office     |    |    |
|    |    |                                 | > visit      |    |    |
+----+----+---------------------------------+--------------+----+----+
| -  |    |                                 | > Nothing    |    |    |
|    |    |                                 |              |    |    |
| Se |    |                                 |              |    |    |
| rv |    |                                 |              |    |    |
| ic |    |                                 |              |    |    |
| es |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| pr |    |                                 |              |    |    |
| ov |    |                                 |              |    |    |
| id |    |                                 |              |    |    |
| ed |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| by |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  a |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| ho |    |                                 |              |    |    |
| sp |    |                                 |              |    |    |
| it |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| or |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  o |    |                                 |              |    |    |
| th |    |                                 |              |    |    |
| er |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| fa |    |                                 |              |    |    |
| ci |    |                                 |              |    |    |
| li |    |                                 |              |    |    |
| ty |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| -  |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| Se |    |                                 |              |    |    |
| rv |    |                                 |              |    |    |
| ic |    |                                 |              |    |    |
| es |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| in |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| ap |    |                                 |              |    |    |
| pr |    |                                 |              |    |    |
| ov |    |                                 |              |    |    |
| ed |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  a |    |                                 |              |    |    |
| lt |    |                                 |              |    |    |
| er |    |                                 |              |    |    |
| na |    |                                 |              |    |    |
| ti |    |                                 |              |    |    |
| ve |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| ca |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| se |    |                                 |              |    |    |
| tt |    |                                 |              |    |    |
| in |    |                                 |              |    |    |
| gs |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| su |    |                                 |              |    |    |
| ch |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| as |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  p |    |                                 |              |    |    |
| ar |    |                                 |              |    |    |
| ti |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| ho |    |                                 |              |    |    |
| sp |    |                                 |              |    |    |
| it |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
| iz |    |                                 |              |    |    |
| at |    |                                 |              |    |    |
| io |    |                                 |              |    |    |
| n, |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| ha |    |                                 |              |    |    |
| lf |    |                                 |              |    |    |
| -w |    |                                 |              |    |    |
| ay |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| ho |    |                                 |              |    |    |
| us |    |                                 |              |    |    |
| e, |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  r |    |                                 |              |    |    |
| es |    |                                 |              |    |    |
| id |    |                                 |              |    |    |
| en |    |                                 |              |    |    |
| ti |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| tr |    |                                 |              |    |    |
| ea |    |                                 |              |    |    |
| tm |    |                                 |              |    |    |
| en |    |                                 |              |    |    |
| t, |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| fu |    |                                 |              |    |    |
| ll |    |                                 |              |    |    |
| -d |    |                                 |              |    |    |
| ay |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| ho |    |                                 |              |    |    |
| sp |    |                                 |              |    |    |
| it |    |                                 |              |    |    |
| al |    |                                 |              |    |    |
| iz |    |                                 |              |    |    |
| at |    |                                 |              |    |    |
| io |    |                                 |              |    |    |
| n, |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| fa |    |                                 |              |    |    |
| ci |    |                                 |              |    |    |
| li |    |                                 |              |    |    |
| ty |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  b |    |                                 |              |    |    |
| as |    |                                 |              |    |    |
| ed |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  i |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
| en |    |                                 |              |    |    |
| si |    |                                 |              |    |    |
| ve |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
| ou |    |                                 |              |    |    |
| tp |    |                                 |              |    |    |
| at |    |                                 |              |    |    |
| ie |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|    |    |                                 |              |    |    |
|  t |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
| at |    |                                 |              |    |    |
| me |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| #  |    |                                 | > *All       |    |    |
| #  |    |                                 | > charges*   |    |    |
| No |    |                                 |              |    |    |
| t  |    |                                 |              |    |    |
| co |    |                                 |              |    |    |
| ve |    |                                 |              |    |    |
| re |    |                                 |              |    |    |
| d: |    |                                 |              |    |    |
|  s |    |                                 |              |    |    |
| er |    |                                 |              |    |    |
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+----+----+---------------------------------+--------------+----+----+

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

*.*

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

-   You or your Plan doctor should call 800/503-7929 or\
    787/641-0773 for assistance in obtaining mental\
    health and substance abuse benefits.

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

+----+----+-------------------------------------------------+----+----+
| *  |    |                                                 |    |    |
| *S |    |                                                 |    |    |
| ec |    |                                                 |    |    |
| ti |    |                                                 |    |    |
| on |    |                                                 |    |    |
| 5  |    |                                                 |    |    |
| (f |    |                                                 |    |    |
| ). |    |                                                 |    |    |
| Pr |    |                                                 |    |    |
| es |    |                                                 |    |    |
| cr |    |                                                 |    |    |
| ip |    |                                                 |    |    |
| ti |    |                                                 |    |    |
| on |    |                                                 |    |    |
| dr |    |                                                 |    |    |
| ug |    |                                                 |    |    |
| be |    |                                                 |    |    |
| ne |    |                                                 |    |    |
| fi |    |                                                 |    |    |
| ts |    |                                                 |    |    |
| ** |    |                                                 |    |    |
+----+----+-------------------------------------------------+----+----+
|    | *  | > **Here are some important things to keep in   | *  |    |
|    | *I | > mind about these benefits:**                  | *I |    |
|    | ** |                                                 | ** |    |
|    |    | -   We cover prescribed drugs and medications,  |    |    |
|    | *  |     as described in the chart beginning on the  | *  |    |
|    | *M |     next page.                                  | *M |    |
|    | ** |                                                 | ** |    |
|    |    | -   All benefits are subject to the             |    |    |
|    | *  |     definitions, limitations and exclusions in  | *  |    |
|    | *P |     this brochure and are payable only when we  | *P |    |
|    | ** |     determine they are medically necessary.     | ** |    |
|    |    |                                                 |    |    |
|    | *  | ```{=html}                                      | *  |    |
|    | *O | <!-- -->                                        | *O |    |
|    | ** | ```                                             | ** |    |
|    |    | -   Be sure to read Section 4, *Your costs for  |    |    |
|    | *  |     covered services,* for valuable information | *  |    |
|    | *R |     about how cost sharing works. Also read     | *R |    |
|    | ** |     Section 9 about coordinating benefits with  | ** |    |
|    |    |     other coverage, including with Medicare.    |    |    |
|    | *  |                                                 | *  |    |
|    | *T |                                                 | *T |    |
|    | ** |                                                 | ** |    |
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|    | *A |                                                 | *A |    |
|    | ** |                                                 | ** |    |
|    |    |                                                 |    |    |
|    | *  |                                                 | *  |    |
|    | *N |                                                 | *N |    |
|    | ** |                                                 | ** |    |
|    |    |                                                 |    |    |
|    | *  |                                                 | *  |    |
|    | *T |                                                 | *T |    |
|    | ** |                                                 | ** |    |
+----+----+-------------------------------------------------+----+----+
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+----+----+-------------------------------------------------+----+----+

*Prescription drug benefits begin on the next page.*

+------------------------------------------+---------------------------+
| > **Benefit Description**                | > **You pay**             |
+------------------------------------------+---------------------------+
| > **Covered medications and supplies**   |                           |
+------------------------------------------+---------------------------+
| > We cover the following medications and | > \$2.50 for generic      |
| > supplies prescribed by a licensed      | > drugs on our Drug List  |
| > physician and obtained from a Plan     | >                         |
| > pharmacy or through our mail order     | > \$5.00 for brand name   |
| > program:                               | > drugs on our Drug List  |
|                                          | >                         |
| -   Drugs and medicines that by Federal  | > 3 applicable copays for |
|     law of the United States require a   | > a 90-day supply of      |
|     physician's prescription for their   | > prescribed maintenance  |
|     purchase, except those listed as     | > drugs, when ordered     |
|     *Not covered*.                       | > through our mail-order  |
|                                          | > program                 |
| -   Insulin                              | >                         |
|                                          | > Note: If there is no    |
| -   Disposable needles and syringes for  | > generic equivalent      |
|     the administration of covered        | > available, you will     |
|     medications                          | > still have to pay the   |
|                                          | > applicable brand name   |
| -   Diabetic supplies including testing  | > copay                   |
|     agents, lancet devices, alcohol      |                           |
|     swabs, glucose elevating agents,     |                           |
|     insulin delivery devices and blood   |                           |
|     glucose monitors                     |                           |
|                                          |                           |
| -   Self administered injectable drugs   |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Oral contraceptive drugs             |                           |
|                                          |                           |
| -   Drugs for sexual dysfunction         |                           |
|                                          |                           |
| -   Growth hormones                      |                           |
|                                          |                           |
| > Note: Drugs to treat sexual            |                           |
| > dysfunction are limited. Contact the   |                           |
| > Plan for dosage limits. You pay the    |                           |
| > applicable drug copay up to the dosage |                           |
| > limits, and all charges after that.    |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Drugs available without a           |                           |
|     prescription, or for which there is  |                           |
|     a non-prescription equivalent        |                           |
|     available*                           |                           |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes (such as Rogaine)*          |                           |
|                                          |                           |
| -   *Vitamins, fluoride, nutrients and   |                           |
|     food supplements even if a physician |                           |
|     prescribes or administers them*      |                           |
|                                          |                           |
| -   *Drugs obtained at a non-Plan        |                           |
|     pharmacy except for out of area      |                           |
|     emergencies*                         |                           |
|                                          |                           |
| -   *Drugs to enhance athletic           |                           |
|     performance*                         |                           |
|                                          |                           |
| -   *Smoking cessation drugs and         |                           |
|     medications, including nicotine      |                           |
|     patches*                             |                           |
|                                          |                           |
| -   *Any drug used for the purpose of    |                           |
|     weight control*                      |                           |
|                                          |                           |
| -   *Prescriptions that are to be taken  |                           |
|     by or administered to the member in  |                           |
|     whole or part, while a patient in a  |                           |
|     hospital, skilled nursing facility,  |                           |
|     convalescent hospital, inpatient     |                           |
|     facility or other facility where     |                           |
|     drugs are ordinarily provided by the |                           |
|     facility on an inpatient basis*      |                           |
|                                          |                           |
| -   *Medical supplies such as dressings  |                           |
|     and antiseptics*                     |                           |
+------------------------------------------+---------------------------+

+--------------------------+-------------------------------------------+
| Section 5 (g). Special   |                                           |
| Features                 |                                           |
+==========================+===========================================+
| > **Feature**            | > **Description**                         |
+--------------------------+-------------------------------------------+
| > **Flexible benefits    | > Under the flexible benefits option, we  |
| > option**               | > determine the most effective way to     |
|                          | > provide services.                       |
|                          |                                           |
|                          | -   We may identify medically appropriate |
|                          |     alternatives to traditional care and  |
|                          |     coordinate other benefits as a less   |
|                          |     costly alternative benefit.           |
|                          |                                           |
|                          | -   Alternative benefits are subject to   |
|                          |     our ongoing review.                   |
|                          |                                           |
|                          | -   By approving an alternative benefit,  |
|                          |     we cannot guarantee you will get it   |
|                          |     in the future.                        |
|                          |                                           |
|                          | -   The decision to offer an alternative  |
|                          |     benefit is solely ours, and we may    |
|                          |     withdraw it at any time and resume    |
|                          |     regular contract benefits.            |
|                          |                                           |
|                          | -   Our decision to offer or withdraw     |
|                          |     alternative benefits is not subject   |
|                          |     to OPM review under the disputed      |
|                          |     claims process.                       |
+--------------------------+-------------------------------------------+
| > **Services for deaf    | > Humana offers telecommunication devices |
| > and hearing impaired** | > for the deaf (TDD) and Teletype (TTY)   |
|                          | > phone lines for the hearing impaired.   |
|                          | > Call\                                   |
|                          | > 1-800-432-7482 to access the service.   |
+--------------------------+-------------------------------------------+
| > **High risk            | > HumanaBeginnings is an outreach program |
| > pregnancies**          | > that provides high-risk plan members    |
|                          | > support and educational materials so    |
|                          | > care can be actively managed during     |
|                          | > pregnancy.                              |
+--------------------------+-------------------------------------------+
| > **Centers of           | > Members can use any facility that is    |
| > excellence**           | > within Humana's contracted National     |
|                          | > Transplant Network. This network has    |
|                          | > over 35 transplant facilities located   |
|                          | > in more than 20 states.                 |
+--------------------------+-------------------------------------------+
| > **24-hour nurse line** | > For any of your health concerns, 24     |
|                          | > hours a day, 7 days a week, you may     |
|                          | > call 800/314-3121 or 787/622-5566, or   |
|                          | > 787/501-0822 after working hours, and   |
|                          | > talk with a registered nurse who will   |
|                          | > discuss treatment options and answer    |
|                          | > your health questions.                  |
+--------------------------+-------------------------------------------+

+----+----+---------------------------------+--------------+----+----+
| S  |    |                                 |              |    |    |
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| ne |    |                                 |              |    |    |
| fi |    |                                 |              |    |    |
| ts |    |                                 |              |    |    |
+====+====+=================================+==============+====+====+
|    | *  | > **Here are some important     |              | *  |    |
|    | *I | > things to keep in mind about  |              | *I |    |
|    | ** | > these benefits:**             |              | ** |    |
|    |    |                                 |              |    |    |
|    | *  | -   Please remember that all    |              | *  |    |
|    | *M |     benefits are subject to the |              | *M |    |
|    | ** |     definitions, limitations,   |              | ** |    |
|    |    |     and exclusions in this      |              |    |    |
|    | *  |     brochure and are payable    |              | *  |    |
|    | *P |     only when we determine they |              | *P |    |
|    | ** |     are medically necessary.    |              | ** |    |
|    |    |                                 |              |    |    |
|    | *  | -   Plan dentists must provide  |              | *  |    |
|    | *O |     or arrange your care.       |              | *O |    |
|    | ** |                                 |              | ** |    |
|    |    | -   We cover hospitalization    |              |    |    |
|    | *  |     for dental procedures only  |              | *  |    |
|    | *R |     when a nondental physical   |              | *R |    |
|    | ** |     impairment exists which     |              | ** |    |
|    |    |     makes hospitalization       |              |    |    |
|    | *  |     necessary to safeguard the  |              | *  |    |
|    | *T |     health of the patient; see  |              | *T |    |
|    | ** |     Section 5 (c) for inpatient |              | ** |    |
|    |    |     hospital benefits. We do    |              |    |    |
|    | *  |     not cover the dental        |              | *  |    |
|    | *A |     procedure unless it is      |              | *A |    |
|    | ** |     described below.            |              | ** |    |
|    |    |                                 |              |    |    |
|    | *  | ```{=html}                      |              | *  |    |
|    | *N | <!-- -->                        |              | *N |    |
|    | ** | ```                             |              | ** |    |
|    |    | -   Be sure to read Section 4,  |              |    |    |
|    | *  |     *Your costs for covered     |              | *  |    |
|    | *T |     services,* for valuable     |              | *T |    |
|    | ** |     information about how cost  |              | ** |    |
|    |    |     sharing works. Also read    |              |    |    |
|    |    |     Section 9 about             |              |    |    |
|    |    |     coordinating benefits with  |              |    |    |
|    |    |     other coverage, including   |              |    |    |
|    |    |     with Medicare.              |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| #  |    |                                 | ###          |    |    |
| ## |    |                                 |  **You pay** |    |    |
|  * |    |                                 |              |    |    |
| *A |    |                                 |              |    |    |
| cc |    |                                 |              |    |    |
| id |    |                                 |              |    |    |
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| ef |    |                                 |              |    |    |
| it |    |                                 |              |    |    |
| ** |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| >  |    |                                 | 25% of       |    |    |
| We |    |                                 | charges      |    |    |
| >  |    |                                 |              |    |    |
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| >  |    |                                 |              |    |    |
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| nj |    |                                 |              |    |    |
| ur |    |                                 |              |    |    |
| y. |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| >  |    |                                 |              |    |    |
| ** |    |                                 |              |    |    |
| De |    |                                 |              |    |    |
| nt |    |                                 |              |    |    |
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| fi |    |                                 |              |    |    |
| ts |    |                                 |              |    |    |
| ** |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+
| >  |    |                                 |              |    |    |
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| an |    |                                 |              |    |    |
| >  |    |                                 |              |    |    |
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| lu |    |                                 |              |    |    |
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| nt |    |                                 |              |    |    |
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| >  |    |                                 |              |    |    |
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| ef |    |                                 |              |    |    |
| it |    |                                 |              |    |    |
| s. |    |                                 |              |    |    |
+----+----+---------------------------------+--------------+----+----+

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

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

Facts about the Point of Service Plan

At your option, you may choose to obtain benefit coverage for medical
services under this Plan using one of three methods:

-   Services directed by the primary care physician. These benefits
    (copayment and coinsurance levels) are listed in Section 5 of this
    brochure.)

You may also access the Plan's Point of Service Benefit Options which
are:

-   **Services not directed by the primary care physician but using Plan
    providers;** or

-   **Services not directed by the primary care physician using non Plan
    providers.**

When services are rendered by Plan providers, the copayment fees
established for certain services will be paid directly to the health
service provider.

When services are rendered by non Plan providers, the member will pay
for all of the services and request reimbursement from Humana.
Reimbursement will be based on the rate contracted by Humana for those
services less the corresponding copayment or coinsurance. **The member
will also be responsible for satisfying the \$100 per individual or
\$300 per family annual deductible**.

For out of area non-emergency services that are not coordinated with
Humana, a coinsurance of 20% of the allowable fee up to \$2,000 will
apply.

**What is covered under the Point of Service Option**

This is a summary of the benefits that you receive when accessing
services that have not been directed by your primary care physician:

-   For all physician's office visit services, you pay an \$8 copay per
    visit. This includes hospital and skilled nursing facility visits.

-   For all inpatient admissions, you pay a \$50 copay per admission.

-   For home visits by a doctor, and for care received in a skilled
    nursing facility, you pay a \$25 copay.

-   For an ambulatory surgery facility, you pay a \$25 copay.

-   For local ambulance service, you pay a \$25 copay (no charge if you
    are transferred between facilities during a hospitalization in the
    Plan's service area).

-   For professional charges for surgery, anesthesia, inpatient
    radiation and inhalation therapy, inpatient and outpatient dialysis
    services, hospice services, costs for blood and blood plasma, home
    health services, and rehabilitation therapy, you pay 25% of the
    charges.

-   For allergy testing and injections, durable medical equipment,
    orthopedic devices, prosthetic devices, and air ambulance charges,
    you pay 50% of the charges.

-   For routine outpatient laboratory, x-ray, and diagnostic tests you
    pay nothing when using plan providers; you pay 25% of covered
    services when using a non-plan provider.

-   For pathology and radiology services provided to hospitalized
    members you pay nothing when using plan providers; you pay 25% of
    covered services when using non-plan providers.

-   For organ and tissue transplants you pay 25% of covered services
    when using plan providers.

-   For emergency services you pay a \$20 copay for plan providers; you
    pay a \$30 copay at a non-plan provider.

-   Mental health services are treated the same as any other illness,
    except that the applicable rates will be based on the contracted
    fees of our mental health provider.

**What is not covered**

-   Prescription drugs obtained at non-plan pharmacies (for out of area
    emergencies -- submit itemized receipts to us for payment).

-   Organ/tissue transplants performed at non-plan facilities.

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

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

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

> The following services will be covered when medically necessary.
>
> **Preventive services** -- the following services will be covered in
> full:

-   Initial oral exam, limited one per policy year

-   Periodic exam, one every six (6) months

-   Panoramic x-ray, limited to one (1) every two (2) years

-   Periapical x-rays, one (1) initial and five (5) additional per
    policy year

-   One bitewing x-ray, one (1) set per policy year

-   Prophylaxis for adult and children, one (1) every six (6) months

-   Topical application of fluoride to children under 19 years, one (1)
    every six (6) months

-   Sealant application, limited to children under 19 years, one (1)
    every six (6) months

-   Space maintainer, to substitute a lost molar, one per area per life

> **Restorative services** -- the following services will be covered
> with 25 percent coinsurance:

-   Amalgam restorations and/or resin restorations

-   Endodontics: includes canal treatment and canal filling for
    anterior, bicuspids and molars

-   Surgical extractions, including pre- and post-surgery care, local
    anesthesia and cutting procedure, if any

-   Palliative treatment

> **Restorative services** -- the following services are excluded from
> coverage:

-   Services related to cosmetic procedures

-   Services offered free by spouse, parents, brothers, sisters or
    children of the insured person

-   Experimental or investigational procedures, services and items

-   Expenses related to injuries resulted from war or riot

-   Services rendered before the effective date of the policy

-   Accidents or illness covered by the State Insurance Fund ("FSE")
    and/or Automobile Accidents Compensation Administration ("ACAA")

-   Any treatment or services not specified on the dental coverage
    selected by the policyholder

-   Services on past policy year are not accumulated for the next year

> No additional premium required; no application to complete.
>
> Dental benefits are offered by Humana Insurance of Puerto Rico, Inc.\
> The toll free number to call is 800/314-3121.
>
> Discounts available at participating providers for:

-   Eye exams

-   Frames and lenses

-   Contact lenses

-   Lasik or PRK

> See separate plan description on how to locate a provider nearest you.
>
> No additional premium required

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

**Medical and hospital benefits** In most cases, providers and
facilities file claims for you. Physicians must file on the form
HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at
1-800/314-3121 or 787/282-7900 ext. 5500.

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

-   Covered member's name and ID number;

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

-   Dates you received the services or supplies;

-   Diagnosis;

-   Type of each service or supply;

-   The charge for each service or supply;

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

-   Receipts, if you paid for your services.

    **Submit your claims to: Humana Puerto Rico\
    P.O. Box 191920\
    San Juan, Puerto Rico 00919-1920**

    **Prescription drugs Submit your claims to: Humana Puerto Rico\
    P.O. Box 191920\
    San Juan, Puerto Rico 00919-1920**

    Contact Customer Service at 800/314-3121 or 787/282-7900 to request
    a drug prescription reimbursement form.

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

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

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

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

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

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) Write to us within 6 months from the date of our decision;   |
| * |     and                                                          |
| * |                                                                  |
|   | (b) Send your request to us at: Humana Puerto Rico, P.O. Box     |
|   |     191920, San Juan, Puerto Rico 00919-1920; and                |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or, if applicable, arrange for the health     |
| * |     care provider to give you the care); or                      |
| * |                                                                  |
|   | (b) Write to you and maintain our denial -- go to step 4; or     |
|   |                                                                  |
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request -- go  |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us -- if we did not answer |
|   |     that request in some way within 30 days; or                  |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: United States Office of Personnel Management,   |
|   | Insurance Services Programs, Health Insurance Group 3, 1900 E    |
|   | Street, NW, Washington, DC 20415-3630.                           |
+---+------------------------------------------------------------------+

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

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

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

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

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at\
    1-800/314-3121 or 787/282-7900 ext. 5500 and we will expedite our
    review; or

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

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

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

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

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

**When you have other**

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

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

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

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

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

-   People 65 years of age and older.

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

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

> Medicare has two parts:

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

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

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

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

**• The Original Medicare Plan**

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

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

> **Claims process when you have the Original Medicare Plan** -- You
> probably will never have to file a claim form when you have both our
> Plan and the Original Medicare Plan.
>
> • When we are the primary payer, we process the claim first.
>
> • When Original Medicare is the primary payer, Medicare processes\
> your claim first. In most cases, your claims will be coordinated
> automatically and we will then provide secondary benefits for covered
> charges. You will not need to do anything. To find out if you need to
> do something to file your claim, call us at 800/314-3121 or
> 787/282-7900 ext. 5500.
>
> **We do not waive any costs if the Original Medicare Plan** **is your
> primary payer.**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.

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

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

**Durable Medical Equipment**

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

-   it can stand repeated use; and

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

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

-   it is appropriate for home use; and

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

**Experimental or**

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

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

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

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

-   is not generally accepted by the medical community

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

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

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

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

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

**Service Area** The geographic area where the participating provider
services are available to covered members.

**Transplant** Services for pre-transplant; the transplant including any
chemotherapy, associated services and post-discharge services, and
treatment of complications after transplant.

**Us/We** Us and we refer to Humana Health Plans of Puerto Rico, Inc.

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

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

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

**Coverage information**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

**When benefits and**

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

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

**When you lose benefits**

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

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

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-   You are a family member no longer eligible for coverage.

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

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

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

**• Temporary Continuation**

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

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

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

**• Converting to**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

> What is SHPS? SHPS is a third-party administrator hired by OPM to
> manage the FSAFEDS Program. SHPS is the largest FSA administrator in
> the nation and will be responsible for enrollment, claims processing,
> customer service, and day-to-day operations of FSAFEDS.
>
> If you are a Federal employee eligible for FEHB -- even if you're not
> enrolled in FEHB -- you can choose to participate in either, or both,
> of the flexible spending accounts. If you are not eligible for FEHB,
> you are not eligible to enroll for a Health Care FSA. However, almost
> all Federal employees are eligible to enroll for the Dependent Care
> FSA. The only exception is intermittent (also called when actually
> employed \[WAE\]) employees expected to work less than 180 days during
> the year.
>
> *Note*: FSAFEDS is the FSA Program established for all Executive
> Branch employees and Legislative Branch employees whose employers
> signed on. Under IRS law, FSAs are not available to annuitants. In
> addition, the U.S. Postal Service and the Judicial Branch, among
> others, are Federal agencies that have their own plans with slightly
> different rules, but the advantages of having an FSA are the same no
> matter what agency you work for.
>
> Plan carefully when deciding how much to contribute to an FSA. Because
> of the tax benefits of an FSA, the IRS places strict guidelines on
> them. You need to estimate how much you want to allocate to an FSA
> because current IRS regulations require you forfeit any funds
> remaining in your account(s) at the end of the FSA plan year. This is
> referred to as the "use-it-or-lose-it" rule. You will have until April
> 29, 2004 to submit claims for your eligible expenses incurred during
> 2003 if you enrolled in FSAFEDS when it was initially offered. You
> will have until April 30, 2005 to submit claims for your eligible
> expenses incurred from January 1 through December 31, 2004 if you
> elect FSAFEDS during this Open Season.
>
> The **FSAFEDS Calculator** at www.fsafeds.com will help you plan your
> FSA allocations and provide an estimate of your tax savings based on
> your individual situation.
>
> Every FEHB health plan includes cost sharing features, such as
> deductibles you must meet before the Plan provides benefits,
> coinsurance or copayments that you pay when you and the Plan share
> costs, and medical services and supplies that are not covered by the
> Plan and for which you must pay. These out-of-pocket costs are
> summarized on page 12 and detailed throughout this brochure. Your
> HCFSA will reimburse you for such costs when they are for tax
> deductible medical care for you and your dependents that is NOT
> covered by this FEHB Plan or any other coverage that you have.
>
> Under this Plan, typical out-of-pocket expenses include:
>
> Copayments for --
>
> office visits
>
> prescription drugs
>
> Coinsurance amounts for some Point of Service benefits.
>
> The IRS governs expenses reimbursable by a HCFSA. See Publication 502
> for a comprehensive list of tax-deductible medical expenses. **Note:
> While you will see insurance premiums listed in Publication 502, they
> are NOT a reimbursable expense for FSA purposes.** Publication 502 can
> be found on the IRS Web site at
> http://www.irs.gov/pub/irs-pdf/p502.pdf. If you do not see your
> service or expense listed in Publication 502, please call a FSAFEDS
> Benefit Counselor at\
> 1-877-FSAFEDS (372-3337), who will be able to answer your specific
> questions.
>
> An FSA lets you allot money for eligible expenses ***before*** your
> agency deducts taxes from your paycheck. This means the amount of
> income that your taxes are based on will be lower, so your tax
> liability will also be lower. Without an FSA, you would still pay for
> these expenses, but you would do so using money remaining in your
> paycheck after Federal (and often state and local) taxes are deducted.
> The following chart illustrates a typical tax savings example:

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

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

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

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

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

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

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

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

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

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

-   E-mail: fsafeds@shps.net

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

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

**The Federal Long Term Care Insurance Program**

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

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

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

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

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

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

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

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

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

**NOTES:**

**NOTES:**

  -----------------------------------------------------------------------
  **Summary of benefits for Humana Health Plans of Puerto Rico, Inc. --
  2004**

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

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

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

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

+--------------------------------------+-----------------------+------+
| **Benefits**                         | **You Pay**           | **Pa |
|                                      |                       | ge** |
+--------------------------------------+-----------------------+------+
| Medical services provided by         | \$5 office visit      | > 14 |
| physicians:                          | copay                 |      |
|                                      |                       |      |
| -   Diagnostic and treatment         |                       |      |
|     services provided in the office  |                       |      |
+--------------------------------------+-----------------------+------+
| Services provided by a hospital:     | > Nothing             | > 2  |
|                                      | >                     | 6-27 |
| -   Inpatient                        | > Nothing             | >    |
|                                      |                       | > 27 |
| -   Outpatient                       |                       |      |
+--------------------------------------+-----------------------+------+
| Emergency benefits:                  | > \$5 per office      | > 29 |
|                                      | > visit; \$20 per     |      |
| -   In-area                          | > visit to an urgent  |      |
|                                      | > care center or      |      |
| -   Out-of-area                      | > hospital            |      |
|                                      | >                     |      |
|                                      | > \$8 per office      |      |
|                                      | > visit; \$30 per     |      |
|                                      | > visit to an urgent  |      |
|                                      | > care center or      |      |
|                                      | > hospital            |      |
+--------------------------------------+-----------------------+------+
| Mental health and substance abuse    | > Regular cost        | > 3  |
| treatment                            | > sharing             | 0-31 |
+--------------------------------------+-----------------------+------+
| Prescription drugs:                  | > \$2.50 copay        | > 33 |
|                                      | >                     |      |
| -   Generic drugs on plan's Drug     | > \$5.00 copay        |      |
|     List                             | >                     |      |
|                                      | > 3 applicable copays |      |
| ```{=html}                           |                       |      |
| <!-- -->                             |                       |      |
| ```                                  |                       |      |
| -   Brand name drugs on plan's Drug  |                       |      |
|     List                             |                       |      |
|                                      |                       |      |
| ```{=html}                           |                       |      |
| <!-- -->                             |                       |      |
| ```                                  |                       |      |
| -   Maintenance drugs (90-day        |                       |      |
|     supply) when ordered through our |                       |      |
|     mail-order program               |                       |      |
+--------------------------------------+-----------------------+------+
| Dental Care                          | > 25% of charges      | > 35 |
|                                      |                       |      |
| -   Accidental injury benefit only   |                       |      |
+--------------------------------------+-----------------------+------+
| Vision Care -- eye exam              | > \$5 per office      | 19   |
|                                      | > visit copay         |      |
+--------------------------------------+-----------------------+------+
| > Special features: *Flexible        |                       | > 34 |
| > Benefits Option; TDD and TTY phone |                       |      |
| > lines; HumanaBeginnings; National  |                       |      |
| > Transplant Network; and            |                       |      |
| > HumanaFirst^®^*                    |                       |      |
+--------------------------------------+-----------------------+------+
| Out-of-pocket maximum                | > We do not have a    | > 12 |
|                                      | > catastrophic        |      |
|                                      | > protection          |      |
|                                      | > out-of-pocket       |      |
|                                      | > maximum.            |      |
+--------------------------------------+-----------------------+------+

**2004 Rate Information for**

**Humana Health Plans of Puerto Rico, Inc.**

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

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

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

+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | **    |       |       |       | **P   |       |
|              |     | Non-P |       |       |       | ostal |       |
|              |     | ostal |       |       |       | Prem  |       |
|              |     | Prem  |       |       |       | ium** |       |
|              |     | ium** |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | **    |       | *     |       | **    |       |
|              |     | Biwee |       | *Mont |       | Biwee |       |
|              |     | kly** |       | hly** |       | kly** |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Type of**  | **  | **Go  | **Y   | **Go  | **Y   | **U   | **Y   |
|              | Cod | v't** | our** | v't** | our** | SPS** | our** |
| **           | e** |       |       |       |       |       |       |
| Enrollment** |     | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  |
|              |     | are** | are** | are** | are** | are** | are** |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| Puerto Rico  |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| Self Only    | *   | *     | *     | **    | *     | *     | **\$9 |
|              | *ZJ | *\$62 | *\$20 | \$135 | *\$45 | *\$74 | .39** |
|              | 1** | .63** | .87** | .69** | .23** | .11** |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| Self and     | *   | **    | *     | **    | **    | **    | *     |
| Family       | *ZJ | \$144 | *\$48 | \$312 | \$104 | \$170 | *\$21 |
|              | 2** | .05** | .01** | .10** | .03** | .45** | .61** |
+--------------+-----+-------+-------+-------+-------+-------+-------+