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Dear Federal Employees Health Benefits Program Participant:

Welcome to the 2005 Open Season! By continuing to introduce pro-consumer
health care ideas, the Office of Personnel Management (OPM) team has
given you greater, cost effective choices. This year several national
and local health plans are offering new options, strengthening the
Federal Employees Health Benefits (FEHB) Program and highlighting once
again its unique and distinctive market-oriented features. I remain firm
in my belief that you, when fully informed as a Federal subscriber, are
in the best position to make the decisions that meet your needs and
those of your family. Plan brochures provide information to help
subscribers make these fully informed decisions. Please take the time to
review the plan's benefits, particularly Section 2, which explains plan
changes.

Exciting new features this year give you additional opportunities to
save and better manage your hard-earned dollars. For 2005, I am very
pleased and enthusiastic about the new High Deductible Health Plans
(HDHP) with a Health Savings Account (HSA) or Health Reimbursement
Arrangement (HRA) component. This combination of health plan and savings
vehicle provides a new opportunity to save and better manage your money.
If an HDHP/HSA is not for you and you are not retired, I encourage you
to consider a Flexible Spending Account (FSA) for health care. FSAs
allow you to reduce your out-of-pocket health care costs by 20 to more
than 40 percent by paying for certain health care expenses with tax-free
dollars, instead of after-tax dollars.

Since prevention remains a major factor in the cost of health care, last
year OPM launched the *HealthierFeds* campaign. Through this effort we
are encouraging Federal team members to take greater responsibility for
living a healthier lifestyle. The positive effect of a healthier life
style brings dividends for you and reduces the demands and costs within
the health care system. This campaign embraces four key "actions" that
can lead to a healthy America: be physically active every day, eat a
nutritious diet, seek out preventative screenings, and make healthy
lifestyle choices. Be sure to visit *HealthierFeds* at
[www.healthierfeds.opm.gov](http://www.healthierfeds.opm.gov/) for more
details on this important initiative. I also encourage you to visit the
Department of Health and Human Services website on Wellness and Safety,
[www.hhs.gov/safety/index.html](http://www.hhs.gov/safety/index.shtml),
which complements and broadens healthier lifestyle resources. The site
provides extensive information from health care experts and
organizations to support your personal interest in staying healthy.

The FEHB Program offers the Federal team the widest array of
cost-effective health care options and the information needed to make
the best choice for you and your family. You will find comprehensive
health plan information in this brochure, in the 2005 Guide to FEHB
Plans, and on the OPM Website at
[www.opm.gov/insure](http://www.opm.gov/insure). I hope you find these
resources useful, and thank you once again for your service to the
nation.

> Sincerely,
>
> ![](media/image7.png)

Kay Coles James

> Director

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

**Notice of the United States Office of Personnel Management's**

**Privacy Practices**

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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-   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
may also call 202-606-0745 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

Unites 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 United States
Department of Health and Human Services.

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

Table of Contents

[Introduction](#Introduction)[]{#Yourrights .anchor}

[3](#introduction)

[Plain Language](#Introduction) [3](#plain-language)

[Stop Health Care Fraud!](#Introduction) [3](#stop-health-care-fraud)

[Preventing medical mistakes](#Introduction)
[5](#preventing-medical-mistakes)

[Section 1. Facts about this HMO plan](#Introduction)
[7](#section-1.-facts-about-this-hmo-plan)

[How we pay providers](#how-we-pay-providers) [7](#how-we-pay-providers)

[Your Rights](#Yourrights) [7](#your-rights)

[Service Area](#service-area) [8](#service-area)

[Section 2. How we change for 2005](#Introduction)
[9](#program-wide-changes)

[Program-wide changes](#program-wide-changes) [9](#program-wide-changes)

[Changes to this Plan](#changes-to-this-plan) [9](#changes-to-this-plan)

[Section 3. How you get care](#Introduction)
[10](#section-3.-how-you-get-care)

[Identification cards](#identification-cards)
[10](#identification-cards)

[Where you get covered care](#where-you-get-covered-care)
[10](#where-you-get-covered-care)

[Plan providers](#plan-providers) [10](#plan-providers)

[Plan facilities](#plan-facilities) [10](#plan-facilities)

[What you must do to get covered
care](#what-you-must-do-to-get-covered-care)
[11](#what-you-must-do-to-get-covered-care)

[Primary care](#primary-care) [11](#primary-care)

[Specialty care](#specialty-care) [11](#specialty-care)

[Hospital care](#hospital-care) [13](#hospital-care)

[Circumstances beyond our control](#circumstances-beyond-our-control)
[13](#circumstances-beyond-our-control)

[Services requiring our prior
approval](#services-requiring-our-prior-approval)
[14](#services-requiring-our-prior-approval)

[Section 4. Your costs for covered services](#Introduction)
[15](#section-4.-your-costs-for-covered-services)

[Copayments](#copayments) [15](#copayments)

[Deductible](#deductible) [15](#deductible)

[Coinsurance](#coinsurance) [15](#coinsurance)

[Eligible Medical Expense (EME)](#eligible-medical-expense-eme)
[15](#eligible-medical-expense-eme)

[Your catastrophic protection out-of-pocket
maximum](#your-catastrophic-protection-out-of-pocket-maximum)
[15](#your-catastrophic-protection-out-of-pocket-maximum)

[Section 5. Benefits -- OVERVIEW *(See page 9 for how our benefits
changed this year and page 71 for a benefits summary.)*](#Introduction)
[16](#section-5.-benefits-overview-see-page-9-for-how-our-benefits-changed-this-year-and-page-71-for-a-benefits-summary.)

[Section 5(a) Medical services and supplies provided by physicians and
other health care professionals](#Introduction)
[18](#section-5a-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)

[Section 5(b) Surgical and anesthesia services provided by physicians
and other health care professionals](#Introduction)
[32](#section-5b-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)

[Section 5(c) Services provided by a hospital or other facility, and
ambulance services](#Introduction)
[37](#section-5c-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

[Section 5(d) Emergency services/accidents](#Introduction)
[41](#section-5d-emergency-servicesaccidents)

[Section 5(e) Mental health and substance abuse benefits](#Introduction)
[43](#section-5e-mental-health-and-substance-abuse-benefits)

[Section 5(f) Prescription drug benefits](#Introduction)
[45](#section-5f-prescription-drug-benefits)

[Section 5(g) Special features](#Introduction)
[48](#section-5g-special-features)

-   
-   
-   
-   
-   
-   

[Flexible benefits option](#flexible-benefits-option)
[48](#flexible-benefits-option)[Telephone Advice Nurse
Service](#telephone-advice-nurse-service)
[48](#telephone-advice-nurse-service)[Services for deaf and hearing
impaired](#services-for-deaf-and-hearing-impaired)
[48](#services-for-deaf-and-hearing-impaired)[Preventive
Health](#preventive-health) [48](#preventive-health)[Disease
Management](#disease-management)
[48](#disease-management)[HPN@YourService](../HPN@YourService)
[49](#__RefHeading___Toc81977154)[Section 5(h) Dental
benefits](#Introduction) [50](#section-5h-dental-benefits)

[Section 5(i) Non-FEHB benefits available to Plan
members](#Introduction)
[51](#section-5i-non-fehb-benefits-available-to-plan-members)

[Section 6. General exclusions -- things we don't cover](#Introduction)
[52](#section-6.-general-exclusions-things-we-dont-cover)

[Section 7. Filing a claim for covered services](#Introduction)
[53](#section-7.-filing-a-claim-for-covered-services)

[Section 8. The disputed claims process](#Introduction)
[54](#section-8.-the-disputed-claims-process)

[Section 9. Coordinating benefits with other coverage](#Introduction)
[56](#section-9.-coordinating-benefits-with-other-coverage)

[When you have other health
coverage](#when-you-have-other-health-coverage)
[56](#when-you-have-other-health-coverage)

[What is Medicare?](#what-is-medicare) [56](#what-is-medicare)

[Should I enroll in Medicare?](#should-i-enroll-in-medicare)
[56](#should-i-enroll-in-medicare)

[The Original Medicare Plan (Part A or Part
B)](#the-original-medicare-plan-part-a-or-part-b)
[57](#the-original-medicare-plan-part-a-or-part-b)

[Medicare Advantage](#medicare-advantage) [59](#medicare-advantage)

[TRICARE and CHAMPVA](#tricare-and-champva) [59](#tricare-and-champva)

[Workers' Compensation](#workers-compensation)
[60](#workers-compensation)

[Medicaid](#medicaid) [60](#medicaid)

[When other Government agencies are responsible for your
care](#when-other-government-agencies-are-responsible-for-your-care)
[60](#when-other-government-agencies-are-responsible-for-your-care)

[When others are responsible for
injuries](#when-others-are-responsible-for-injuries)
[60](#when-others-are-responsible-for-injuries)

[Section 10. Definitions of terms we use in this
brochure](#Introduction)
[61](#section-10.-definitions-of-terms-we-use-in-this-brochure)

[Section 11. FEHB Facts](#Introduction) [62](#section-11.-fehb-facts)

[Coverage information](#Introduction) [62](#coverage-information)

[No pre-existing condition
limitation](#no-pre-existing-condition-limitation)
[62](#no-pre-existing-condition-limitation)

[Where you can get information about enrolling in the FEHB
Program](#where-you-can-get-information-about-enrolling-in-the-fehb-program)
[62](#where-you-can-get-information-about-enrolling-in-the-fehb-program)

[Types of coverage available for you and your
family](#types-of-coverage-available-for-you-and-your-family)
[62](#types-of-coverage-available-for-you-and-your-family)

[Children's Equity Act](#childrens-equity-act)
[63](#childrens-equity-act)

[When benefits and premiums start](#when-benefits-and-premiums-start)
[63](#when-benefits-and-premiums-start)

[When you retire](#when-you-retire) [63](#when-you-retire)

[When you lose benefits](#when-you-lose-benefits)
[64](#when-you-lose-benefits)

[When FEHB coverage ends](#when-fehb-coverage-ends)
[64](#when-fehb-coverage-ends)

[Spouse equity coverage](#spouse-equity-coverage)
[64](#spouse-equity-coverage)

[Temporary Continuation of Coverage
(TCC)](#temporary-continuation-of-coverage-tcc)
[64](#temporary-continuation-of-coverage-tcc)

[Converting to individual coverage](#converting-to-individual-coverage)
[64](#converting-to-individual-coverage)

[Getting a Certificate of Group Health Plan
Coverage](#getting-a-certificate-of-group-health-plan-coverage)
[65](#getting-a-certificate-of-group-health-plan-coverage)

[Section 12. Two Federal Programs complement FEHB
benefits](#Introduction)
[66](#section-12.-two-federal-programs-complement-fehb-benefits)

[The Federal Flexible Spending Account Program --
FSAFEDS](#Introduction)
[66](#the-federal-flexible-spending-account-program-fsafeds)

[The Federal Long Term Care Insurance Program](#Introduction)
[69](#the-federal-long-term-care-insurance-program)

[Index](#Introduction) [70](#index)

[Summary of benefits for the Health Plan of Nevada -
2005](#summary-of-benefits-for-the-health-plan-of-nevada---2005)
[71](#summary-of-benefits-for-the-health-plan-of-nevada---2005)

[2005 Rate Information for Health Plan of
Nevada](#rate-information-for-health-plan-of-nevada)
[72](#rate-information-for-health-plan-of-nevada)

# Introduction

This brochure describes the benefits of Health Plan of Nevada under our
contract (CS 1942) with the United States Office of Personnel
Management, as authorized by the Federal Employees Health Benefits law.
The address for Health Plan of Nevada's administrative offices is:

Health Plan of Nevada

P.O. Box 15645

Las Vegas, NV 89114-5645

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

If you are enrolled in this Plan, you are entitled to the benefits
described in this brochure. If you are enrolled in Self and Family
coverage, each eligible family member is also entitled to these
benefits. You do not have a right to benefits that were available before
January 1, 2005, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2005, and changes are summarized on
page 71. Rates are shown at the end of this brochure.

# Plain Language

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
    Health Plan of Nevada*.*

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

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

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

# Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your
Federal Employees Health Benefits 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
that 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:

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

If the provider does not resolve the matter, call us at (702) 242-7300
or (800) 777-1840 and explain the situation.

If we do not resolve the issue:

-   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).

-   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.

# Preventing medical mistakes

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?"

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-   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](http://www.ahrq.gov/consumer/pathqpack.htm)l.
    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 health care providers and
    improve the quality of care you receive.

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

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

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

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

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

# Section 1. Facts about this HMO plan

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 pay only the copayments and
coinsurance described in this brochure. When you receive emergency
services from non-Plan providers, you may have to submit claim forms.

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

### How we pay providers

We contract with individual physicians, medical groups, and hospitals to
provide the benefits in this brochure. These Plan providers accept a
negotiated payment from us, and you will only be responsible for your
copayments or coinsurance.

When we contract with a doctor or medical group to provide health care
services, the contract specifies the amount the doctor or medical group
will be paid for providing services -- either on a fixed monthly basis
or as a payment per service provided.

We have several types of payment arrangements with our doctors:

Arrangement A: Your doctor may be part of a contracted medical group and
may receive a salary. Some medical groups may pay their doctors a bonus.

Arrangement B: Your doctor may receive a fixed amount of money each
month, called a "capitation," to provide services to all Plan patients
they see. Capitation may be considered to be an incentive plan.

Arrangement C: Your doctor may be paid a pre-determined amount for each
service he/she provides.

### 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 Web site
([www.opm.gov/insure](http://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.

-   Health Plan of Nevada has operated as a mixed model HMO in Nevada
    for 22 years. Health Plan of Nevada. has been awarded "Commendable"
    status by the National Committee for Quality Assurance (NCQA), an
    independent, not-for-profit organization dedicated to measuring the
    quality of America's healthcare. Accreditation, effective July 2003,
    is for the commercial HMO, commercial point-of-service (POS) and
    Medicare HMO product lines in Nevada.

-   We understand the importance of getting your questions answered.
    Whether you need an answer to a benefit question or have a concern
    about a claim, or need help in selecting a provider, we are
    available Monday through Friday, 8 a.m. to 5 p.m. at (702) 242-7300
    or (800) 777-1840.

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-   At times, services requested on your behalf by your provider may not
    be approved by Health Plan of Nevada. The decision to deny coverage
    for services requested, courses of treatment or inpatient care is
    made by a physician. These denials are based upon medical necessity,
    benefit coverage and your individual needs. Written notification of
    the denial will be sent to you, your primary care provider and the
    provider who requested the service. You have the right to appeal
    these decisions.

If you want more information about us, call (702) 242-7300 or (800)
777-1840, or write to Health Plan of Nevada, P.O. Box 15645, Las Vegas,
NV 89114-5645. You may also contact us by fax at (702) 242-9350 or visit
our Web site at
[http://fehbp.healthplanofnevada.com](http://fehbp.healthplanofnevada.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:

Serving: Clark, Esmeralda and Nye counties

**Enrollment Code:**

**NM1 Self Only**

**NM2 Self and Family**

Serving: Lyon and Mineral counties and portions of Washoe County as
defined by the towns listed below:

Sparks, Sun Valley, Wadsworth and Reno

**Enrollment Code:**

**2L1 Self Only**

**2L2 Self and Family**

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.

# Section 2. How we change for 2005

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

-   In Section 9, we revised the **Medicare Primary Payer Chart** and
    updated the language regarding Medicare Advantage plans (formerly
    called Medicare + Choice plans).

-   In Section 12, we revised the language regarding the Flexible
    Spending Account Program - *FSAFEDS* and the Federal Long Term Care
    Insurance Program.

### Changes to this Plan

-   If you are enrolled in **Code NM**, your share of the non-Postal
    premium will increase by 1% for Self Only or 1% for Self and Family.

-   We expanded our service area to include Lyon, Mineral and portions
    of Washoe counties.

-   You now pay \$10 for a 30-day therapeutic supply of generic drugs.

-   You now pay \$25 for a 30-day therapeutic supply of brand-name
    formulary drugs.

-   You now pay \$40 for a 30-day therapeutic supply of non-formulary
    drugs.

-   We added a benefit for medical treatment in a Phase II, III or IV
    clinical trial for the treatment of cancer or chronic fatigue
    syndrome conducted in the state of Nevada with a \$10 office visit
    or specialist visit copayment.

# Section 3. How you get care

+--------------------+-------------------------------------------------+
| ### Id             | We will send you an identification (ID) card    |
| entification cards | 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 (702) 242-7300 or (800) 777-1840 or  |
|                    | write to us at P.O. Box 15645, Las Vegas, NV    |
|                    | 89114-5645. You may also request replacement    |
|                    | cards through our Web site at                   |
|                    | [http://fehbp.healthplanofnev                   |
|                    | ada.com](http://fehbp.healthplanofnevada.com/). |
+--------------------+-------------------------------------------------+
| ### Where yo       | You get care from "Plan providers" and "Plan    |
| u get covered care | facilities." You will only pay copayments       |
|                    | and/or coinsurance, and you will not have to    |
|                    | file claims.                                    |
+--------------------+-------------------------------------------------+
| #                  | Plan providers are physicians and other health  |
| ### Plan providers | 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 web site.                   |
|                    |                                                 |
|                    | You should join our Plan because you prefer the |
|                    | 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.                               |
+--------------------+-------------------------------------------------+
| ##                 | Plan facilities are hospitals and other         |
| ## Plan facilities | 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 web site.                   |
+--------------------+-------------------------------------------------+

+--------------------+-------------------------------------------------+
| ###                | It depends on the type of care you need. First, |
| What you must do t | you and each family member must choose a        |
| o get covered care | primary care provider. This decision is         |
|                    | important since your primary care provider      |
|                    | provides or arranges for most of your health    |
|                    | care. This plan has a provider directory, which |
|                    | we urge you to review before choosing your      |
|                    | primary care provider.                          |
+--------------------+-------------------------------------------------+
| #### Primary care  | Your primary care provider can be a family      |
|                    | practitioner, pediatrician, or internist who    |
|                    | practices as a primary care provider*.* Women   |
|                    | may also select an Obstetrician/Gynecologist.   |
|                    | Your primary care provider will provide most of |
|                    | your health care, or give you a referral to see |
|                    | a specialist.                                   |
|                    |                                                 |
|                    | If you want to change primary care providers or |
|                    | if your primary care provider leaves the Plan,  |
|                    | call us. We will help you select a new one.     |
|                    |                                                 |
|                    | Termination with a Plan provider's contract     |
|                    | will not release the provider from treating     |
|                    | you, except for reasons of medical incompetence |
|                    | or professional misconduct as determined by us. |
|                    |                                                 |
|                    | Coverage is available until the latest of the   |
|                    | following dates:                                |
|                    |                                                 |
|                    | -   The 120^th^ day following the date the      |
|                    |     contract was terminated between the         |
|                    |     provider and us, or                         |
|                    |                                                 |
|                    | -   If the medical condition is pregnancy, the  |
|                    |     45^th^ day after the date of delivery or,   |
|                    |     if the pregnancy does not end in delivery,  |
|                    |     the date of the end of the pregnancy.       |
|                    |                                                 |
|                    | You or your Plan provider may submit a request  |
|                    | for continuity of care to the address shown     |
|                    | below. If we agree to the continued treatment,  |
|                    | we will pay for covered services at the Plan    |
|                    | provider level of benefits for a limited time,  |
|                    | as outlined above. The Plan provider may not    |
|                    | seek payment from you for any amounts for which |
|                    | you would not be responsible if the provider    |
|                    | were still a Plan provider.                     |
|                    |                                                 |
|                    | Health Plan of Nevada                           |
|                    |                                                 |
|                    | Attn: Provider Services Department              |
|                    |                                                 |
|                    | P.O. Box 15645                                  |
|                    |                                                 |
|                    | Las Vegas, NV 89114-5645                        |
|                    |                                                 |
|                    | Phone: (702) 242-7300 or (800) 777-1840         |
+--------------------+-------------------------------------------------+
| #                  | Your primary care provider will refer you to a  |
| ### Specialty care | specialist for needed care. When you receive a  |
|                    | referral from your primary care provider, you   |
|                    | must return to the primary care provider after  |
|                    | the consultation, unless your primary care      |
|                    | provider authorized a certain number of visits  |
|                    | without additional referrals. The primary care  |
|                    | provider must provide or authorize all          |
|                    | follow-up care. Do not go to the specialist for |
|                    | return visits unless your primary care provider |
|                    | gives you a referral. However, women may see    |
|                    | their Obstetrician/Gynecologist without a       |
|                    | referral                                        |
|                    |                                                 |
|                    | Here are some other things you should know      |
|                    | about specialty care:                           |
|                    |                                                 |
|                    | -   If you need to see a specialist frequently  |
|                    |     because of a chronic, complex, or serious   |
|                    |     medical condition, your primary care        |
|                    |     provider will work with the plan and your   |
|                    |     specialist to develop a treatment plan that |
|                    |     allows you to see your specialist for a     |
|                    |     certain number of visits without additional |
|                    |     referrals. Your primary care provider will  |
|                    |     use our criteria when creating your         |
|                    |     treatment plan (the physician may have to   |
|                    |     get an authorization or approval            |
|                    |     beforehand).                                |
+--------------------+-------------------------------------------------+
| ####               | -   If you are seeing a specialist when you     |
|                    |     enroll in our Plan, talk to your primary    |
|                    |     care provider. Your primary care provider   |
|                    |     will decide what treatment you need. If he  |
|                    |     or she decides to refer you to a            |
|                    |     specialist, ask if you can see your current |
|                    |     specialist. If your current specialist does |
|                    |     not participate with us, you must receive   |
|                    |     treatment from a specialist who does.       |
|                    |     Generally, we will not pay for you to see a |
|                    |     specialist who does not participate with    |
|                    |     our Plan.                                   |
|                    |                                                 |
|                    | -   If you are seeing a specialist and your     |
|                    |     specialist leaves the Plan, call your       |
|                    |     primary care provider, who will arrange for |
|                    |     you to see another specialist. You may      |
|                    |     receive services from your current          |
|                    |     specialist until we can make arrangements   |
|                    |     for you to see someone else.                |
|                    |                                                 |
|                    | -   If you have a chronic and disabling         |
|                    |     condition and lose access to your           |
|                    |     specialist because we:                      |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   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 program Plan; or               |
|                    |                                                 |
|                    | -   Reduce our service area and you enroll in   |
|                    |     another FEHB Plan,                          |
|                    |                                                 |
|                    | you may be able to continue seeing your         |
|                    | specialist.                                     |
|                    |                                                 |
|                    | -   Termination with a Plan provider's contract |
|                    |     will not release the provider from treating |
|                    |     you, except for reasons of medical          |
|                    |     incompetence or professional misconduct as  |
|                    |     determined by us.                           |
|                    |                                                 |
|                    | Coverage is available until the latest of the   |
|                    | following dates:                                |
|                    |                                                 |
|                    | -   The 120^th^ day following the date the      |
|                    |     contract was terminated between the         |
|                    |     provider and us, or                         |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   If the medical condition is pregnancy, the  |
|                    |     45^th^ day after the date of delivery or,   |
|                    |     if the pregnancy does not end in delivery,  |
|                    |     the date of the end of the pregnancy.       |
|                    |                                                 |
|                    | You or your Plan provider may submit a request  |
|                    | for continuity of care to the address shown     |
|                    | below. If we agree to the continued treatment,  |
|                    | we will pay for covered services at the Plan    |
|                    | provider level of benefits for a limited time,  |
|                    | as outlined above. The Plan provider may not    |
|                    | seek payment from you for any amounts for which |
|                    | you would not be responsible if the provider    |
|                    | were still a Plan provider.                     |
|                    |                                                 |
|                    | Health Plan of Nevada                           |
|                    |                                                 |
|                    | Attn: Provider Services Department              |
|                    |                                                 |
|                    | P.O. Box 15645                                  |
|                    |                                                 |
|                    | Las Vegas, NV 89114-5645                        |
|                    |                                                 |
|                    | Phone: (702) 242-7300 or (800) 777-1840         |
+--------------------+-------------------------------------------------+

+--------------------+-------------------------------------------------+
| #### Hospital care | Your Plan primary care provider or specialist   |
|                    | will make necessary hospital arrangements and   |
|                    | supervise your care. This includes admission to |
|                    | a skilled nursing or other type of facility.    |
|                    |                                                 |
|                    | If you are in the hospital when your enrollment |
|                    | in our Plan begins, call our customer service   |
|                    | department immediately at (702) 242-7300 or     |
|                    | (800) 777-1840. 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  | Under certain extraordinary circumstances, such |
| beyond our control | 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. |
+--------------------+-------------------------------------------------+

+--------------------+-------------------------------------------------+
| ### S              | Your primary care provider has authority to     |
| ervices requiring  | refer you for most services. For certain        |
| our prior approval | 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 prior  |
|                    | authorization. Your physician must obtain prior |
|                    | authorization for services such as:             |
|                    |                                                 |
|                    | -   All non-emergency hospital admissions       |
|                    |                                                 |
|                    | -   Admissions to skilled nursing facilities    |
|                    |     and inpatient hospice facilities            |
|                    |                                                 |
|                    | -   All non-emergency inpatient and outpatient  |
|                    |     surgeries                                   |
|                    |                                                 |
|                    | -   Many diagnostic procedures                  |
|                    |                                                 |
|                    | -   Physical, occupational and speech therapy   |
|                    |                                                 |
|                    | -   Inpatient and outpatient mental health and  |
|                    |     substance abuse treatment                   |
|                    |                                                 |
|                    | -   Home health                                 |
|                    |                                                 |
|                    | -   Prosthetic devices and durable medical      |
|                    |     equipment                                   |
|                    |                                                 |
|                    | -   Certain prescription drugs                  |
|                    |                                                 |
|                    | -   Pharmaceutical compounds                    |
|                    |                                                 |
|                    | -   Genetic disease testing                     |
|                    |                                                 |
|                    | -   Clinical trials or studies for the          |
|                    |     treatment of cancer or chronic fatigue      |
|                    |     syndrome conducted in the state of Nevada   |
|                    |                                                 |
|                    | -   Dental anesthesia for enrolled dependent    |
|                    |     children when determined to be medically    |
|                    |     necessary                                   |
|                    |                                                 |
|                    | It is best to contact your primary care         |
|                    | provider before you seek any services. Failure  |
|                    | to follow the requirements of the prior         |
|                    | authorization process will result in higher     |
|                    | out-of-pocket costs to you.                     |
|                    |                                                 |
|                    | Contact our member services department at (702) |
|                    | 242-7300 or (800) 777-1840 for additional       |
|                    | details.                                        |
+--------------------+-------------------------------------------------+

# Section 4. Your costs for covered services

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

+------------------+---------------------------------------------------+
| ### Copayments   | A copayment is a fixed amount of money you pay to |
|                  | the provider, facility, pharmacy, etc., when you  |
|                  | receive services.                                 |
|                  |                                                   |
|                  | Example: When you see your primary care provider  |
|                  | you pay a copayment of \$10 per office visit and  |
|                  | when you go in the hospital you pay \$100 per     |
|                  | admission.                                        |
+------------------+---------------------------------------------------+
| ### Deductible   | We do not have a deductible.                      |
+------------------+---------------------------------------------------+
| ### Coinsurance  | Coinsurance is the percentage of our negotiated   |
|                  | fee that you must pay for your care.              |
|                  |                                                   |
|                  | Example: In our Plan, you pay 50% of eligible     |
|                  | medical expense (EME) for costs associated with   |
|                  | vision supplies and non-dental treatment of       |
|                  | temporomandibular joint pain dysfunction          |
|                  | syndrome.                                         |
+------------------+---------------------------------------------------+
| ##               | Charges up to the Plan reimbursement schedule     |
| # Eligible Medic | amount, incurred by you while covered under this  |
| al Expense (EME) | Plan for covered services. Plan providers have    |
|                  | agreed to accept the Plan's reimbursement         |
|                  | schedule amount as payment in full for covered    |
|                  | services, plus your payment of any applicable     |
|                  | copayment or coinsurance. Non-plan providers have |
|                  | not. If you use the services of non-Plan          |
|                  | providers, you will receive no benefit payments   |
|                  | or reimbursement for charges for the service,     |
|                  | except in the case of emergency services,         |
|                  | urgently needed services, or other covered        |
|                  | services provided by non-Plan providers that are  |
|                  | prior authorized by the Plan. In no event will    |
|                  | the Plan pay for more than the applicable Plan    |
|                  | reimbursement schedule amount for such services.  |
+------------------+---------------------------------------------------+
| ### You          | After your copayments and coinsurance total       |
| r catastrophic p | \$2,000 per person or \$5,000 per family          |
| rotection out-of | enrollment in any calendar year, you do not have  |
| -pocket maximum  | to pay any more for covered services. However,    |
|                  | copayments for prescription drugs do not count    |
|                  | toward your catastrophic protection out-of-pocket |
|                  | maximum, and you must continue to pay copayments  |
|                  | for them.                                         |
|                  |                                                   |
|                  | Be sure to keep accurate records of your          |
|                  | copayments and coinsurance since you are          |
|                  | responsible for informing us when you reach the   |
|                  | maximum.                                          |
+------------------+---------------------------------------------------+

# Section 5. Benefits -- OVERVIEW *(See page 9 for how our benefits changed this year and page 71 for a benefits summary.)*

*Note: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
(702) 242-7300 or (800) 777-1840 or at our Web site at
[http://fehbp.healthplanofnevada.com.](http://www.xxx.xxx/)*

[Section 5(a) Medical services and supplies provided by physicians and
other health care professionals
18](#section-5a-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)

[Diagnostic and treatment services
18](#diagnostic-and-treatment-services)

[Lab, X-ray and other diagnostic tests
19](#lab-x-ray-and-other-diagnostic-tests)

[Preventive care, adult 20](#preventive-care-adult)

[Preventive care, children 21](#preventive-care-children)

[Maternity care 22](#maternity-care)

[Family planning 23](#family-planning)

[Infertility services 23](#infertility-services)

[Allergy care 24](#allergy-care)

[Treatment therapies 25](#treatment-therapies)

[Physical and occupational therapies
25](#physical-and-occupational-therapies)

[Speech therapy 26](#speech-therapy)

[Hearing services (testing, treatment, and supplies)
26](#hearing-services-testing-treatment-and-supplies)

[Vision services (testing, treatment, and supplies)
26](#vision-services-testing-treatment-and-supplies)

[Foot care 27](#foot-care)

[Orthopedic and prosthetic devices
28](#orthopedic-and-prosthetic-devices)

[Durable medical equipment (DME) 29](#durable-medical-equipment-dme)

[Home health services 29](#home-health-services)

[Chiropractic 30](#chiropractic)

[Alternative treatments 30](#alternative-treatments)

[Educational classes and programs 31](#educational-classes-and-programs)

[Section 5(b) Surgical and anesthesia services provided by physicians
and other health care professionals
32](#section-5b-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)

[Surgical procedures 32](#surgical-procedures)

[Reconstructive surgery 33](#reconstructive-surgery)

[Oral and maxillofacial surgery 34](#oral-and-maxillofacial-surgery)

[Organ/tissue transplants 35](#organtissue-transplants)

[Anesthesia 36](#anesthesia)

[Section 5(c) Services provided by a hospital or other facility, and
ambulance services
37](#section-5c-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

[Inpatient hospital 37](#inpatient-hospital)

[Outpatient hospital or ambulatory surgical center
38](#outpatient-hospital-or-ambulatory-surgical-center)

[Extended care benefits/Skilled nursing care facility benefits
39](#extended-care-benefitsskilled-nursing-care-facility-benefits)

[Hospice care 39](#hospice-care)

[Ambulance 40](#ambulance)

[Section 5(d) Emergency services/accidents
41](#section-5d-emergency-servicesaccidents)

[Emergency within our service area 42](#__RefHeading___Toc80526504)

[Emergency outside our service area 42](#__RefHeading___Toc80526505)

[Ambulance 42](#__RefHeading___Toc80526506)

[Section 5(e) Mental health and substance abuse benefits
43](#section-5e-mental-health-and-substance-abuse-benefits)

[Mental health and substance abuse benefits
43](#mental-health-and-substance-abuse-benefits)

[Section 5(f) Prescription drug benefits
45](#section-5f-prescription-drug-benefits)

[Covered medications and supplies 47](#covered-medications-and-supplies)

[Section 5(g) Special features 48](#section-5g-special-features)

[Flexible benefits option 48](#flexible-benefits-option)

[Telephone Advice Nurse Service 48](#telephone-advice-nurse-service)

[Services for deaf and hearing impaired
48](#services-for-deaf-and-hearing-impaired)

[Preventive Health 48](#preventive-health)

[Disease Management 48](#disease-management)

[HPN@YourService 49](#__RefHeading___Toc80526518)

[Section 5(h) Dental benefits 50](#section-5h-dental-benefits)

[Accidental injury benefit 50](#accidental-injury-benefit)

[Dental benefits 50](#dental-benefits)

[Section 5(i) Non-FEHB benefits available to Plan members
51](#section-5i-non-fehb-benefits-available-to-plan-members)

[Summary of benefits for Health Plan of Nevada *-* 2005
71](#summary-of-benefits-for-the-health-plan-of-nevada---2005)

[2005 Rate Information for Health Plan of Nevada
72](#rate-information-for-health-plan-of-nevada)

## Section 5(a) Medical services and supplies provided by physicians and other health care professionals

+---+---+-------------------------------------+---------------------+---+---+
|   | * | **Here are some important things    |                     | * |   |
|   | * | you should keep in mind about these |                     | * |   |
|   | I | benefits:**                         |                     | I |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Plan physicians must provide or |                     | * |   |
|   | * |     arrange your care.              |                     | * |   |
|   | P |                                     |                     | P |   |
|   | * | -   We have no calendar year        |                     | * |   |
|   | * |     deductible.                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Be sure to read Section 4,      |                     | * |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | O |     services*, for valuable         |                     | O |   |
|   | * |     information about how cost      |                     | * |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   |   |     Section 9 about coordinating    |                     |   |   |
|   | * |     benefits with other coverage,   |                     | * |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | R |                                     |                     | R |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | N |                                     |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$10 per office     |   |   |
| r |   |                                     | visit               |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
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| p |   |                                     |                     |   |   |
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| y |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| p |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$20 per office     |   |   |
| r |   |                                     | visit               |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
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| s |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | Nothing             |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     | You pay             |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$5 plus office     |   |   |
|   |   |                                     | visit copayment     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| L |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
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| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | 50% of EME          |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| G |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$750               |   |   |
|   |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
| ( |   |                                     |                     |   |   |
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| E |   |                                     |                     |   |   |
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| ) |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

+------------------------------------------+---------------------------+
| ###### Preventive care, adult            | You pay                   |
+------------------------------------------+---------------------------+
| Routine screenings, such as:             | \$5 per test plus office  |
|                                          | visit copayment           |
| -   Total Blood Cholesterol              |                           |
|                                          |                           |
| -   Colorectal Cancer Screening,         |                           |
|     including                            |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Fecal occult blood test              |                           |
|                                          |                           |
| -   Double contrast barium enema -- once |                           |
|     every five years starting at age 50  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Routine Prostate Specific Antigen    |                           |
|     (PSA) test -- one annually for men   |                           |
|     age 40 and older                     |                           |
|                                          |                           |
| -   Screening for Chlamydial infection   |                           |
|                                          |                           |
| -   Routine mammogram -- covered for     |                           |
|     women age 35 and older as follows:   |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   From age 35 through 39, one during   |                           |
|     this five year period                |                           |
|                                          |                           |
| -   Age 40 and older, one every calendar |                           |
|     year                                 |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Osteoporosis screening               |                           |
|                                          |                           |
| -   Routine Pap test                     |                           |
|                                          |                           |
| Note: The office visit is covered if the |                           |
| Pap test is received on the same day;    |                           |
| see *Diagnostic and treatment services*, |                           |
| above.                                   |                           |
+------------------------------------------+---------------------------+
| -   Sigmoidoscopy -- one every five      | \$50 per procedure        |
|     years starting at age 50; or         |                           |
|                                          |                           |
| -   Colonoscopy -- one every 10 years    |                           |
|     starting at age 50                   |                           |
+------------------------------------------+---------------------------+
| -   Routine immunizations limited to:    | \$10 per office visit     |
|                                          |                           |
| ```{=html}                               | No charge at immunization |
| <!-- -->                                 | clinics                   |
| ```                                      |                           |
| -   Tetanus-diphtheria (Td) booster,     |                           |
|     once every 10 years, ages 19 and     |                           |
|     over (except as provided for under   |                           |
|     Childhood immunizations)             |                           |
|                                          |                           |
| -   Influenza vaccine, annually          |                           |
|                                          |                           |
| -   Pneumococcal vaccine, age 65 and     |                           |
|     older                                |                           |
+------------------------------------------+---------------------------+

*Preventive care, adult - continued on next page*

+------------------------------------------+---------------------------+
| ###                                      | You pay                   |
| ### Preventive care, adult *(continued)* |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Physical exams required for         |                           |
|     obtaining or continuing employment,  |                           |
|     licensing, insurance, attending      |                           |
|     schools or camp, travel, sports, or  |                           |
|     adoption purposes*                   |                           |
|                                          |                           |
| -   *Exams or treatment ordered by a     |                           |
|     court, or in connection with legal   |                           |
|     proceedings*                         |                           |
|                                          |                           |
| -   *Immunizations related to foreign    |                           |
|     travel*                              |                           |
+------------------------------------------+---------------------------+
| ###### Preventive care, children         |                           |
+------------------------------------------+---------------------------+
| -   Childhood immunizations recommended  | \$10 per office visit     |
|     by the American Academy of           |                           |
|     Pediatrics                           |                           |
|                                          |                           |
| -   Well-child care charges for routine  |                           |
|     examinations, immunizations and care |                           |
|     (up to age 22)                       |                           |
|                                          |                           |
| -   Examinations, such as:               |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Eye exams through age 17 to          |                           |
|     determine the need for vision        |                           |
|     correction                           |                           |
|                                          |                           |
| -   Ear exams through age 17 to          |                           |
|     determine the need for hearing       |                           |
|     correction                           |                           |
|                                          |                           |
| -   Examinations done on the day of      |                           |
|     immunizations (up to age 22)         |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Physical exams required for         |                           |
|     obtaining or continuing employment,  |                           |
|     licensing, insurance, attending      |                           |
|     schools or camp, travel, sports, or  |                           |
|     adoption purposes*                   |                           |
|                                          |                           |
| -   *Exams or treatment ordered by a     |                           |
|     court, or in connection with legal   |                           |
|     proceedings*                         |                           |
|                                          |                           |
| -   *Immunizations related to foreign    |                           |
|     travel*                              |                           |
+------------------------------------------+---------------------------+
| ###### Maternity care                    | You pay                   |
+------------------------------------------+---------------------------+
| Complete maternity (obstetrical) care,   | \$15 per office visit     |
| such as:                                 |                           |
|                                          |                           |
| -   Prenatal care                        |                           |
|                                          |                           |
| -   Delivery                             |                           |
|                                          |                           |
| -   Postnatal care                       |                           |
|                                          |                           |
| Note: Here are some things to keep in    |                           |
| mind:                                    |                           |
|                                          |                           |
| -   You do not need to have your normal  |                           |
|     delivery prior authorized.           |                           |
|                                          |                           |
| -   You may remain in the hospital up to |                           |
|     48 hours after a vaginal 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. Circumcision is covered  |                           |
|     under the *Surgical benefits         |                           |
|     (Section 5(b))*.                     |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   We pay hospitalization and surgeon   |                           |
|     services (delivery) the same as for  |                           |
|     any illness and injury. See          |                           |
|     *Hospital benefits (Section 5(c))*   |                           |
|     and *Surgical benefits (Section      |                           |
|     5(b))*.                              |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Routine sonograms to determine      |                           |
|     fetal age, size or sex*              |                           |
|                                          |                           |
| -   *Amniocentesis, except when          |                           |
|     medically necessary under the        |                           |
|     guidelines of the American College   |                           |
|     of Obstetrics and Gynecology*        |                           |
|                                          |                           |
| -   *Services and supplies rendered in   |                           |
|     connection with member acting as or  |                           |
|     utilizing the services of a          |                           |
|     surrogate mother*                    |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Family planning                   |                           |
+------------------------------------------+---------------------------+
| A range of voluntary family planning     | \$10 per office visit     |
| services, limited to:                    |                           |
|                                          |                           |
| -   Voluntary sterilization (See         |                           |
|     *Surgical procedures Section 5 (b))* |                           |
|                                          |                           |
| -   Surgically implanted contraceptives  |                           |
|     (such as Norplant)                   |                           |
|                                          |                           |
| -   Injectable contraceptive drugs (such |                           |
|     as Depo provera)                     |                           |
|                                          |                           |
| -   Intrauterine devices (IUDs)          |                           |
|                                          |                           |
| -   Diaphragms                           |                           |
|                                          |                           |
| Note: We cover oral contraceptives under |                           |
| the prescription drug benefit. See       |                           |
| *Section 5(f)*.                          |                           |
|                                          |                           |
| Note: Other copayments may apply for     |                           |
| surgical services. See *Section 5(b)*.   |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   Reversal of voluntary surgical       |                           |
|     sterilization                        |                           |
|                                          |                           |
| -   Voluntary abortions                  |                           |
+------------------------------------------+---------------------------+
| ###### Infertility services              |                           |
+------------------------------------------+---------------------------+
| Diagnosis and treatment of infertility   | \$10 per office visit     |
| such as:                                 |                           |
|                                          |                           |
| -   Diagnostic and therapeutic           |                           |
|     infertility services determined to   |                           |
|     be medically necessary and prior     |                           |
|     authorized by the Plan.              |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Laboratory studies                   |                           |
|                                          |                           |
| -   Diagnostic procedures                |                           |
|                                          |                           |
| -   Artificial insemination services, up |                           |
|     to six cycles per member per         |                           |
|     lifetime                             |                           |
+------------------------------------------+---------------------------+

*Infertility services - continued on next page*

+------------------------------------------+---------------------------+
| #                                        | You pay                   |
| ##### Infertility services *(continued)* |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Assisted reproductive technology    |                           |
|     (ART) procedures, such as:*          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *in vitro fertilization*             |                           |
|                                          |                           |
| -   *embryo transfer, gamete             |                           |
|     intra-fallopian transfer (GIFT) and  |                           |
|     zygote intra-fallopian transfer      |                           |
|     (ZIFT)*                              |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Services and supplies related to    |                           |
|     excluded ART procedures*             |                           |
|                                          |                           |
| -   *Cost of donor sperm*                |                           |
|                                          |                           |
| -   *Cost of donor egg*                  |                           |
|                                          |                           |
| -   *Injectable and oral fertility       |                           |
|     drugs*                               |                           |
|                                          |                           |
| -   *Low tubal transfers*                |                           |
+------------------------------------------+---------------------------+
| ###### Allergy care                      |                           |
+------------------------------------------+---------------------------+
| -   Testing and treatment                | \$10 per office visit     |
|                                          |                           |
| -   Allergy injections                   |                           |
+------------------------------------------+---------------------------+
| -   Allergy serum                        | Nothing                   |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Provocative food testing*           |                           |
|                                          |                           |
| -   *Sublingual allergy desensitization* |                           |
+------------------------------------------+---------------------------+
| ###### Treatment therapies               | You pay                   |
+------------------------------------------+---------------------------+
| -   Chemotherapy and radiation therapy   | \$10 per office visit     |
|                                          |                           |
| Note: High dose chemotherapy in          |                           |
| association with autologous bone marrow  |                           |
| transplants is limited to those          |                           |
| transplants listed under Organ/Tissue    |                           |
| Transplants on page 35.                  |                           |
|                                          |                           |
| -   Respiratory and inhalation therapy   |                           |
|                                          |                           |
| -   Dialysis -- hemodialysis and         |                           |
|     peritoneal dialysis                  |                           |
|                                          |                           |
| -   Intravenous (IV)/Infusion Therapy -- |                           |
|     Home IV and antibiotic therapy       |                           |
|                                          |                           |
| -   Growth hormone therapy (GHT)         |                           |
|                                          |                           |
| Note: Growth hormone is covered under    |                           |
| the prescription drug benefit *(Section  |                           |
| 5(f))*. We will only cover GHT when we   |                           |
| prior authorize the treatment. Call      |                           |
| (702) 242-7300 or (800) 777-1840 for     |                           |
| prior authorization. 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 and prior authorization  |                           |
| is given. If you do not request prior    |                           |
| authorization 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*.            |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Sports medicine treatment intended  |                           |
|     to primarily improve athletic        |                           |
|     ability*                             |                           |
+------------------------------------------+---------------------------+
| ###                                      |                           |
| ### Physical and occupational therapies  |                           |
+------------------------------------------+---------------------------+
| -   Two consecutive months per condition | \$5 per office visit      |
|     for 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.                |                           |
|                                          |                           |
| -   Cardiac rehabilitation is provided   |                           |
|     for up to 30 days following a heart  |                           |
|     transplant, bypass surgery or a      |                           |
|     myocardial infarction.               |                           |
|                                          |                           |
| Note: Cardiac rehabilitation services    |                           |
| must be provided on a monitored basis.   |                           |
+------------------------------------------+---------------------------+

*Physical and occupational therapies - continued on next page*

+------------------------------------------+---------------------------+
| ###### Physical                          | You pay                   |
| and occupational therapies *(continued)* |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Long-term rehabilitative therapy*   |                           |
|                                          |                           |
| -   *Exercise programs*                  |                           |
|                                          |                           |
| -   *Milieu therapy, biofeedback,        |                           |
|     behavior modification, sensitivity   |                           |
|     training, hydrotherapy,              |                           |
|     electrohypnosis, electrosleep        |                           |
|     therapy, electronarcosis,            |                           |
|     narcosynthesis, rolfing, residential |                           |
|     treatment, vocational rehabilitation |                           |
|     and wilderness programs*             |                           |
|                                          |                           |
| -   *Treatment for mental retardation*   |                           |
+------------------------------------------+---------------------------+
| ###### Speech therapy                    |                           |
+------------------------------------------+---------------------------+
| -   Two consecutive months per condition | \$5 per office visit      |
|     for the services of a speech         |                           |
|     therapist                            |                           |
+------------------------------------------+---------------------------+
| ###### Hearing ser                       |                           |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| -   First hearing aid and testing only   | \$10 per office visit     |
|     when necessitated by accidental      |                           |
|     injury                               |                           |
|                                          |                           |
| -   Hearing testing for children through |                           |
|     age 17 (see *Preventive care,        |                           |
|     children)*                           |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *All other hearing testing*          |                           |
|                                          |                           |
| -   *Hearing aids, testing and           |                           |
|     examinations for them*               |                           |
+------------------------------------------+---------------------------+
| ###### Vision ser                        |                           |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| -   Annual eye refraction                | \$10 per office visit     |
|                                          |                           |
| Note: See *Preventive care, children*    |                           |
| for eye exams for children               |                           |
+------------------------------------------+---------------------------+
| -   One pair of eyeglasses or contact    | 50% of costs              |
|     lenses to correct an impairment      |                           |
|     directly caused by accidental ocular |                           |
|     injury or intraocular surgery (such  |                           |
|     as for cataracts)                    |                           |
+------------------------------------------+---------------------------+

*Vision services - continued on next page*

+------------------------------------------+---------------------------+
| ###### Vision services (testing          | You pay                   |
| , treatment, and supplies) *(continued)* |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Eye examination required as a       |                           |
|     condition of employment or by a      |                           |
|     government body*                     |                           |
|                                          |                           |
| -   *Low vision aids*                    |                           |
|                                          |                           |
| -   *Orthoptics or vision training and   |                           |
|     exercises*                           |                           |
|                                          |                           |
| -   *Medical or surgical treatment of    |                           |
|     the eyes*                            |                           |
|                                          |                           |
| -   *Any surgical procedure for the      |                           |
|     improvement of vision when vision    |                           |
|     can be made adequate through the use |                           |
|     of glasses or contact lenses*        |                           |
+------------------------------------------+---------------------------+
| ###### Foot care                         |                           |
+------------------------------------------+---------------------------+
| -   Routine foot care when you are under | \$10 per office visit     |
|     active treatment for a metabolic or  |                           |
|     peripheral vascular disease, such as |                           |
|     diabetes.                            |                           |
|                                          |                           |
| Note: 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)*                            |                           |
+------------------------------------------+---------------------------+
| #                                        | You pay                   |
| ##### Orthopedic and prosthetic devices  |                           |
+------------------------------------------+---------------------------+
| -   Internal prosthetic devices, such as | 50% of cost, not to       |
|     artificial joints, pacemakers,       | exceed \$200 per device   |
|     cochlear implants and surgically     |                           |
|     implanted breast implants following  |                           |
|     mastectomy                           |                           |
|                                          |                           |
| Note: See *5(b)* for coverage of the     |                           |
| surgery to insert the device.            |                           |
|                                          |                           |
| -   Externally worn breast prostheses    |                           |
|     and surgical bras, including         |                           |
|     necessary replacements, following a  |                           |
|     mastectomy                           |                           |
|                                          |                           |
| -   Terminal devices, such as hand or    |                           |
|     hook                                 |                           |
|                                          |                           |
| -   Artificial limbs and eyes; stump     |                           |
|     hose                                 |                           |
|                                          |                           |
| -   Braces which include only rigid and  |                           |
|     semi-rigid devices used for          |                           |
|     supporting a weak or deformed body   |                           |
|     member or restricting or eliminating |                           |
|     motion of a diseased or injured part |                           |
|     of the body                          |                           |
|                                          |                           |
| -   Foot orthotics when part of a lower  |                           |
|     body brace                           |                           |
|                                          |                           |
| -   Lumbosacral supports                 |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Adjustment of an initial Prosthetic  |                           |
|     or Orthotic Device required by wear  |                           |
|     or by change in the patient's        |                           |
|     condition when ordered by a Plan     |                           |
|     provider                             |                           |
+------------------------------------------+---------------------------+
| -   Corrective orthopedic appliances for | 50% of EME                |
|     non-dental treatment of              |                           |
|     temporomandibular joint (TMJ) pain   |                           |
|     dysfunction syndrome                 |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Arch supports*                      |                           |
|                                          |                           |
| -   *Special shoe accessories or         |                           |
|     corrective shoes unless they are an  |                           |
|     integral part of a lower body brace* |                           |
|                                          |                           |
| -   *Heel pads and heel cups*            |                           |
|                                          |                           |
| -   *Corsets, trusses, elastic           |                           |
|     stockings, support hose, and other   |                           |
|     supportive devices*                  |                           |
|                                          |                           |
| -   *Prosthetic replacements provided    |                           |
|     less than three years after the last |                           |
|     one we covered*                      |                           |
+------------------------------------------+---------------------------+
| ###### Durable medical equipment (DME)   | You pay                   |
+------------------------------------------+---------------------------+
| Rental or purchase, at our option,       | Nothing                   |
| including repair and adjustment, of      |                           |
| durable medical equipment prescribed by  |                           |
| your Plan physician and prior authorized |                           |
| by the Plan, such as oxygen and dialysis |                           |
| equipment. Under this benefit, we also   |                           |
| cover:                                   |                           |
|                                          |                           |
| -   Wheelchairs -- limited to coverage   |                           |
|     of single standard manual wheelchair |                           |
|     as deemed medically necessary and    |                           |
|     appropriate                          |                           |
|                                          |                           |
| -   Hospital beds                        |                           |
|                                          |                           |
| -   Traction equipment                   |                           |
|                                          |                           |
| -   Walkers                              |                           |
|                                          |                           |
| -   Crutches                             |                           |
|                                          |                           |
| -   Insulin pumps                        |                           |
|                                          |                           |
| Note: Call us at (702) 242-7300 or (800) |                           |
| 777-1840 as soon as your Plan physician  |                           |
| prescribes this equipment.               |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Motorized wheelchairs*              |                           |
|                                          |                           |
| -   *Custom wheelchairs*                 |                           |
|                                          |                           |
| -   *More than one piece of equipment    |                           |
|     serving essentially the same         |                           |
|     function except for replacements as  |                           |
|     authorized by the Plan. Coverage for |                           |
|     alternate or spare equipment is not  |                           |
|     provided.*                           |                           |
+------------------------------------------+---------------------------+
| ###### Home health services              |                           |
+------------------------------------------+---------------------------+
| Covered services and supplies provided   | Nothing                   |
| by a Home Health Care agency include:    |                           |
|                                          |                           |
| -   Professional services of a           |                           |
|     registered nurse, licensed practical |                           |
|     nurse, licensed vocational nurse or  |                           |
|     a health aide on an intermittent     |                           |
|     basis.                               |                           |
|                                          |                           |
| -   Physical therapy, speech therapy and |                           |
|     occupational therapy by licensed     |                           |
|     therapists.                          |                           |
|                                          |                           |
| -   Medical and surgical supplies that   |                           |
|     are customarily furnished by the     |                           |
|     Home Health Care agency or program   |                           |
|     for its patients.                    |                           |
|                                          |                           |
| -   Prescribed drugs furnished and       |                           |
|     charged for by the Home Health Care  |                           |
|     agency or program. Prescribed drugs  |                           |
|     under this provision do not include  |                           |
|     self-injectable prescription drugs.  |                           |
|                                          |                           |
| -   Health aid services furnished to     |                           |
|     member only when receiving nursing   |                           |
|     services or therapy.                 |                           |
+------------------------------------------+---------------------------+

*Home health services - continued on next page*

+------------------------------------------+---------------------------+
| #                                        | 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*                      |                           |
|                                          |                           |
| -   *Housekeeping or meal service*       |                           |
+------------------------------------------+---------------------------+
| ###### Chiropractic                      |                           |
+------------------------------------------+---------------------------+
| -   Chiropractic services for manual     | \$10 per office visit     |
|     manipulation of the spine (except    |                           |
|     for reductions of fractures or       |                           |
|     dislocations)                        |                           |
|                                          |                           |
| Note: Limited to 60 consecutive calendar |                           |
| days per condition.                      |                           |
+------------------------------------------+---------------------------+
| ###### Alternative treatments            |                           |
+------------------------------------------+---------------------------+
| -   Medical treatment in a Phase II, III | \$10 per office visit     |
|     or IV clinical trial or study for    |                           |
|     the treatment of cancer or chronic   |                           |
|     fatigue syndrome conducted in the    |                           |
|     state of Nevada                      |                           |
|                                          |                           |
| Note: See *Prescription drug benefits    |                           |
| (Section 5(f))* for coverage of drugs    |                           |
| and medicines.                           |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Any portion of the clinical trial   |                           |
|     or study that is customarily paid    |                           |
|     for by a government or a             |                           |
|     biotechnical, pharmaceutical or      |                           |
|     medical industry*                    |                           |
|                                          |                           |
| -   *Services that are specifically      |                           |
|     excluded from coverage under this    |                           |
|     Plan regardless of whether such      |                           |
|     services are provided under the      |                           |
|     clinical trial or study*             |                           |
|                                          |                           |
| -   *Services that are customarily       |                           |
|     provided by the sponsors of the      |                           |
|     clinical trial or study free of      |                           |
|     charge in the clinical trial or      |                           |
|     study*                               |                           |
|                                          |                           |
| -   *Expenses related to participation   |                           |
|     in the clinical trial or study       |                           |
|     including, but not limited to,       |                           |
|     travel, housing and other expenses*  |                           |
|                                          |                           |
| -   *Expenses incurred by a person who   |                           |
|     accompanies a member during the      |                           |
|     clinical trial or study*             |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Educational classes and programs  | You pay                   |
+------------------------------------------+---------------------------+
| Coverage is limited to:                  | \$10 per office visit     |
|                                          |                           |
| -   Smoking Cessation -- Up to \$100 for | \$5 per educational site  |
|     one smoking cessation program per    | visit                     |
|     member per lifetime                  |                           |
|                                          |                           |
| Note: See *Prescription drug benefits    |                           |
| (Section 5(f))* for coverage of smoking  |                           |
| cessation medication.                    |                           |
|                                          |                           |
| -   Diabetes self-management             |                           |
|                                          |                           |
| -   Education -- Includes coverage for   |                           |
|     education for treatment of diabetes. |                           |
|     Covered services include medically   |                           |
|     necessary training and education     |                           |
|     for:                                 |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   the care and management of diabetes, |                           |
|     after initial diagnosis of diabetes, |                           |
|     to include counseling in nutrition   |                           |
|     and the proper use of equipment and  |                           |
|     supplies for the treatment of        |                           |
|     diabetes                             |                           |
|                                          |                           |
| -   a subsequent diagnosis that          |                           |
|     indicates a significant change in    |                           |
|     the symptoms or condition which      |                           |
|     requires modification of the         |                           |
|     self-management program              |                           |
|                                          |                           |
| -   the development of new techniques    |                           |
|     and treatment for diabetes           |                           |
+------------------------------------------+---------------------------+
| -   Diabetes supplies, including:        | \$5 per 30-day            |
|                                          | therapeutic supply        |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   syringes                             |                           |
|                                          |                           |
| -   needles                              |                           |
|                                          |                           |
| -   blood glucose measuring strips       |                           |
|                                          |                           |
| -   urine checking reagents              |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Disposable needles and syringes for  |                           |
|     the administration of covered        |                           |
|     medications                          |                           |
+------------------------------------------+---------------------------+
| -   Diabetes equipment, including:       | \$20 per unit (maximum    |
|                                          | one unit per year)        |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   blood glucose monitor                |                           |
|                                          |                           |
| -   lancet device                        |                           |
|                                          |                           |
| Note: See *Durable medical equipment     |                           |
| (Section 5(a))* for coverage of insulin  |                           |
| pumps. See *Prescription drug benefits   |                           |
| (Section 5(f))* for coverage of diabetes |                           |
| medication.                              |                           |
+------------------------------------------+---------------------------+

## Section 5(b) Surgical and anesthesia services provided by physicians and other health care professionals

+---+---+------------------------------------+--------------------+---+---+
|   | * | **Here are some important things   |                    | * |   |
|   | * | you should keep in mind about      |                    | * |   |
|   | I | these benefits:**                  |                    | I |   |
|   | * |                                    |                    | * |   |
|   | * | -   Please remember that all       |                    | * |   |
|   |   |     benefits are subject to the    |                    |   |   |
|   | * |     definitions, limitations, and  |                    | * |   |
|   | * |     exclusions in this brochure    |                    | * |   |
|   | M |     and are payable only when we   |                    | M |   |
|   | * |     determine they are medically   |                    | * |   |
|   | * |     necessary.                     |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   Plan physicians must provide   |                    | * |   |
|   | * |     or arrange your care.          |                    | * |   |
|   | P |                                    |                    | P |   |
|   | * | -   We have no calendar year       |                    | * |   |
|   | * |     deductible*.*                  |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   Be sure to read Section 4,     |                    | * |   |
|   | * |     *Your costs for covered        |                    | * |   |
|   | O |     services*, for valuable        |                    | O |   |
|   | * |     information about how cost     |                    | * |   |
|   | * |     sharing works. Also read       |                    | * |   |
|   |   |     Section 9 about coordinating   |                    |   |   |
|   | * |     benefits with other coverage,  |                    | * |   |
|   | * |     including with Medicare.       |                    | * |   |
|   | R |                                    |                    | R |   |
|   | * | -   The amounts listed below are   |                    | * |   |
|   | * |     for the charges billed by a    |                    | * |   |
|   |   |     physician or other health care |                    |   |   |
|   | * |     professional for your surgical |                    | * |   |
|   | * |     care. Look in Section 5(c) for |                    | * |   |
|   | T |     charges associated with the    |                    | T |   |
|   | * |     facility (i.e. hospital,       |                    | * |   |
|   | * |     surgical center, etc.).        |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   YOU MUST GET PRIOR             |                    | * |   |
|   | * |     AUTHORIZATION FOR SURGICAL     |                    | * |   |
|   | A |     PROCEDURES. Please refer to    |                    | A |   |
|   | * |     the prior authorization        |                    | * |   |
|   | * |     information in Section 3 to be |                    | * |   |
|   |   |     sure which services require    |                    |   |   |
|   | * |     prior authorization and        |                    | * |   |
|   | * |     identify which surgeries       |                    | * |   |
|   | N |     require prior authorization.   |                    | N |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
|   | T |                                    |                    | T |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
+---+---+------------------------------------+--------------------+---+---+
| B |   |                                    | You pay            |   |   |
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+---+---+------------------------------------+--------------------+---+---+
| # |   |                                    |                    |   |   |
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+---+---+------------------------------------+--------------------+---+---+
| A |   |                                    | \$5 plus office    |   |   |
| c |   |                                    | visit copayment in |   |   |
| o |   |                                    | a physician's      |   |   |
| m |   |                                    | office             |   |   |
| p |   |                                    |                    |   |   |
| r |   |                                    | Nothing in an      |   |   |
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| n |   |                                    | Nothing for        |   |   |
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|   |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| * |   |                                    |                    |   |   |
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|   |   |                                    |                    |   |   |
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|   |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
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| ( |   |                                    |                    |   |   |
| S |   |                                    |                    |   |   |
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|   |   |                                    |                    |   |   |
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|   |   |                                    |                    |   |   |
| 5 |   |                                    |                    |   |   |
| ( |   |                                    |                    |   |   |
| b |   |                                    |                    |   |   |
| ) |   |                                    |                    |   |   |
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| ) |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+

*Surgical procedures - continued on next page*

+------------------------------------------+---------------------------+
| ###### Surgical procedures *(continued)* | You pay                   |
+------------------------------------------+---------------------------+
| -   Insertion of internal prosthetic     | \$5 plus office visit     |
|     devices. See *Orthopedic and         | copayment in a            |
|     prosthetic devices (Section 5(a))*   | physician's office        |
|     for device coverage information.     |                           |
|                                          | Nothing in an outpatient  |
| -   Treatment of burns                   | facility                  |
|                                          |                           |
| -   Surgically implanted contraceptives  | Nothing for inpatient     |
|                                          | admissions                |
| -   Voluntary sterilization (e.g., Tubal |                           |
|     ligation, Vasectomy)                 |                           |
|                                          |                           |
| Note: Generally, we pay for internal     |                           |
| prostheses (devices) according to where  |                           |
| the procedure is done. For example, we   |                           |
| pay hospital benefits for a pacemaker    |                           |
| and surgery benefits for insertion of    |                           |
| the pacemaker.                           |                           |
+------------------------------------------+---------------------------+
| -   Surgical treatment of morbid obesity | 50% of EME                |
|     \-- a condition in which an          |                           |
|     individual weighs 100 pounds or 100% |                           |
|     over his or her normal weight        |                           |
|     according to current underwriting    |                           |
|     standards; eligible members must be  |                           |
|     age 18 or over. Surgical treatment   |                           |
|     of morbid obesity is covered only as |                           |
|     a treatment of last resort.          |                           |
|                                          |                           |
| Note: Copayment for any covered services |                           |
| rendered in the treatment of             |                           |
| complications in connection with Gastric |                           |
| Restrictive Surgery is 50% of EME.       |                           |
+------------------------------------------+---------------------------+
| -   Surgical Assistant Services          | Nothing                   |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Reversal of voluntary               |                           |
|     sterilization*                       |                           |
|                                          |                           |
| -   *Routine treatment of conditions of  |                           |
|     the foot* (see *Foot care (Section   |                           |
|     5(a)*)                               |                           |
+------------------------------------------+---------------------------+
| ###### Reconstructive surgery            |                           |
+------------------------------------------+---------------------------+
| -   Surgery to correct a function defect | \$5 plus office visit     |
|                                          | copayment in a            |
| -   Surgery to correct a condition       | physician's office        |
|     caused by injury or illness if:      |                           |
|                                          | Nothing in an outpatient  |
| ```{=html}                               | facility                  |
| <!-- -->                                 |                           |
| ```                                      | Nothing for inpatient     |
| -   The condition produced a major       | admissions                |
|     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 is a    |                           |
|     significant deviation from the       |                           |
|     common form or norm. Examples of     |                           |
|     congenital anomalies are: cleft lip, |                           |
|     cleft palate, birthmarks, webbed     |                           |
|     fingers, and webbed toes.            |                           |
+------------------------------------------+---------------------------+

*Reconstructive surgery - continued on next page*

+------------------------------------------+---------------------------+
| ###                                      | You pay                   |
| ### Reconstructive surgery *(continued)* |                           |
+------------------------------------------+---------------------------+
| -   All stages of breast reconstruction  | Nothing for inpatient     |
|     surgery following a mastectomy, such | admissions                |
|     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 Section 5(a)*)               |                           |
|                                          |                           |
| 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    |                           |
+------------------------------------------+---------------------------+
| -   Oral surgical procedures, limited    | \$10 in a physician's     |
|     to:                                  | office                    |
|                                          |                           |
| -   Reduction of fractures of the jaws   | Nothing in an outpatient  |
|     or facial bones                      | facility                  |
|                                          |                           |
| -   Surgical correction of cleft lip,    | Nothing for inpatient     |
|     cleft palate or severe functional    | admissions                |
|     malocclusion                         |                           |
|                                          |                           |
| -   Excision of leukoplakia or           |                           |
|     malignancies                         |                           |
|                                          |                           |
| -   Excision of cysts and incision of    |                           |
|     abscesses when done as independent   |                           |
|     procedures                           |                           |
|                                          |                           |
| -   Treatment of tumors and cysts        |                           |
|     requiring pathological examination   |                           |
|     of the jaws, cheeks, lips, tongue,   |                           |
|     roof and floor of the mouth          |                           |
|                                          |                           |
| -   Removal of teeth necessary in order  |                           |
|     to perform radiation therapy         |                           |
|                                          |                           |
| -   Removal of stones from salivary      |                           |
|     ducts                                |                           |
|                                          |                           |
| -   Other surgical procedures that do    |                           |
|     not involve the teeth or their       |                           |
|     supporting structures                |                           |
+------------------------------------------+---------------------------+
| -   Non-dental treatment of              | 50% of EME                |
|     temporomandibular joint (TMJ) pain   |                           |
|     dysfunction syndrome                 |                           |
+------------------------------------------+---------------------------+

*Oral and maxillofacial surgery - continued on next page*

+------------------------------------------+---------------------------+
| ###### Oral                              | You pay                   |
|  and maxillofacial surgery *(continued)* |                           |
+------------------------------------------+---------------------------+
| *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)*         |                           |
|                                          |                           |
| -   *Shortening of the mandible or       |                           |
|     maxillae for cosmetic purposes*      |                           |
|                                          |                           |
| -   *Charges for dental services in      |                           |
|     connection with TMJ*                 |                           |
+------------------------------------------+---------------------------+
| ###### Organ/tissue transplants          |                           |
+------------------------------------------+---------------------------+
| Limited to:                              | Nothing for inpatient     |
|                                          | admissions                |
| -   Cornea                               |                           |
|                                          |                           |
| -   Heart                                |                           |
|                                          |                           |
| -   Lung                                 |                           |
|                                          |                           |
| -   Kidney                               |                           |
|                                          |                           |
| -   Liver                                |                           |
|                                          |                           |
| -   Pancreas                             |                           |
|                                          |                           |
| -   Allogenic (donor) bone marrow        |                           |
|     transplants                          |                           |
|                                          |                           |
| -   Autologous bone marrow transplants   |                           |
|     (autologous stem cell and peripheral |                           |
|     stem cell support) for the following |                           |
|     conditions: acute lymphocytic        |                           |
|     leukemia; advanced Hodgkin's         |                           |
|     lymphoma; advanced non-Hodgkin's     |                           |
|     lymphoma; advanced neuroblastoma;    |                           |
|     breast cancer; multiple myeloma;     |                           |
|     epithelial ovarian cancer; and       |                           |
|     testicular, mediastinal,             |                           |
|     retroperitoneal and ovarian germ     |                           |
|     cell tumors                          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Intestinal transplants (small        |                           |
|     intestine) and the small intestine   |                           |
|     with the liver or small intestine    |                           |
|     with multiple organs such as the     |                           |
|     liver, stomach, and pancreas         |                           |
|                                          |                           |
| Limited Benefits -- Treatment for breast |                           |
| cancer, multiple myeloma, and epithelial |                           |
| ovarian cancer may be provided in an NCI |                           |
| or NIH-approved clinical trial at a      |                           |
| Plan-designated center of excellence and |                           |
| if approved by the Plan's medical        |                           |
| director in accordance with the Plan's   |                           |
| protocols.                               |                           |
|                                          |                           |
| Note: We cover related medical and       |                           |
| hospital expenses of the donor when we   |                           |
| cover the recipient.                     |                           |
+------------------------------------------+---------------------------+

*Organ/tissue transplants - continued on next page*

+------------------------------------------+---------------------------+
| #####                                    | You pay                   |
| # Organ/tissue transplants *(continued)* |                           |
+------------------------------------------+---------------------------+
| -   Transportation, lodging and meals    | All costs exceeding \$200 |
|                                          | per day and \$10,000 per  |
| Note: Prior authorization is required.   | transplant period         |
+------------------------------------------+---------------------------+
| -   Organ procurement                    | All costs exceeding       |
|                                          | \$15,000 of EME           |
+------------------------------------------+---------------------------+
| -   Retransplantation services           | All costs exceeding 50%   |
|                                          | of EME                    |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Donor screening tests and donor     |                           |
|     search expenses, except those        |                           |
|     performed for the actual donor*      |                           |
|                                          |                           |
| -   *Implants of artificial organs*      |                           |
|                                          |                           |
| -   *Transplants not listed as covered*  |                           |
+------------------------------------------+---------------------------+
| ###### Anesthesia                        |                           |
+------------------------------------------+---------------------------+
| Professional services provided in --     | Nothing                   |
|                                          |                           |
| -   Hospital (inpatient)                 |                           |
|                                          |                           |
| -   Hospital outpatient department       |                           |
|                                          |                           |
| -   Skilled nursing facility             |                           |
|                                          |                           |
| -   Ambulatory surgical center           |                           |
|                                          |                           |
| -   Physician office                     |                           |
+------------------------------------------+---------------------------+

## Section 5(c) Services provided by a hospital or other facility, and ambulance services 

+---+---+-------------------------------------+---------------------+---+---+
|   | * | **Here are some important things    |                     | * |   |
|   | * | you should keep in mind about these |                     | * |   |
|   | I | benefits:**                         |                     | I |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Plan physicians must provide or |                     | * |   |
|   | * |     arrange your care and you must  |                     | * |   |
|   | P |     be hospitalized in a Plan       |                     | P |   |
|   | * |     facility.                       |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | -   We have no calendar year        |                     |   |   |
|   | * |     deductible.                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | O | -   Be sure to read Section 4,      |                     | O |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | * |     services*, for valuable         |                     | * |   |
|   |   |     information about how cost      |                     |   |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   | * |     Section 9 about coordinating    |                     | * |   |
|   | R |     benefits with other coverage,   |                     | R |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | -   The amounts listed below are    |                     |   |   |
|   | * |     for the charges billed by the   |                     | * |   |
|   | * |     facility (i.e., hospital or     |                     | * |   |
|   | T |     surgical center) or ambulance   |                     | T |   |
|   | * |     service for your surgery or     |                     | * |   |
|   | * |     care. Any costs associated with |                     | * |   |
|   |   |     the professional charge (i.e.,  |                     |   |   |
|   | * |     physicians, etc.) are in        |                     | * |   |
|   | * |     Sections 5(a) or (b).           |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * | -   **YOU MUST GET PRIOR            |                     | * |   |
|   | * |     AUTHORIZATION OF ELECTIVE       |                     | * |   |
|   |   |     HOSPITAL STAYS.** Please refer  |                     |   |   |
|   | * |     to Section 3 to be sure which   |                     | * |   |
|   | * |     services require prior          |                     | * |   |
|   | N |     authorization.                  |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| I |   |                                     |                     |   |   |
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| p |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| p |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| R |   |                                     | \$100 per admission |   |   |
| o |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+

*Inpatient hospital - continued on next page*

+------------------------------------------+---------------------------+
| Inpatient hospital *(continued)*         | You pay                   |
+------------------------------------------+---------------------------+
| -   Medical supplies including oxygen    | \$100 per admission       |
|     and its administration               |                           |
|                                          |                           |
| -   Blood or blood plasma, if not        |                           |
|     donated or replaced                  |                           |
|                                          |                           |
| -   Intravenous injections and solutions |                           |
|                                          |                           |
| -   Take-home items                      |                           |
|                                          |                           |
| -   Medical supplies, appliances,        |                           |
|     medical equipment, and any covered   |                           |
|     items billed by a hospital for use   |                           |
|     at home                              |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Custodial care*                     |                           |
|                                          |                           |
| -   *Non-covered facilities*             |                           |
|                                          |                           |
| -   *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, maternity, and  | \$50 per visit            |
|     other treatment rooms                |                           |
|                                          |                           |
| -   Prescribed drugs and medicines       |                           |
|                                          |                           |
| -   Clinical pathology and laboratory    |                           |
|     services and supplies and x-rays     |                           |
|                                          |                           |
| -   Dressing, splints, casts, and        |                           |
|     sterile tray services                |                           |
|                                          |                           |
| -   Medical supplies including oxygen    |                           |
|                                          |                           |
| -   Blood or blood plasma, if not        |                           |
|     donated or replaced                  |                           |
|                                          |                           |
| -   Pre-surgical testing                 |                           |
|                                          |                           |
| -   Intravenous injections and solutions |                           |
|                                          |                           |
| 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 benefit             | You pay                   |
| s/Skilled nursing care facility benefits |                           |
+------------------------------------------+---------------------------+
| Skilled nursing facility (SNF):          | \$100 per admission       |
|                                          |                           |
| -   Bed, board, and general nursing care |                           |
|                                          |                           |
| -   Prescribed drugs and medicines       |                           |
|                                          |                           |
| -   Clinical pathology and laboratory    |                           |
|     services and supplies and x-rays     |                           |
|                                          |                           |
| -   Dressing, splints, casts, and        |                           |
|     sterile tray services                |                           |
|                                          |                           |
| -   Oxygen and its administration        |                           |
|                                          |                           |
| -   Blood or blood plasma, if not        |                           |
|     donated or replaced                  |                           |
|                                          |                           |
| -   Intravenous injections and solutions |                           |
|                                          |                           |
| Note: Maximum benefit of 100 days per    |                           |
| member per calendar year.                |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Custodial care*                     |                           |
+------------------------------------------+---------------------------+
| ###### Hospice care                      |                           |
+------------------------------------------+---------------------------+
| Supportive and palliative care for       | \$100 per admission       |
| terminally ill members is covered in the |                           |
| home or in a hospice facility. Covered   |                           |
| services include:                        |                           |
|                                          |                           |
| -   Inpatient hospice services           |                           |
|                                          |                           |
| -   Inpatient respite services           |                           |
+------------------------------------------+---------------------------+
| -   Outpatient respite services          | \$5 per visit             |
+------------------------------------------+---------------------------+
| -   Bereavement services                 | \$20 per visit            |
|                                          |                           |
| Note: Limited to five (5) group therapy  |                           |
| sessions or a maximum of \$500,          |                           |
| whichever is less, per event.            |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Independent nursing*                |                           |
|                                          |                           |
| -   *Homemaker services*                 |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Ambulance                         | You pay                   |
+------------------------------------------+---------------------------+
| -   Covered services include ground      | \$50 per trip             |
|     ambulance transportation to the      |                           |
|     nearest appropriate facility         |                           |
+------------------------------------------+---------------------------+
| -   Emergency air ambulance              | 50% of EME                |
+------------------------------------------+---------------------------+
| Note: Ambulance services will be         |                           |
| reviewed on a retrospective basis to     |                           |
| determine medical necessity. The member  |                           |
| will be fully liable for the cost of     |                           |
| ambulance services that are not          |                           |
| medically necessary.                     |                           |
|                                          |                           |
| Note: Non-emergency medically necessary  |                           |
| benefits are payable only upon prior     |                           |
| authorization from the Plan.             |                           |
+------------------------------------------+---------------------------+

## Section 5(d) Emergency services/accidents

+---+---+-------------------------------------+---------------------+---+---+
| # | * | **Here are some important things to |                     | * |   |
| # | * | keep in mind about these            |                     | * |   |
| # | I | benefits:**                         |                     | I |   |
| # | * |                                     |                     | * |   |
| # | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   We have no calendar year        |                     | * |   |
|   | * |     deductible.                     |                     | * |   |
|   | P |                                     |                     | P |   |
|   | * | -   Be sure to read Section 4,      |                     | * |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   |   |     services,* for valuable         |                     |   |   |
|   | * |     information about how cost      |                     | * |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   | O |     Section 9 about coordinating    |                     | O |   |
|   | * |     benefits with other coverage,   |                     | * |   |
|   | * |     including with Medicare.        |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | R |                                     |                     | R |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
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|   | * |                                     |                     | * |   |
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|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
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| a |   |                                     |                     |   |   |
| [ |   |                                     |                     |   |   |
| ] |   |                                     |                     |   |   |
| { |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| _ |   |                                     |                     |   |   |
| _ |   |                                     |                     |   |   |
| R |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| H |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| _ |   |                                     |                     |   |   |
| _ |   |                                     |                     |   |   |
| _ |   |                                     |                     |   |   |
| T |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| 8 |   |                                     |                     |   |   |
| 0 |   |                                     |                     |   |   |
| 5 |   |                                     |                     |   |   |
| 2 |   |                                     |                     |   |   |
| 6 |   |                                     |                     |   |   |
| 5 |   |                                     |                     |   |   |
| 0 |   |                                     |                     |   |   |
| 4 |   |                                     |                     |   |   |
| . |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| } |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$25 per visit plus |   |   |
|   |   |                                     | amount exceeding    |   |   |
|   |   |                                     | EME                 |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| ' |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$20 per visit plus |   |   |
|   |   |                                     | amount exceeding    |   |   |
|   |   |                                     | EME                 |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$50 per visit plus |   |   |
|   |   |                                     | amount exceeding    |   |   |
|   |   |                                     | EME                 |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     | Waived if admitted  |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| [ |   |                                     |                     |   |   |
| ] |   |                                     |                     |   |   |
| { |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| _ |   |                                     |                     |   |   |
| _ |   |                                     |                     |   |   |
| R |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| H |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| _ |   |                                     |                     |   |   |
| _ |   |                                     |                     |   |   |
| _ |   |                                     |                     |   |   |
| T |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| 8 |   |                                     |                     |   |   |
| 0 |   |                                     |                     |   |   |
| 5 |   |                                     |                     |   |   |
| 2 |   |                                     |                     |   |   |
| 6 |   |                                     |                     |   |   |
| 5 |   |                                     |                     |   |   |
| 0 |   |                                     |                     |   |   |
| 5 |   |                                     |                     |   |   |
| . |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| } |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$50 per visit plus |   |   |
|   |   |                                     | amount exceeding    |   |   |
|   |   |                                     | EME                 |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| ' |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$40 per visit plus |   |   |
|   |   |                                     | amount exceeding    |   |   |
|   |   |                                     | EME                 |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$75 per visit plus |   |   |
|   |   |                                     | amount exceeding    |   |   |
|   |   |                                     | EME                 |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     | Waived if admitted  |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges*       |   |   |
| N |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | 50% of EME          |   |   |
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+---+---+-------------------------------------+---------------------+---+---+

## Section 5(e) Mental health and substance abuse benefits

+---+---+-----------------------------------+----------------------+---+---+
|   | * | When you get our approval for     |                      | * |   |
|   | * | services and follow a treatment   |                      | * |   |
|   | I | plan we approve, cost-sharing and |                      | I |   |
|   | * | limitations for Plan mental       |                      | * |   |
|   | * | health and substance abuse        |                      | * |   |
|   |   | benefits will be no greater than  |                      |   |   |
|   | * | for similar benefits for other    |                      | * |   |
|   | * | illnesses and conditions.         |                      | * |   |
|   | M |                                   |                      | M |   |
|   | * | **Here are some important things  |                      | * |   |
|   | * | to keep in mind about these       |                      | * |   |
|   |   | benefits:**                       |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * | -   Please remember that all      |                      | * |   |
|   | P |     benefits are subject to the   |                      | P |   |
|   | * |     definitions, limitations, and |                      | * |   |
|   | * |     exclusions in this brochure   |                      | * |   |
|   |   |     and are payable only when we  |                      |   |   |
|   | * |     determine they are medically  |                      | * |   |
|   | * |     necessary.                    |                      | * |   |
|   | O |                                   |                      | O |   |
|   | * | -   We have no calendar year      |                      | * |   |
|   | * |     deductible.                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * | -   Be sure to read Section 4,    |                      | * |   |
|   | * |     *Your costs for covered       |                      | * |   |
|   | R |     services*, for valuable       |                      | R |   |
|   | * |     information about how cost    |                      | * |   |
|   | * |     sharing works. Also read      |                      | * |   |
|   |   |     Section 9 about coordinating  |                      |   |   |
|   | * |     benefits with other coverage, |                      | * |   |
|   | * |     including with Medicare.      |                      | * |   |
|   | T |                                   |                      | T |   |
|   | * | -   **YOU MUST GET PRIOR          |                      | * |   |
|   | * |     AUTHORIZATION OF THESE        |                      | * |   |
|   |   |     SERVICES.** See the           |                      |   |   |
|   | * |     instructions after the        |                      | * |   |
|   | * |     benefits description below.   |                      | * |   |
|   | A |                                   |                      | A |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | N |                                   |                      | N |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | T |                                   |                      | T |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
+---+---+-----------------------------------+----------------------+---+---+
| B |   |                                   | You pay              |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| f |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| D |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| c |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| M |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| h |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| h |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| A |   |                                   | Your cost sharing    |   |   |
| l |   |                                   | responsibilities are |   |   |
| l |   |                                   | no greater than for  |   |   |
| d |   |                                   | other illnesses or   |   |   |
| i |   |                                   | conditions.          |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$10 per visit       |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$5 per procedure    |   |   |
|   |   |                                   | plus office visit    |   |   |
|   |   |                                   | copayment            |   |   |
|   |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$100 per admission  |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| * |   |                                   | *All charges*        |   |   |
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| a |   |                                   |                      |   |   |
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| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| f |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| v |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| f |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| h |   |                                   |                      |   |   |
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| r |   |                                   |                      |   |   |
| . |   |                                   |                      |   |   |
| * |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+

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

+-----------------------------------------------------------------------+
| Mental health and substance abuse benefits *(continued)*              |
+-----------------------------------------------------------------------+
| **Prior authorization** To be eligible to receive these benefits you  |
| must obtain a treatment plan and follow all of the following network  |
| authorization processes:                                              |
|                                                                       |
| Contacting Behavioral Healthcare Options (BHO) to make arrangements   |
| to authorize medically necessary care. BHO may be contacted at (800)  |
| 873-2246. You may obtain more information on BHO by visiting their    |
| website at                                                            |
| [http://behav                                                         |
| ioralhealthcareoptions.com](http://behavioralhealthcareoptions.com/). |
+-----------------------------------------------------------------------+
| **Limitation** We may limit your benefits if you do not obtain a      |
| treatment plan.                                                       |
+-----------------------------------------------------------------------+

## Section 5(f) Prescription drug benefits

+---+---+---+--------------------------------------------------------+---+---+
|   |   | * | **Here are some important things to keep in mind about | * |   |
|   |   | * | these benefits:**                                      | * |   |
|   |   | I |                                                        | I |   |
|   |   | * | -   We cover prescribed drugs and medications, as      | * |   |
|   |   | * |     described in the chart beginning on page 47.       | * |   |
|   |   |   |                                                        |   |   |
|   |   | * | -   All benefits are subject to the definitions,       | * |   |
|   |   | * |     limitations and exclusions in this brochure and    | * |   |
|   |   | M |     are payable only when we determine they are        | M |   |
|   |   | * |     medically necessary.                               | * |   |
|   |   | * |                                                        | * |   |
|   |   |   | -   We have no calendar year deductible.               |   |   |
|   |   | * |                                                        | * |   |
|   |   | * | -   Be sure to read Section 4, *Your costs for covered | * |   |
|   |   | P |     services,* for valuable information about how cost | P |   |
|   |   | * |     sharing works. Also read Section 9 about           | * |   |
|   |   | * |     coordinating benefits with other coverage,         | * |   |
|   |   |   |     including with Medicare.                           |   |   |
|   |   | * |                                                        | * |   |
|   |   | * |                                                        | * |   |
|   |   | O |                                                        | O |   |
|   |   | * |                                                        | * |   |
|   |   | * |                                                        | * |   |
|   |   |   |                                                        |   |   |
|   |   | * |                                                        | * |   |
|   |   | * |                                                        | * |   |
|   |   | R |                                                        | R |   |
|   |   | * |                                                        | * |   |
|   |   | * |                                                        | * |   |
|   |   |   |                                                        |   |   |
|   |   | * |                                                        | * |   |
|   |   | * |                                                        | * |   |
|   |   | T |                                                        | T |   |
|   |   | * |                                                        | * |   |
|   |   | * |                                                        | * |   |
|   |   |   |                                                        |   |   |
|   |   | * |                                                        | * |   |
|   |   | * |                                                        | * |   |
|   |   | A |                                                        | A |   |
|   |   | * |                                                        | * |   |
|   |   | * |                                                        | * |   |
|   |   |   |                                                        |   |   |
|   |   | * |                                                        | * |   |
|   |   | * |                                                        | * |   |
|   |   | N |                                                        | N |   |
|   |   | * |                                                        | * |   |
|   |   | * |                                                        | * |   |
|   |   |   |                                                        |   |   |
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|   |   | * |                                                        | * |   |
|   |   | T |                                                        | T |   |
|   |   | * |                                                        | * |   |
|   |   | * |                                                        | * |   |
+---+---+---+--------------------------------------------------------+---+---+
|   | * |   |                                                        |   |   |
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| 1 |   |   |                                                        |   |   |
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| 4 |   |   |                                                        |   |   |
| - |   |   |                                                        |   |   |
| 5 |   |   |                                                        |   |   |
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| 5 |   |   |                                                        |   |   |
+---+---+---+--------------------------------------------------------+---+---+

*Prescription drug benefits begin on the next page*

+------------------------------------------+---------------------------+
| **Benefit Description**                  | **You pay**               |
+------------------------------------------+---------------------------+
| ###### Covered medications and supplies  |                           |
+------------------------------------------+---------------------------+
| We cover the following medications and   | \$10 per generic          |
| supplies prescribed by a physician and   | prescription              |
| obtained from a Plan pharmacy or through |                           |
| our mail order program:                  | \$25 per brand-name       |
|                                          | prescription              |
| -   Drugs and medicines that by Federal  |                           |
|     law of the United States require a   | \$40 per non-formulary    |
|     physician's prescription for their   | prescription              |
|     purchase, except those listed as     |                           |
|     *Not covered.*                       | Note: You pay two         |
|                                          | applicable copayments for |
| -   Insulin (See *Educational classes    | a 90-day therapeutic      |
|     and programs (Section 5(a))* for     | supply of maintenance     |
|     coverage of diabetes supplies)       | medication obtained       |
|                                          | through our mail order    |
| -   Drugs for sexual dysfunction. Sexual | program.                  |
|     dysfunction drugs have specific      |                           |
|     dispensing limitations and require   |                           |
|     prior authorization by the Plan.     |                           |
|     Contact the Plan for details.        |                           |
|                                          |                           |
| -   Oral contraceptive drugs             |                           |
|                                          |                           |
| -   Smoking cessation drugs (e.g.,       |                           |
|     nicotine patches)                    |                           |
|                                          |                           |
| -   Growth hormone                       |                           |
|                                          |                           |
| -   Orphan drugs                         |                           |
|                                          |                           |
| -   Self-injectable drugs                |                           |
|                                          |                           |
| -   Pediatric and prenatal vitamins      |                           |
|                                          |                           |
| Note: A "self-injectable" is to be       |                           |
| administered subcutaneously or           |                           |
| intramuscularly and does not require     |                           |
| administration by a licensed             |                           |
| practitioner.                            |                           |
+------------------------------------------+---------------------------+
| -   Compounds, when medically necessary  | \$40                      |
|     and prior authorized by the Plan     |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges*             |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes*                            |                           |
|                                          |                           |
| -   *Nonprescription medicines (except   |                           |
|     insulin)*                            |                           |
|                                          |                           |
| -   *Anorexic agents*                    |                           |
|                                          |                           |
| -   *Injectable and oral drugs to treat  |                           |
|     fertility*                           |                           |
|                                          |                           |
| -   *Drugs to enhance athletic           |                           |
|     performance*                         |                           |
|                                          |                           |
| -   *Drugs obtained at a non-Plan        |                           |
|     pharmacy, except for out-of-area     |                           |
|     emergencies*                         |                           |
|                                          |                           |
| -   *Drugs and medicines approved by the |                           |
|     FDA for experimental or              |                           |
|     investigational use except when      |                           |
|     prescribed for the treatment of      |                           |
|     cancer or chronic fatigue syndrome*  |                           |
+------------------------------------------+---------------------------+

## Section 5(g) Special features

+----------------------+-----------------------------------------------+
| Feature              | Description                                   |
+----------------------+-----------------------------------------------+
| ##### Flex           | Under the flexible benefits option, we        |
| ible benefits option | determine the most effective way to provide   |
|                      | services.                                     |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| ##### Telephone      | It doesn\'t matter if it\'s day or night, a   |
| Advice Nurse Service | holiday or weekend, our free Telephone Advice |
|                      | Nurse Service is open to provide helpful      |
|                      | advice on simple medical concerns. Depending  |
|                      | on your situation, our Telephone Advice Nurse |
|                      | may help you decide whether to seek urgent    |
|                      | care or wait until the next day to see your   |
|                      | primary care provider. When you have health   |
|                      | questions or concerns, call our Telephone     |
|                      | Advice Nurse Service at (702) 242-7330 or     |
|                      | (800) 288-2264                                |
+----------------------+-----------------------------------------------+
| ####                 | We have a TTY/TDD number for use by           |
| # Services for deaf  | hearing-impaired members. The TTY/TDD number  |
| and hearing impaired | is (702) 242-9214 or (800) 349-3538.          |
+----------------------+-----------------------------------------------+
| ###                  | We offer numerous preventive health           |
| ## Preventive Health | management programs to assist members with    |
|                      | early detection and prevention of serious     |
| ####                 | illnesses. These programs may include member  |
| # Disease Management | notifications for childhood immunizations,    |
|                      | annual reminders for breast and cervical      |
|                      | cancer screenings, educational classes or     |
|                      | consults for nutrition and fitness, smoking   |
|                      | cessation, prenatal care, stress management,  |
|                      | weight management for adults and children,    |
|                      | and women's health issues.                    |
|                      |                                               |
|                      | We also provide programs to assist those      |
|                      | members with chronic conditions to better     |
|                      | manage their health. We offer disease         |
|                      | management programs for childhood asthma,     |
|                      | congestive heart failure, diabetes, and       |
|                      | chronic obstructive pulmonary disease. In     |
|                      | addition, we offer education classes and      |
|                      | consults to help members with arthritis, back |
|                      | care, carpal tunnel syndrome, hypertension,   |
|                      | and cholesterol reduction.                    |
+----------------------+-----------------------------------------------+

*Special features -- continued on next page*

+----------------------+-----------------------------------------------+
| Special features     |                                               |
| *(continued)*        |                                               |
+----------------------+-----------------------------------------------+
| Feature              | Description                                   |
+----------------------+-----------------------------------------------+
| #####                | Online Member Center is available 24 hours a  |
| [[]{#__RefHeading___ | day                                           |
| Toc81977154 .anchor} |                                               |
| HPN@YourService](mai | Day, night and even on holidays, you may      |
| lto:HPN@YourService) | access information about your benefits        |
|                      | through the Health Plan of Nevada online      |
|                      | member center. Take advantage of these        |
|                      | convenient service features:                  |
|                      |                                               |
|                      | -   Change your address                       |
|                      |                                               |
|                      | -   Request new ID cards                      |
|                      |                                               |
|                      | -   Verify your coverage for pharmacy         |
|                      |     services                                  |
|                      |                                               |
|                      | -   Check your copayment amounts for medical  |
|                      |     services                                  |
|                      |                                               |
|                      | -   Review the status of a claim              |
|                      |                                               |
|                      | -   Find out who is on record as your primary |
|                      |     care provider (PCP)                       |
|                      |                                               |
|                      | -   Check status of a prior authorization     |
|                      |     request                                   |
|                      |                                               |
|                      | Simply visit us at                            |
|                      | [http://fehbp.healthplanofnevad               |
|                      | a.com](http://fehbp.healthplanofnevada.com/). |
|                      | First time visitors will need to register for |
|                      | a user ID and password.                       |
+----------------------+-----------------------------------------------+

## Section 5(h) Dental benefits

+---+---+------------------------------------+---------------------+---+---+
|   | * | **Here are some important things   |                     | * |   |
|   | * | to keep in mind about these        |                     | * |   |
|   | I | benefits:**                        |                     | I |   |
|   | * |                                    |                     | * |   |
|   | * | -   Please remember that all       |                     | * |   |
|   |   |     benefits are subject to the    |                     |   |   |
|   | * |     definitions, limitations, and  |                     | * |   |
|   | * |     exclusions in this brochure    |                     | * |   |
|   | M |     and are payable only when we   |                     | M |   |
|   | * |     determine they are medically   |                     | * |   |
|   | * |     necessary.                     |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   Plan dentists must provide or  |                     | * |   |
|   | * |     arrange your care.             |                     | * |   |
|   | P |                                    |                     | P |   |
|   | * | -   We have no calendar year       |                     | * |   |
|   | * |     deductible.                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   We cover hospitalization for   |                     | * |   |
|   | * |     dental procedures only when a  |                     | * |   |
|   | O |     non-dental physical impairment |                     | O |   |
|   | * |     exists which makes             |                     | * |   |
|   | * |     hospitalization necessary to   |                     | * |   |
|   |   |     safeguard the health of the    |                     |   |   |
|   | * |     patient. See Section 5(c) for  |                     | * |   |
|   | * |     inpatient hospital benefits.   |                     | * |   |
|   | R |     We do not cover the dental     |                     | R |   |
|   | * |     procedure unless it is         |                     | * |   |
|   | * |     described below.               |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   Be sure to read Section 4,     |                     | * |   |
|   | * |     *Your costs for covered        |                     | * |   |
|   | T |     services,* for valuable        |                     | T |   |
|   | * |     information about how cost     |                     | * |   |
|   | * |     sharing works. Also read       |                     | * |   |
|   |   |     Section 9 about coordinating   |                     |   |   |
|   | * |     benefits with other coverage,  |                     | * |   |
|   | * |     including with Medicare.       |                     | * |   |
|   | A |                                    |                     | A |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | N |                                    |                     | N |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | T |                                    |                     | T |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
+===+===+====================================+=====================+===+===+
| # |   |                                    | You pay             |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
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+---+---+------------------------------------+---------------------+---+---+
| W |   |                                    | \$10 per office     |   |   |
| e |   |                                    | visit               |   |   |
| c |   |                                    |                     |   |   |
| o |   |                                    | \$50 per outpatient |   |   |
| v |   |                                    | facility            |   |   |
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+---+---+------------------------------------+---------------------+---+---+
| - |   |                                    | Nothing             |   |   |
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| d |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
| w |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
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| t |   |                                    |                     |   |   |
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| r |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| z |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
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| l |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| D |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
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| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| W |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
| . |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+

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

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

-   Health Plan of Nevada is pleased to offer a Supplemental Dental
    program to FEHB members with dentists who have agreed to participate
    in our dental program and provide dental care services to members.
    You may obtain information regarding this program by contacting us,
    or by obtaining an enrollment packet during open season. Procedures
    not listed on the benefit schedule are not covered. [You are
    required to re-enroll into the supplemental dental plan every year
    during the open enrollment period]{.underline}. Please refer to the
    supplemental dental information provided by the plan for further
    information on this program, including premiums, what is covered
    under the supplemental program and limitations and exclusions.

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```
-   If you are enrolled in this Plan through FEHB, have Medicare Part A
    coverage and have purchased Part B coverage, you may also enroll in
    the Plan's Senior Dimensions Medicare Advantage program. The Senior
    Dimensions program provides all Medicare covered Part A and Part B
    benefits, as well as some benefits not covered by Medicare. It is an
    arrangement between Medicare and this Plan in which Medicare pays a
    specific amount to this plan for each Medicare beneficiary who
    enrolls in the Plan.

> Like your FEHB enrollment in this Plan, you are required to obtain
> your services from this Plan's doctors and providers, except for
> emergencies and out-of-area urgent care. The rules regarding
> enrollment and disenrollment are fully explained in the Plan's
> Evidence of Coverage. For a copy of these rules and or more
> information, please contact Member Services at (702) 242-7300 or (800)
> 777-1840.
>
> If you choose to enroll in Senior Dimensions, you will be responsible
> for paying the Medicare Part B premium. You must complete an
> additional enrollment form in order to be enrolled in Senior
> Dimensions.
>
> If you are Medicare eligible and are interested in enrolling in a
> Medicare Advantage program sponsored by this Plan without dropping
> your enrollment in this Plan's FEHB, call (702) 242-7300 or (800)
> 777-1840 for information on the benefits available under the Medicare
> Advantage program.

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

The exclusions in this section apply to all benefits. **Although we may
list a specific service as a benefit, we will not cover it unless your
Plan doctor determines it is medically necessary to prevent, diagnose,
or treat your illness, disease, injury, or condition and we agree, as
discussed under** *What Services Require Our Prior Approval* **on page
14.**

We do not cover the following:

-   Care by non-Plan providers except for authorized referrals or
    emergencies. See *Emergency benefits 5(d)*;

-   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 except clinical trials for studies for the treatment of
    cancer or chronic fatigue syndrome conducted in the state of Nevada.

-   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;

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-   Services, drugs, or supplies you receive from a provider or facility
    barred from the participation in 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      | In most cases, providers and facilities file      |
| hospital         | claims for you. Physicians must file on the form  |
| benefits         | HCFA-1500, Health Insurance Claim Form. Your      |
|                  | facility will file on the UB-92 form. For claims  |
|                  | questions and assistance, call us at (702)        |
|                  | 242-7300 or (800) 777-1840.                       |
|                  |                                                   |
|                  | When you must file a claim -- such as for         |
|                  | services you receive outside the Plan's service   |
|                  | area -- submit it on the HCFA-1500 or a claim     |
|                  | form that includes the information shown below.   |
|                  | Bills and receipts should be itemized and show:   |
|                  |                                                   |
|                  | -   Covered member's name and ID number;          |
|                  |                                                   |
|                  | -   Name and address of the physician or facility |
|                  |     that provided the service or supply;          |
|                  |                                                   |
|                  | -   Dates you received the services or supplies;  |
|                  |                                                   |
|                  | -   Diagnosis;                                    |
|                  |                                                   |
|                  | -   Type of each service or supply;               |
|                  |                                                   |
|                  | -   The charge for each service or supply;        |
|                  |                                                   |
|                  | -   A copy of the explanation of benefits,        |
|                  |     payments, or denial from any primary payer -- |
|                  |     such as the Medicare Summary Notice (MSN);    |
|                  |     and                                           |
|                  |                                                   |
|                  | -   Receipts, if you paid for your services.      |
|                  |                                                   |
|                  | **Submit your claims to:**                        |
|                  |                                                   |
|                  | **Health Plan of Nevada**                         |
|                  |                                                   |
|                  | **Attn: Claims**                                  |
|                  |                                                   |
|                  | **P.O. Box 15645**                                |
|                  |                                                   |
|                  | **Las Vegas, NV 89114-5645**                      |
+------------------+---------------------------------------------------+
| Prescription     | To submit claims for drugs, contact the plan at   |
| drugs            | (702) 242-7300 or (800) 777-1840. We will assist  |
|                  | you in completing a Direct Member Reimbursement   |
|                  | form and help you process your claim.             |
+------------------+---------------------------------------------------+
| Deadline for     | Send us all of the documents for your claim as    |
| filing your      | soon as possible. You must submit the claim by    |
| claim            | 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     | Please reply promptly when we ask for additional  |
| more information | 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 prior
authorization:

+----+-----------------------------------------------------------------+
| St | Description                                                     |
| ep |                                                                 |
+----+-----------------------------------------------------------------+
| 1  | Ask us in writing to reconsider our initial decision. You must: |
|    |                                                                 |
|    | a)  Write to us within 6 months from the date of our decision;  |
|    |     and                                                         |
|    |                                                                 |
|    | b)  Send your request to us at: P.O. Box 15645, Las Vegas, NV   |
|    |     89114-5645; 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.           |
+----+-----------------------------------------------------------------+
| 2  | We have 30 days from the date we receive your request to:       |
|    |                                                                 |
|    | 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.                                                     |
+----+-----------------------------------------------------------------+
| 3  | You or your provider must send the information so that we       |
|    | receive it within 60 days of our request. We will then decide   |
|    | 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.                         |
+----+-----------------------------------------------------------------+
| 4  | If you do not agree with our decision, you may ask OPM to       |
|    | review it.                                                      |
+----+-----------------------------------------------------------------+
|    | 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.                          |
+----+-----------------------------------------------------------------+
| T  |                                                                 |
| he |                                                                 |
| di |                                                                 |
| sp |                                                                 |
| ut |                                                                 |
| ed |                                                                 |
| cl |                                                                 |
| ai |                                                                 |
| ms |                                                                 |
| p  |                                                                 |
| ro |                                                                 |
| ce |                                                                 |
| ss |                                                                 |
| *  |                                                                 |
| (c |                                                                 |
| on |                                                                 |
| ti |                                                                 |
| nu |                                                                 |
| ed |                                                                 |
| )* |                                                                 |
+----+-----------------------------------------------------------------+
|    | 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    |
| *5 | information it collects from you and us to decide whether our   |
| ** | 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 prior        |
|    | authorization or prior approval. This is the only deadline that |
|    | may not be extended.                                            |
|    |                                                                 |
|    | OPM may disclose the information it collects during the review  |
|    | process to support their disputed claim decision. This          |
|    | information will become part of the court record.               |
+----+-----------------------------------------------------------------+
|    | You may not sue until you have completed the disputed claims    |
|    | process. Further, Federal law governs your lawsuit, benefits,   |
|    | and payment of benefits. The Federal court will base its review |
|    | on the record that was before OPM when OPM decided to uphold or |
|    | overturn our decision. You may recover only the amount of       |
|    | benefits in dispute.                                            |
+----+-----------------------------------------------------------------+

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

a)  We haven't responded yet to your initial request for care or prior
    authorization, then call us at (702) 242-7300 or (800) 777-1840 and
    we will expedite our review; or

b)  We denied your initial request for care or prior authorization,
    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

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

+------------------+---------------------------------------------------+
| ### Whe          | You must tell us if you or a covered family       |
| n you have other | member have coverage under another group health   |
|  health coverage | 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.                               |
+------------------+---------------------------------------------------+
| ### W            | Medicare is a Health Insurance Program for:       |
| hat is Medicare? |                                                   |
|                  | -   People 65 years of age or older.              |
|                  |                                                   |
|                  | -   Some people with disabilities under 65 years  |
|                  |     of age.                                       |
|                  |                                                   |
|                  | -   People with End-Stage Renal Disease           |
|                  |     (permanent kidney failure requiring dialysis  |
|                  |     or a transplant).                             |
|                  |                                                   |
|                  | Medicare has two parts:                           |
|                  |                                                   |
|                  | -   Part A (Hospital Insurance). Most people do   |
|                  |     not have to pay for Part A. If you or your    |
|                  |     spouse worked for at least 10 years in        |
|                  |     Medicare-covered employment, you should be    |
|                  |     able to qualify for premium-free Part A       |
|                  |     insurance. (Someone who was a Federal         |
|                  |     employee on January 1, 1983 or since          |
|                  |     automatically qualifies.) Otherwise, if you   |
|                  |     are age 65 or older, you may be able to buy   |
|                  |     it. Contact 1-800-MEDICARE for more           |
|                  |     information.                                  |
|                  |                                                   |
|                  | -   Part B (Medical Insurance). Most people pay   |
|                  |     monthly for Part B. Generally, Part B         |
|                  |     premiums are withheld from your monthly       |
|                  |     Social Security check or your retirement      |
|                  |     check.                                        |
+------------------+---------------------------------------------------+
| #                | The decision to enroll in Medicare is yours. We   |
| ### Should I enr | encourage you to apply for Medicare benefits 3    |
| oll in Medicare? | 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 |
|                  | Advantage 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 (Original Medicare) is |
| ## The Original  | available everywhere in the United States. It is  |
| Medicare Plan (P | the way everyone used to get Medicare benefits    |
| art A or Part B) | and is the way most people get their Medicare     |
|                  | Part A and Part B benefits now. You may go to any |
|                  | doctor, specialist, or hospital that accepts      |
|                  | Medicare. The Original Medicare Plan pays its     |
|                  | share and you pay your share. Some things are not |
|                  | covered under Original Medicare, like             |
|                  | prescription drugs.                               |
|                  |                                                   |
|                  | When you are enrolled in Original Medicare along  |
|                  | with this Plan, you still need to follow the      |
|                  | rules in this brochure for us to cover your care. |
+------------------+---------------------------------------------------+
|                  | **Claims process when you have the Original       |
|                  | Medicare Plan** -- You probably will never have   |
|                  | to file a claim form when you have both our Plan  |
|                  | and the Original Medicare Plan.                   |
|                  |                                                   |
|                  | -   When we are the primary payer, we process the |
|                  |     claim first.                                  |
|                  |                                                   |
|                  | -   When Original Medicare is the primary payer,  |
|                  |     Medicare processes your claim first. In most  |
|                  |     cases, your claim will be coordinated         |
|                  |     automatically and we will then provide        |
|                  |     secondary benefits for covered charges. You   |
|                  |     will not need to do anything. To find out if  |
|                  |     you need to do something to file your claim,  |
|                  |     call us at (702) 242-7300 or (800) 777-1840.  |
|                  |     You may also contact us by fax at (702)       |
|                  |     242-9350 or see our Web site at               |
|                  |     [http://fe                                    |
|                  | hbp.healthplanofnevada.com](http://www.xxx.xxx/). |
|                  |                                                   |
|                  | **We do not waive any costs if the Original       |
|                  | Medicare Plan is your primary payer**             |
|                  |                                                   |
|                  | *(Primary Payer chart is on next page)*           |
+------------------+---------------------------------------------------+

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

+----------------------------------------------------+-------+--------+
| > **Primary Payer Chart**                          |       |        |
+----------------------------------------------------+-------+--------+
| **A. When you - or your covered spouse - are age   | **The |        |
| 65 or over and have Medicare and you...**          | pr    |        |
|                                                    | imary |        |
|                                                    | payer |        |
|                                                    | for   |        |
|                                                    | the   |        |
|                                                    | indiv |        |
|                                                    | idual |        |
|                                                    | with  |        |
|                                                    | Med   |        |
|                                                    | icare |        |
|                                                    | is    |        |
|                                                    | ...** |        |
+----------------------------------------------------+-------+--------+
|                                                    | **    | **This |
|                                                    | Medic | Plan** |
|                                                    | are** |        |
+----------------------------------------------------+-------+--------+
| 1)  Have FEHB coverage on your own as an active    |       |        |
|     employee or through your spouse who is an      |       |        |
|     active employee                                |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Have FEHB coverage on your own as an annuitant |       |        |
|     or through your spouse who is an annuitant     |       |        |
+----------------------------------------------------+-------+--------+
| 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) and you are not covered      |       |        |
|     under FEHB through your spouse under #1 above  |       |        |
+----------------------------------------------------+-------+--------+
| 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) and |       |        |
|     you are not covered under FEHB through your    |       |        |
|     spouse under #1 above                          |       |        |
+----------------------------------------------------+-------+--------+
| 6)  Are enrolled in Part B only, regardless of     | for   | for    |
|     your employment status                         | Part  | other  |
|                                                    | B     | se     |
|                                                    | ser   | rvices |
|                                                    | vices |        |
+----------------------------------------------------+-------+--------+
| 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...**      |       |        |
+----------------------------------------------------+-------+--------+
| 1)  Have Medicare solely based on end stage renal  |       |        |
|     disease (ESRD) and...                          |       |        |
|                                                    |       |        |
| -   It is within the first 30 months of            |       |        |
|     eligibility for or entitlement to Medicare due |       |        |
|     to ESRD (30-month coordination period)         |       |        |
+----------------------------------------------------+-------+--------+
| -   It is beyond the 30-month coordination period  |       |        |
|     and you or a family member are still entitled  |       |        |
|     to Medicare due to ESRD                        |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Become eligible for Medicare due to ESRD while |       | for    |
|     already a Medicare beneficiary and**...**      |       | 30     |
|                                                    |       | -month |
| -   This Plan was the primary payer before         |       | coordi |
|     eligibility due to ESRD                        |       | nation |
|                                                    |       | period |
+----------------------------------------------------+-------+--------+
| -   Medicare was the primary payer before          |       |        |
|     eligibility due to ESRD                        |       |        |
+----------------------------------------------------+-------+--------+
| **C. When either you or a covered family member    |       |        |
| are eligible for Medicare solely due to disability |       |        |
| and you...**                                       |       |        |
+----------------------------------------------------+-------+--------+
| 1)  Have FEHB coverage on your own as an active    |       |        |
|     employee or through a family member who is an  |       |        |
|     active employee                                |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Have FEHB coverage on your own as an annuitant |       | []{    |
|     or through a family member who is an annuitant |       | .mark} |
+----------------------------------------------------+-------+--------+
| **D. When you are covered under the FEHB Spouse    |       |        |
| Equity provision as a former spouse**              |       |        |
+----------------------------------------------------+-------+--------+

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

+--------------------+-------------------------------------------------+
| ####               | If you are eligible for Medicare, you may       |
| Medicare Advantage | choose to enroll in and get your Medicare       |
|                    | benefits from a Medicare Advantage plan. These  |
|                    | are private health care choices (like HMOs) in  |
|                    | some areas of the country. In most Medicare     |
|                    | Advantage plans, you can only go to doctors,    |
|                    | specialists, or hospitals that are part of the  |
|                    | plan. Medicare Advantage plans provide all the  |
|                    | benefits that Original Medicare covers. Some    |
|                    | cover extras, like prescription drugs. To learn |
|                    | more about enrolling in a Medicare Advantage    |
|                    | plan, contact Medicare at 1-800-MEDICARE        |
|                    | (1-800-633-4227) or at                          |
|                    | [www.medicare.gov](http://www.medicare.gov/).   |
|                    |                                                 |
|                    | If you enroll in a Medicare Advantage plan, the |
|                    | following options are available to you:         |
|                    |                                                 |
|                    | **This Plan and our Medicare Advantage:** You   |
|                    | may enroll in our Medicare Advantage plan and   |
|                    | also remain enrolled in our FEHB plan. If you   |
|                    | are a FEHB annuitant and enrolled in our        |
|                    | Medicare Advantage plan, we waive the           |
|                    | copayments for your FEHB coverage. If you are   |
|                    | an active FEHB employee and enrolled in our     |
|                    | Medicare Advantage plan, we do not waive cost   |
|                    | sharing for your FEHB coverage.                 |
|                    |                                                 |
|                    | **This Plan and another plan's Medicare         |
|                    | Advantage plan:** You may enroll in another     |
|                    | plan's Medicare Advantage plan and also remain  |
|                    | enrolled in our FEHB plan. We will still        |
|                    | provide benefits when your Medicare Advantage   |
|                    | plan is primary, even out of the Medicare       |
|                    | Advantage 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 Advantage plan,     |
|                    | tell us. We will need to know whether you are   |
|                    | in the Original Medicare Plan or in a Medicare  |
|                    | Advantage plan so we can correctly coordinate   |
|                    | benefits with Medicare.                         |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in a        |
|                    | Medicare Advantage plan:** If you are an        |
|                    | annuitant or former spouse, you can suspend     |
|                    | your FEHB coverage to enroll in a Medicare      |
|                    | Advantage plan, eliminating your FEHB premium.  |
|                    | (OPM does not contribute to your Medicare       |
|                    | Advantage 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 Advantage plan's service area.     |
+--------------------+-------------------------------------------------+
| ### T              | TRICARE is the health care program for eligible |
| RICARE and CHAMPVA | 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.                                        |
+--------------------+-------------------------------------------------+

+--------------------+-------------------------------------------------+
| ### Wor            | We do not cover services that:                  |
| kers' Compensation |                                                 |
|                    | -   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.                                           |
+--------------------+-------------------------------------------------+
| ### 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 o         | We do not cover services and supplies when a    |
| ther Government ag | local, State, or Federal government agency      |
| encies are respons | directly or indirectly pays for them.           |
| ible for your care |                                                 |
+--------------------+-------------------------------------------------+
| ### When           | When you receive money to compensate you for    |
|  others are respon | medical or hospital care for injuries or        |
| sible for injuries | illness caused by another person, you must      |
|                    | reimburse us for any expenses we paid. However, |
|                    | we will cover the cost of treatment that        |
|                    | exceeds the amount you received in the          |
|                    | settlement.                                     |
|                    |                                                 |
|                    | If you do not seek damages you must agree to    |
|                    | let us try. This is called subrogation. If you  |
|                    | need more information, contact us for our       |
|                    | subrogation procedures.                         |
+--------------------+-------------------------------------------------+

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

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

  Coinsurance         Coinsurance is the percentage of our allowance that
                      you must pay for your care. See page 15.

  Copayment           A copayment is a fixed amount of money you pay when
                      you receive covered services. See page 15.

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

  Custodial care      Care that is designed essentially to assist
                      individuals in meeting activities of daily living.
                      These include personal care services (help in
                      walking and getting in or out of bed; assistance in
                      bathing, dressing, feeding, and using the toilet;
                      preparation of special diets; and supervision over
                      medication which can usually be self-administered)
                      that do not require the continuing attention of
                      trained medical or paramedical personnel. Custodial
                      care that lasts 90 days or more is sometimes known
                      as Long term care.

  Eligible Medical    Charges up to the Plan reimbursement schedule
  Expense (EME)       amount, incurred by you while covered under this
                      Plan for covered services. Plan providers have
                      agreed to accept the Plan\'s reimbursement schedule
                      amount as payment in full for covered services,
                      plus your payment of any applicable copayment.
                      Non-plan providers have not. If you use the
                      services of non-plan providers, you will receive no
                      benefit payments or reimbursement for charges for
                      the service, except in the case of emergency
                      services, urgently needed services, or other
                      covered services provided by a non-plan provider
                      that are prior authorized by the Plan. In no event
                      will the Plan pay more than the applicable Plan
                      reimbursement schedule amount for such services.

  Experimental or     This plan regularly evaluates for possible coverage
  investigational     new medical technologies and new applications of
  services            existing technologies. New technologies may include
                      medical procedures, drugs and devices. The
                      evaluation process includes a review of information
                      on the proposed service from appropriate government
                      regulatory bodies as well as from published
                      scientific evidence.

  Medical necessity   Medical necessity (also "Medically Necessary")
                      means a service is needed to improve a specific
                      health condition or to preserve your health.
                      Medical necessity is present when the Plan
                      determines that the care requested is: consistent
                      with the diagnosis and treatment of your illness or
                      injury; the most appropriate level of service which
                      can be safely provided to you; and, not provided
                      solely for your convenience or that of your
                      provider or hospital. When applied to inpatient
                      services, Medically Necessary further means that
                      your condition requires treatment in a hospital
                      rather than any other setting. Services and
                      accommodations are not automatically considered to
                      be Medically Necessary because a physician
                      prescribes them.

  Us/We               Us and We refer to Health Plan of Nevada.

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

# Section 11. FEHB Facts

### Coverage information

+------------------+---------------------------------------------------+
| #### No p        | We will not refuse to cover the treatment of a    |
| re-existing cond | condition you had before you enrolled in this     |
| ition limitation | Plan solely because you had the condition before  |
|                  | you enrolled.                                     |
+------------------+---------------------------------------------------+
| #### W           | See                                               |
| here you can get | [www.opm.gov/insure](http://www.opm.gov/insure).  |
|  information abo | Also, your employing or retirement office can     |
| ut enrolling in  | answer your questions, and give you a *Guide to   |
| the FEHB Program | Federal Employees Health Benefits Plans,*         |
|                  | brochures for other plans, and other materials    |
|                  | you need to make an informed decision about your  |
|                  | FEHB coverage. These materials tell you:          |
|                  |                                                   |
|                  | -   When you may change your enrollment;          |
|                  |                                                   |
|                  | -   How you can cover your family members;        |
|                  |                                                   |
|                  | -   What happens when you transfer to another     |
|                  |     Federal agency, go on leave without pay,      |
|                  |     enter military service, or retire;            |
|                  |                                                   |
|                  | -   When your enrollment ends; and                |
|                  |                                                   |
|                  | -   When the next open season for enrollment      |
|                  |     begins.                                       |
|                  |                                                   |
|                  | We don't determine who is eligible for coverage   |
|                  | and, in most cases, cannot change your enrollment |
|                  | status without information from your employing or |
|                  | retirement office.                                |
+------------------+---------------------------------------------------+
| #### Typ         | Self Only coverage is for you alone. Self and     |
| es of coverage a | Family coverage is for you, your spouse, and your |
| vailable for you | unmarried dependent children under age 22,        |
|  and your family | 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 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.                                             |
+------------------+---------------------------------------------------+
| #### Child       | OPM has implemented the Federal Employees Health  |
| ren's Equity Act | Benefits Children's Equity Act of 2000. This law  |
|                  | mandates that you be enrolled for Self and Family |
|                  | coverage in the 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.                                      |
+------------------+---------------------------------------------------+
| ####             | The benefits in this brochure are effective       |
| When benefits an | January 1. If you joined this Plan during Open    |
| d premiums start | 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 2005 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 2004 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, you can usually stay in the FEHB |
|  When you retire | 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 FE     | You will receive an additional 31 days of         |
| HB coverage ends | coverage, for no additional premium, when:        |
|                  |                                                   |
|                  | -   Your enrollment ends, unless you cancel your  |
|                  |     enrollment, or                                |
|                  |                                                   |
|                  | -   You are a family member no longer eligible    |
|                  |     for coverage.                                 |
|                  |                                                   |
|                  | You may be eligible for spouse equity coverage or |
|                  | Temporary Continuation of Coverage (TCC), or a    |
|                  | conversion policy (a non-FEHB individual policy.) |
+------------------+---------------------------------------------------+
| #### Spouse      | If you are divorced from a Federal employee or    |
|  equity coverage | annuitant, you may not continue to get benefits   |
|                  | under your former spouse's enrollment. This is    |
|                  | the case even when the court has ordered your     |
|                  | former spouse to provide 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 Web site,                              |
|                  | [www.opm.gov/insure](http://www.opm.gov/insure).  |
+------------------+---------------------------------------------------+
| #### Temporar    | If you leave Federal service, or if you lose      |
| y Continuation o | coverage because you no longer qualify as a       |
| f Coverage (TCC) | 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 Federal job, if you are a covered       |
|                  | dependent child and you turn 22 or marry, etc.    |
|                  |                                                   |
|                  | You may not elect TCC if you are fired from your  |
|                  | Federal job due to gross misconduct.              |
|                  |                                                   |
|                  | **Enrolling in TCC.** Get the RI 79-27, which     |
|                  | describes TCC, and the RI 70-5, the *Guide to     |
|                  | Federal Employees Health Benefits Plans for       |
|                  | Temporary Continuation of Coverage and Former     |
|                  | Spouse Enrollees,* from your employing or         |
|                  | retirement office or from                         |
|                  | [www.opm.gov/insure](http://www.opm/gov/insure).  |
|                  | It explains what you have to do to enroll.        |
+------------------+---------------------------------------------------+
| #### C           | You may convert to a non-FEHB individual policy   |
| onverting to ind | if:                                               |
| ividual coverage |                                                   |
|                  | -   Your coverage under TCC or the spouse equity  |
|                  |     law ends (If you canceled your coverage or    |
|                  |     did not pay your premium, you cannot          |
|                  |     convert);                                     |
|                  |                                                   |
|                  | -   You decided not to receive coverage under TCC |
|                  |     or the spouse equity law; or                  |
|                  |                                                   |
|                  | -   You are not eligible for coverage under TCC   |
|                  |     or the spouse equity law.                     |
|                  |                                                   |
|                  | If you leave Federal service, your employing      |
|                  | office will notify you of your right to convert.  |
|                  | You must apply in writing to us within 31 days    |
|                  | after you receive this notice. However, if you    |
|                  | are a family member who is losing coverage, the   |
|                  | employing or retirement office will **not**       |
|                  | notify you. You must apply in writing to us       |
|                  | within 31 days after you are no longer eligible   |
|                  | for coverage.                                     |
|                  |                                                   |
|                  | Your benefits and rates will differ from those    |
|                  | under the FEHB Program; however, you will not     |
|                  | have to answer questions about your health, and   |
|                  | we will not impose a waiting period or limit your |
|                  | coverage due to pre-existing conditions.          |
+------------------+---------------------------------------------------+

+------------------+---------------------------------------------------+
| #### Get         | The Health Insurance Portability and              |
| ting a Certifica | Accountability Act of 1996 (HIPAA) is a Federal   |
| te of Group Heal | law that offers limited Federal protections for   |
| th Plan Coverage | health coverage availability and continuity to    |
|                  | people who lose employer group coverage. If you   |
|                  | leave the FEHB Program, we will give you a        |
|                  | Certificate of Group Health Plan Coverage that    |
|                  | indicates how long you have been enrolled with    |
|                  | us. You can use this certificate when getting     |
|                  | health insurance or other health care coverage.   |
|                  | Your new plan must reduce or eliminate waiting    |
|                  | periods, limitations, or exclusions for health    |
|                  | related conditions based on the information in    |
|                  | the certificate, as long as you enroll within 63  |
|                  | days of losing coverage under this Plan. If you   |
|                  | have been enrolled with us for less than 12       |
|                  | months, but were previously enrolled in other     |
|                  | FEHB plans, you may also request a certificate    |
|                  | from those plans.                                 |
|                  |                                                   |
|                  | For more information, get OPM pamphlet RI 79-27,  |
|                  | *Temporary Continuation of Coverage* *(TCC) under |
|                  | the FEHB Program*. See also the FEHB Web site at  |
|                  | [www.opm.gov/                                     |
|                  | insure/health](http://www.opm.gov/insure/health); |
|                  | refer to the "TCC and HIPAA" frequently asked     |
|                  | questions. These highlight HIPAA rules, such as   |
|                  | the requirement that Federal employees must       |
|                  | exhaust any TCC eligibility as one condition for  |
|                  | guaranteed access to individual health coverage   |
|                  | under HIPAA, and information about Federal and    |
|                  | State agencies you can contact for more           |
|                  | information.                                      |
+------------------+---------------------------------------------------+

# Section 12. Two Federal Programs complement FEHB benefits

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

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

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

+------------------+---------------------------------------------------+
| -   What is an   | It is a tax-favored benefit that allows you to    |
|     FSA?         | 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 FSAFEDS:   |
+------------------+---------------------------------------------------+
| Health Care      | -   Covers eligible health care expenses not      |
| Flexible         |     reimbursed by this Plan, or any other         |
| Spending Account |     medical, dental, or vision care plan you or   |
| (HCFSA)          |     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 of a "family member" than is used  |
|                  |     under the FEHB Program to provide benefits by |
|                  |     your FEHB Plan.                               |
|                  |                                                   |
|                  | -   The maximum annual amount that can be         |
|                  |     allotted for the HCFSA is \$4,000. .*Note:*   |
|                  |     The Federal workforce includes a number of    |
|                  |     employees married to each other. If each      |
|                  |     spouse/employee is eligible for FEHB          |
|                  |     coverage, both may enroll for a HCFSA up to   |
|                  |     the maximum of \$4,000 each (\$8,000 total).  |
|                  |     Both are covered under each other's HCFSA.    |
|                  |     The minimum annual amount is \$250.           |
+------------------+---------------------------------------------------+
| Dependent Care   | -   Covers eligible dependent care expenses       |
| Flexible         |     incurred so you, and your spouse, if married, |
| Spending Account |     can work, look for work, or attend school     |
| (DCFSA)          |     full-time.                                    |
|                  |                                                   |
|                  | -   Qualifying dependents for this account        |
|                  |     include your dependent children under age 13, |
|                  |     or any person of any age whom you claim as a  |
|                  |     dependent on your Federal Income Tax return   |
|                  |     (and who is mentally or physically incapable  |
|                  |     of self care).                                |
|                  |                                                   |
|                  | -   The maximum annual amount that can be         |
|                  |     allotted for the DCFSA is \$5,000. The        |
|                  |     minimum annual amount is \$250. *Note:* The   |
|                  |     IRS limits contributions to a DCFSA. For      |
|                  |     single taxpayers and taxpayers filing a joint |
|                  |     return, the maximum is \$5,000 per year. For  |
|                  |     taxpayers who file their taxes separately     |
|                  |     with a spouse, the maximum is \$2,500 per     |
|                  |     year. The limit includes any childcare        |
|                  |     subsidy you may receive.                      |
+------------------+---------------------------------------------------+
| -   Enroll       | You **must make an election** to enroll in an FSA |
|     during Open  | during the 2005 FEHB Open Season. Even if you     |
|     Season       | enrolled during 2004, you must make a new         |
|                  | election to continue participating in 2005.       |
|                  | Enrollment is easy!                               |
|                  |                                                   |
|                  | -   **Online: visit                               |
|                  |     [www.FSAFEDS.com](http://www.FSAFEDS.com/)    |
|                  |     and click on [Enroll]{.underline}.**          |
|                  |                                                   |
|                  | -   Telephone: call an FSAFEDS Benefits Counselor |
|                  |     toll-free ~~number~~ at 1-877-FSAFEDS         |
|                  |     (372-3337), Monday through Friday, from 9     |
|                  |     a.m. until 9 p.m., Eastern Time. TTY:         |
|                  |     1-800-952-0450.                               |
+------------------+---------------------------------------------------+

+------------------+--------------------------------+--------+--------+
| 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 is responsible for         |        |        |
|                  | enrollment, claims processing, |        |        |
|                  | customer service, and          |        |        |
|                  | day-to-day operations of       |        |        |
|                  | FSAFEDS.                       |        |        |
+------------------+--------------------------------+--------+--------+
| Who is eligible  | If you are a Federal employee  |        |        |
| to enroll?       | eligible for FEHB -- even if   |        |        |
|                  | you're not enrolled in FEHB -- |        |        |
|                  | you can choose to participate  |        |        |
|                  | in either, or both, of the     |        |        |
|                  | FSAs. *However, if you enroll  |        |        |
|                  | in a High Deductible Health    |        |        |
|                  | Plan (HDHP) with a Health      |        |        |
|                  | Savings Account (HSA), you are |        |        |
|                  | not eligible to participate in |        |        |
|                  | an HCFSA*.                     |        |        |
|                  |                                |        |        |
|                  | Almost all Federal employees   |        |        |
|                  | are eligible to enroll for a   |        |        |
|                  | DCFSA. The only exception is   |        |        |
|                  | intermittent (also called      |        |        |
|                  | "when actually employed"       |        |        |
|                  | \[WAE\]) employees expected to |        |        |
|                  | work fewer than 180 days       |        |        |
|                  | during the year.               |        |        |
|                  |                                |        |        |
|                  | *Note:* FSAFEDS is the FSA     |        |        |
|                  | Program established for all    |        |        |
|                  | Executive Branch employees and |        |        |
|                  | Legislative Branch employees   |        |        |
|                  | whose employers have signed on |        |        |
|                  | to participate. Under IRS law, |        |        |
|                  | FSAs are not available to      |        |        |
|                  | annuitants. Also, the U.S.     |        |        |
|                  | Postal Service and the         |        |        |
|                  | Judicial Branch, among others, |        |        |
|                  | have their own plans with      |        |        |
|                  | slightly different rules.      |        |        |
|                  | However, the advantages of     |        |        |
|                  | having an FSA are the same     |        |        |
|                  | regardless of the agency for   |        |        |
|                  | which you work.                |        |        |
+------------------+--------------------------------+--------+--------+
| -   How much     | Plan carefully when deciding   |        |        |
|     should I     | how much to contribute to an   |        |        |
|     contribute   | FSA. Because of the tax        |        |        |
|     to my FSA?   | benefits an FSA provides, the  |        |        |
|                  | IRS places strict guidelines   |        |        |
|                  | on how the money can be used.  |        |        |
|                  | Under current IRS tax rules,   |        |        |
|                  | you are required to forfeit    |        |        |
|                  | any money for which you did    |        |        |
|                  | not incur an eligible expense  |        |        |
|                  | under your FSA account(s)      |        |        |
|                  | during the Plan Year. This is  |        |        |
|                  | known as the                   |        |        |
|                  | "use-it-or-lose-it" rule. You  |        |        |
|                  | will have until April 30,      |        |        |
|                  | following the end of the Plan  |        |        |
|                  | Year to submit claims for your |        |        |
|                  | eligible expenses incurred     |        |        |
|                  | from January 1through December |        |        |
|                  | 31. For example if you enroll  |        |        |
|                  | in FSAFEDS for the 2005 Plan   |        |        |
|                  | Year, you will have until      |        |        |
|                  | April 30, 2006, to submit      |        |        |
|                  | claims for eligible expenses.  |        |        |
|                  |                                |        |        |
|                  | The [FSAFEDS                   |        |        |
|                  | Calculator]{.underline} at     |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.fsafeds.com/) |        |        |
|                  | will help you plan your FSA    |        |        |
|                  | allocations and provide an     |        |        |
|                  | estimate of your tax savings   |        |        |
|                  | based on your individual       |        |        |
|                  | situation.                     |        |        |
+------------------+--------------------------------+--------+--------+
| -   What can my  | Every FEHB plan includes cost  |        |        |
|     HCFSA pay    | sharing features, such as      |        |        |
|     for?         | 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   |        |        |
|                  | 15 and detailed throughout     |        |        |
|                  | this brochure. Your HCFSA will |        |        |
|                  | reimburse you when those costs |        |        |
|                  | are for medical care that you, |        |        |
|                  | your spouse and/or your        |        |        |
|                  | dependents receive that is NOT |        |        |
|                  | covered or reimbursed by this  |        |        |
|                  | FEHB Plan or any other         |        |        |
|                  | coverage that you have.        |        |        |
|                  |                                |        |        |
|                  | Under this Plan, typical       |        |        |
|                  | out-of-pocket expenses         |        |        |
|                  | include: pharmacy, office      |        |        |
|                  | visit and diagnostic test      |        |        |
|                  | copayments. The most common    |        |        |
|                  | and significant expenses not   |        |        |
|                  | covered by the Plan are        |        |        |
|                  | non-injury related dental      |        |        |
|                  | services, eyeglasses and       |        |        |
|                  | contact lenses, and services,  |        |        |
|                  | drugs or supplies provided by  |        |        |
|                  | non-plan providers.            |        |        |
|                  |                                |        |        |
|                  | 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>. |        |        |
|                  | The FSAFEDS Web site also has  |        |        |
|                  | a comprehensive list of        |        |        |
|                  | eligible expenses at           |        |        |
|                  | [www.FSAFEDS.com/fsafeds/eli   |        |        |
|                  | gibleexpenses.asp](http://www. |        |        |
|                  | irs.gov/pub/irs-pdf/p502.pdf). |        |        |
|                  | If you do not see your service |        |        |
|                  | or expense listed, please call |        |        |
|                  | an FSAFEDS Benefits Counselor  |        |        |
|                  | at 1-877-FSAFEDS (372-3337),   |        |        |
|                  | who will be able to answer     |        |        |
|                  | your specific questions.       |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax savings  | An FSA lets you allot money    |        |        |
|     with an FSA  | 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 be less. 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 | **Wi   |
|                  |                                | FSA**  | thout\ |
|                  |                                |        | FSA**  |
+------------------+--------------------------------+--------+--------+
|                  | If your taxable income is:     | \$     | \$     |
|                  |                                | 50,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | And you deposit this amount    | \      | -\$0-  |
|                  | into an FSA:                   | $2,000 |        |
+------------------+--------------------------------+--------+--------+
|                  | Your taxable income is now:    | \$     | \$     |
|                  |                                | 48,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | Subtract Federal & Social      | \$     | \$     |
|                  | Security taxes:                | 13,807 | 14,383 |
+------------------+--------------------------------+--------+--------+
|                  | If you spend after-tax dollars | -\$0-  | \      |
|                  | for expenses:                  |        | $2,000 |
+------------------+--------------------------------+--------+--------+
|                  | 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 the retirement |        |        |
|                  | system in which you are        |        |        |
|                  | enrolled (CSRS or FERS), your  |        |        |
|                  | state of residence, and your   |        |        |
|                  | individual tax situation. In   |        |        |
|                  | this example, the individual   |        |        |
|                  | received \$2,000 in services   |        |        |
|                  | for \$1,424 - a discount of    |        |        |
|                  | almost 36%! You may also wish  |        |        |
|                  | to consult a tax professional  |        |        |
|                  | for more information on the    |        |        |
|                  | tax implications of an FSA.    |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax credits  | You *cannot* claim expenses on |        |        |
|     and          | your Federal income tax return |        |        |
|     deductions   | 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      | The HCFSA is Federal Income    |        |        |
| expenses         | Tax-free from the first        |        |        |
|                  | dollar. In addition, you may   |        |        |
|                  | be reimbursed from your 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      |        |        |
|                  | shown above, 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 an HCFSA is also |        |        |
|                  | exempt from FICA taxes. This   |        |        |
|                  | exemption is not available on  |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return.                        |        |        |
+------------------+--------------------------------+--------+--------+
| Dependent care   | The DCFSA generally allows     |        |        |
| expenses         | many families to save more     |        |        |
|                  | than they would with the       |        |        |
|                  | Federal tax credit for         |        |        |
|                  | dependent care expenses. Note  |        |        |
|                  | that you may only be           |        |        |
|                  | reimbursed from the DCFSA up   |        |        |
|                  | to your current account        |        |        |
|                  | balance. If you file a claim   |        |        |
|                  | for more than your current     |        |        |
|                  | balance, it will be held until |        |        |
|                  | additional payroll allotments  |        |        |
|                  | have been added to your        |        |        |
|                  | account.                       |        |        |
|                  |                                |        |        |
|                  | Visit                          |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.FSAFEDS.com/) |        |        |
|                  | and download the [Dependent    |        |        |
|                  | Care Tax Credit                |        |        |
|                  | Worksheet]{.underline} from    |        |        |
|                  | the Forms and Literature page  |        |        |
|                  | to help you determine what is  |        |        |
|                  | best for your situation. You   |        |        |
|                  | may also wish to consult a tax |        |        |
|                  | professional for more details. |        |        |
+------------------+--------------------------------+--------+--------+

+------------------+---------------------------------------------------+
| -   Does it cost | Section 1127 of the National Defense              |
|     me anything  | Authorization Act (Public Law 108-136) requires   |
|     to           | agencies that offer FSAFEDS to employees to cover |
|     participate  | the administrative fee(s) on behalf of their      |
|     in FSAFEDS?  | employees. However, 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, resulting in the forfeiture of funds   |
|                  | remaining in your account (the IRS                |
|                  | "use-it-or-lose-it" rule).                        |
+------------------+---------------------------------------------------+
| -   Contact us   | To learn more or to enroll, please visit the      |
|                  | **FSAFEDS Web site** at                           |
|                  | [www.FSAFEDS.com](http://www.FSAFEDS.com/), or    |
|                  | contact SHPS directly via email or by phone.      |
|                  | FSAFEDS Benefits Counselors are available Monday  |
|                  | through Friday, from 9:00 a.m. until 9:00 p.m.    |
|                  | Eastern Time.                                     |
|                  |                                                   |
|                  | -   E-mail: <FSAFEDS@shps.net>                    |
|                  |                                                   |
|                  | -   Telephone: 1-877-FSAFEDS (1-877-372-3337)     |
|                  |                                                   |
|                  | -   TTY: 1-800-952-0450                           |
+------------------+---------------------------------------------------+

### The Federal Long Term Care Insurance Program

+------------------+---------------------------------------------------+
| -   It's         | Why should you consider applying for coverage     |
|     important    | under the Federal Long Term Care Insurance        |
|     protection   | Program (FLTCIP)?                                 |
|                  |                                                   |
|                  | -   **FEHB plans do not cover the cost of long    |
|                  |     term care.** Also called "custodial care,"    |
|                  |     long term care is help you receive to perform |
|                  |     activities of daily living -- such as bathing |
|                  |     or dressing yourself - or supervision you     |
|                  |     receive because of a severe cognitive         |
|                  |     impairment. The need for long term care can   |
|                  |     strike anyone at any age and the cost of care |
|                  |     can be substantial.                           |
|                  |                                                   |
|                  | ```{=html}                                        |
|                  | <!-- -->                                          |
|                  | ```                                               |
|                  | -   **The Federal Long Term Care Insurance        |
|                  |     Program can help protect you from the         |
|                  |     potentially high cost of long term care.**    |
|                  |     This coverage gives you options regarding the |
|                  |     type of care you receive and where you        |
|                  |     receive it. With FLTCIP coverage, you won't   |
|                  |     have to worry about relying on your loved     |
|                  |     ones to provide or pay for your care.         |
|                  |                                                   |
|                  | ```{=html}                                        |
|                  | <!-- -->                                          |
|                  | ```                                               |
|                  | -   **It's to your advantage to apply sooner      |
|                  |     rather than later. In order to qualify for    |
|                  |     coverage under the FLTCIP,** you must apply   |
|                  |     and pass a medical screening (called          |
|                  |     underwriting). Certain medical conditions, or |
|                  |     combinations of 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 future       |
|                  |     change in your health disqualify you from     |
|                  |     obtaining coverage. Also, the younger you are |
|                  |     when you apply, the lower your premiums.      |
|                  |                                                   |
|                  | ```{=html}                                        |
|                  | <!-- -->                                          |
|                  | ```                                               |
|                  | -   **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.      |
|                  |     Newly married spouses of employees also have  |
|                  |     a limited opportunity to apply using          |
|                  |     abbreviated underwriting.                     |
|                  |                                                   |
|                  | ```{=html}                                        |
|                  | <!-- -->                                          |
|                  | ```                                               |
|                  | -   **Qualified relatives are also eligible to    |
|                  |     apply.** Qualified relatives include spouses  |
|                  |     and adult children of employees and           |
|                  |     annuitants, and parents, parents-in-law, and  |
|                  |     stepparents of employees.                     |
+------------------+---------------------------------------------------+
| -   To find out  | Call 1-800-LTC-FEDS (1-800-582-3337) (TTY         |
|     more and to  | 1-800-843-3557) or visit                          |
|     request an   | [www.ltcfeds.com](http://www.ltcfeds.com/).       |
|     application  |                                                   |
+------------------+---------------------------------------------------+

# Index

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

Accidental injury 26, 33, 50

Allergy tests 24

Allogenic (donor) bone marrow transplants 35

Alternative treatments 30

Ambulance 40, 42

Anesthesia 6, 36, 50

Autologous bone marrow transplant 25, 35

Biopsy 32

Blood or blood plasma 38, 39

Casts 37, 38, 39

Catastrophic protection out-of-pocket maximum 15, 71

Changes for 2005 9

Chemotherapy 25

Chiropractic 30

Cholesterol tests 20

Circumcision 22

Claims 46, 53, 54, 55, 57, 58, 67

Coinsurance 15, 61

Colorectal cancer screening 20

Congenital anomalies 32, 33

Contraceptive drugs and devices 23, 33, 47

Crutches 29

Deductible 15, 51

Definitions 61

Dental care 50, 51

Diagnostic services 18, 19

Disputed claims review 51, 54

Donor expenses 24, 35, 36

Dressing 37, 38, 39

Durable medical equipment 14, 29, 31

Educational classes and programs 31, 48

Effective date of enrollment\... 3, 10, 13, 61 62, 63

Emergency 7, 8, 15, 40, 41, 42, 61

Experimental or investigational 47, 52, 61

Eyeglasses 26, 67

Family planning 23

Fecal occult blood test 20

Fraud 3, 4

General exclusions 52

Hearing services 26

Home health services 14, 29, 30

Hospice 39

Hospital 13, 14, 18, 36, 37, 38, 42, 43, 53

Immunizations 20, 21, 48

Infertility 23, 24

Inpatient hospital benefits 14, 37, 38

Insulin 47

Magnetic Resonance Imagings (MRIs) 19

Mammogram 20

Maternity benefits 22, 37, 38

Medicaid 60

Medically necessary 14, 61

Medicare 50, 56, 58, 59

Medicare Advantage 59

Original 57

Members

Associate 72

Family 3, 56, 58, 61, 62

Mental Health/Substance Abuse Benefits 14, 43, 44

Newborn care 22

Non-FEHB 51, 64

Nurse

Licensed Practical Nurse (LPN) 29

Registered Nurse (RN) 29

Telephone Advice Nurse 48

Occupational therapy 14, 25, 26, 29

Ocular injury 26

Oral and maxillofacial surgery 34, 35

Out-of-pocket expenses 15, 71

Oxygen 29, 38, 39

Pap test 20

Physician 10, 18, 32

Prescription drugs 14, 15, 45, 46, 47, 53

Preventive care, adult 20, 21

Preventive care, children 21

Preventive services 7, 48

Prior approval 14

Prior authorization 14, 44, 45, 47, 49

Prosthetic devices 14, 27, 28, 33, 34

Psychologist 43

Radiation therapy 25, 34

Room and board 37

Second surgical opinion 18

Skilled nursing facility care.. 13, 14, 18, 36 39

Smoking cessation 31, 47, 48

Social worker 43

Speech therapy 14, 26, 29

Splints 37, 38, 39

Subrogation 60

Substance abuse 14, 43, 44

Surgery 5, 32, 33, 34, 35

Anesthesia 14, 36

Oral 34, 35

Outpatient 14, 32, 33, 34, 36, 38

Reconstructive 33, 34

Syringes 31

Telephone Advice Nurse 48

Temporary Continuation of Coverage (TCC) 63, 64, 65

Transplants 25, 35, 36

Treatment therapies 25

Vision care 26, 27

Vision services 26, 27

Wheelchairs 29

Workers\' Compensation 58, 60

X-rays 19

# Summary of benefits for the Health Plan of Nevada *-* 2005

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

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

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

+----------------------------------------+-----------------------+----+
| **Benefits**                           | **You pay**           | ** |
|                                        |                       | Pa |
|                                        |                       | ge |
|                                        |                       | ** |
+----------------------------------------+-----------------------+----+
| Medical services provided by           | Office visit copay:   | 18 |
| physicians:                            | \$10 primary care;    |    |
|                                        | \$10 specialist       |    |
| -   Diagnostic and treatment services  |                       |    |
|     provided in the office             |                       |    |
+----------------------------------------+-----------------------+----+
| Services provided by a hospital:       | \$100 per admission   | 37 |
|                                        |                       |    |
| -   Inpatient                          | \$50 per visit        | 38 |
|                                        |                       |    |
| -   Outpatient                         |                       |    |
+----------------------------------------+-----------------------+----+
| Emergency benefits                     | \$25 per visit        | 42 |
|                                        |                       |    |
| -   In-area                            | \$50 per visit        | 42 |
|                                        |                       |    |
| -   Out-of-area                        |                       |    |
+----------------------------------------+-----------------------+----+
| Mental health and substance abuse      | Regular cost sharing  | 43 |
| treatment                              |                       |    |
+----------------------------------------+-----------------------+----+
| Prescription drugs                     | \$10 generic          | 45 |
|                                        | preferred             |    |
|                                        |                       |    |
|                                        | \$25 brand preferred  |    |
|                                        |                       |    |
|                                        | \$40 non-preferred    |    |
+----------------------------------------+-----------------------+----+
| Dental care .                          | No benefit.           | 50 |
+----------------------------------------+-----------------------+----+
| Vision care .                          | \$10 per visit for    | 26 |
|                                        | one refraction        |    |
|                                        | annually and 50% of   |    |
|                                        | costs associated with |    |
|                                        | vision supplies       |    |
+----------------------------------------+-----------------------+----+
| Special features: Flexible benefits    |                       | 48 |
| option, Telephone Advice Nurse         |                       |    |
| Service, Services for the deaf and     |                       |    |
| hearing impaired, Preventive           |                       |    |
| Health/Disease Management,             |                       |    |
| <HPN@YourService>                      |                       |    |
+----------------------------------------+-----------------------+----+
| Protection against catastrophic costs  | Nothing after         | 15 |
|                                        | \$2,000/Self Only or  |    |
| (your catastrophic protection          | \$5,000/Family        |    |
| out-of-pocket maximum)                 | enrollment per year   |    |
|                                        |                       |    |
|                                        | Some costs do not     |    |
|                                        | count toward this     |    |
|                                        | protection            |    |
+----------------------------------------+-----------------------+----+

# 2005 Rate Information for Health Plan of Nevada

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

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

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

+-------------+----------+--------------------------+-----------------+
| **Type**    | **Code** | ***Non-Postal Premium*** | ***Postal       |
|             |          |                          | Premium***      |
| **of**      |          | **                       |                 |
|             |          | [Biweekly]{.underline}** | **[Biweekly     |
| **E         |          | *                        | ]{.underline}** |
| nrollment** |          | *[Monthly]{.underline}** |                 |
|             |          |                          | **USPS Your**   |
|             |          | **Gov't Your Gov't       |                 |
|             |          | Your**                   | **Share Share** |
|             |          |                          |                 |
|             |          | **Share Share Share      |                 |
|             |          | Share**                  |                 |
+-------------+----------+--------------------------+-----------------+

Las Vegas metropolitan area and surrounding communities

+-------------+----------+--------------------------+-----------------+
| **Self      | **NM1**  | **\$ 69.46 \$23.15       | **\$ 82.19      |
| Only**      |          | \$150.50 \$ 50.16**      | \$10.42**       |
|             | **NM2**  |                          |                 |
| **Self &    |          | **\$177.84 \$59.28       | **\$210.44      |
| Family**    |          | \$385.32 \$128.44**      | \$26.68**       |
+-------------+----------+--------------------------+-----------------+

Reno/Sparks metropolitan area

+-------------+----------+--------------------------+-----------------+
| **Self      | **2L1**  | **\$118.22 \$ 39.40      | **\$139.89      |
| Only**      |          | \$256.13 \$ 85.38**      | \$17.73**       |
|             | **2L2**  |                          |                 |
| **Self &    |          | **\$298.23 \$105.30      | **\$352.08      |
| Family**    |          | \$646.17 \$228.15**      | \$51.45**       |
+-------------+----------+--------------------------+-----------------+

[]{#Introduction .anchor}