**CDPHP Universal Benefits, Inc.**

**Formerly Capital District Physicians' Health Plan, Inc. (CDPHP)**

HYPERLINK http://www.cdphp.com www.cdphp.com
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**A Prepaid Comprehensive Medical Plan**

![](media/image2.png){width="1.4826388888888888in"
height="1.5in"}**Serving:** Upstate, Hudson Valley, and Central New York

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

**Geographic service area to enroll. See page 6 for requirements.**

**Enrollment codes for this Plan:**

**SG1 Self Only**

**SG2 Self and Family**

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**RI 73-549**

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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,
>
> 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),

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice,
look at [www.opm.gov/insure](http://www.opm.gov/insure) on the Web. You
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 [3](#introduction)

Plain Language [3](#plain-language)

Stop Health Care Fraud! [4](#stop-health-care-fraud)

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

Section 1. Facts about this prepaid plan
[6](#section-1.-facts-about-this-prepaid-plan)

How we pay providers [6](#how-we-pay-providers)

Your Rights [6](#your-rights)

Service Area [6](#service-area)

Section 2. How we change for 2005
[7](#section-2.-how-we-change-for-2005)

Program-wide changes [7](#program-wide-changes)

Changes to this Plan [7](#changes-to-this-plan)

Section 3. How you get care [8](#section-3.-how-you-get-care)

Identification cards [8](#identification-cards)

Where you get covered care [8](#where-you-get-covered-care)

• Plan providers [8](#plan-providers)

• Plan facilities [8](#plan-facilities)

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

• Primary care [8](#primary-care)

• Specialty care [8](#specialty-care)

• Hospital care [9](#hospital-care)

Circumstances beyond our control [9](#circumstances-beyond-our-control)

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

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

Copayments [10](#copayments)

Deductible [10](#deductible)

Coinsurance [10](#coinsurance)

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

Section 5. Benefits -- OVERVIEW *(See page 7 for how our benefits
changed this year and page 55 for a benefits summary.)*
[11](#section-5.-benefits-overview-see-page-8-for-how-our-benefits-changed-this-year-and-page-52-for-a-benefits-summary.)

Section 5(a) Medical services and supplies provided by physicians and
other health care professionals
[12](#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
[20](#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
[23](#section-5c-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

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

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

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

Section 5(g) Special features [31](#section-5g-special-features)

-   
-   
-   
-   
-   

Flexible benefits option [31](#flexible-benefits-option)Non-emergency
care for full-time students out of the area
[31](#non-emergency-care-for-full-time-students-out-of-the-area)Services
for deaf and hearing impaired
[31](#services-for-deaf-and-hearing-impaired)Childbirth Education
Reimbursement Progam
[31](#childbirth-education-reimbursement-progam)Centers of excellence
[31](#centers-of-excellence)Section 5(h) Dental benefits
[32](#section-5h-dental-benefits)

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

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

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

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

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

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

What is Medicare? [38](#what-is-medicare)

• Should I enroll in Medicare? [38](#should-i-enroll-in-medicare)

• The Original Medicare Plan (Part A or Part B)
[39](#__RefHeading___Toc82425548)

• Medicare Advantage [41](#medicare-advantage)

TRICARE and CHAMPVA [41](#tricare-and-champva)

Workers' Compensation [42](#__RefHeading___Toc82425551)

Medicaid [42](#medicaid)

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

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

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

Section 11. FEHB Facts [44](#section-11.-fehb-facts)

Coverage information [44](#coverage-information)

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

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

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

• Children's Equity Act [45](#childrens-equity-act)

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

• When you retire [45](#when-you-retire)

When you lose benefits [45](#when-you-lose-benefits)

• When FEHB coverage ends [45](#when-fehb-coverage-ends)

• Spouse equity coverage [46](#spouse-equity-coverage)

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

• Converting to individual coverage
[46](#converting-to-individual-coverage)

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

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

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

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

Index [51](#index)

Summary of benefits for CDPHP UBI *-* 2005
[52](#summary-of-benefits-for-cdphp-ubi---2005)

2005 Rate Information for CDPHP UBI Back cover

# Introduction

This brochure describes the benefits of CDPHP Universal Benefits, Inc.
(CDPHP UBI) under Capital District Physicians' Health Plan's contract
(CS 2901) with the United States Office of Personnel Management, as
authorized by the Federal Employees Health Benefits law. The address for
CDPHP UBI administrative offices is:

CDPHP UBI

Patroon Creek Corporate Center

1223 Washington Avenue

Albany, NY 12206

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 8. 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
    CDPHP UBI*.*

-   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 (518)
    641-3228 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?"

-   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?

-   <http://www.ahrq.gov/consumer/pathqpack.html>. 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 prepaid plan

This Plan is a prepaid comprehensive medical plan. We require you to see
specific physicians, hospitals, and other providers that contract with
us. You are encouraged to select a personal doctor within the Plan's
network The Plan is solely responsible for the selection of these
providers in your area. Contact the Plan for a copy of their most recent
CDPHP UBI provider directory.

Prepaid plans 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,
coinsurance, and deductibles described in this brochure. When you
receive emergency services from non-Plan providers, you may have to
submit claim forms. With the exception of emergency services, all
services by non-participating practitioners and providers must be
authorized in advance by CDPHP UBI. When you choose a non-participating
provider, and the care has not been preauthorized by CDPHP UBI, you will
pay all charges.

**You should join a prepaid plan 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.

### 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.

-   CDPHP Universal Benefits, Inc. (CDPHP UBI) is licensed under Article
    43 in New York State.

-   CDPHP UBI is an affiliate of Capital District Physicians' Health
    Plan, Inc. (CDPHP), a health plan that has been in existence for 20
    years.

-   CDPHP UBI is a non-profit health services corporation.

If you want more information about us, call 1-877-269-2134, or write to
CDPHP UBI, Patroon Creek Corporate Center, 1223 Washington Ave., Albany,
NY 12206. You may also contact us by fax at (518) 641-5005 or visit our
Web site at www.cdphp.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: Albany,
Broome, Chenango, Columbia, Delaware, Dutchess, Essex, Fulton, Greene,
Hamilton, Herkimer, Madison, Montgomery, Oneida, Orange, Otsego,
Rensselaer, Saratoga, Schenectady, Schoharie, Tioga, Ulster, Warren, and
Washington counties.

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).

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

-   Your share of the non-Postal premium will increase by 5.2% for Self
    Only and decrease by 3% for Self and Family for enrollment code SG.
    Enrollment codes PW and QB have been consolidated under enrollment
    code SG for 2005.

-   Your share of the Postal premium will increase by 5.2% for Self Only
    and decrease by 13.5% for Self and Family for enrollment code SG.
    Enrollment codes PW and QB have been consolidated under enrollment
    code SG for 2005.

-   The HMO plan will be replaced by a Prepaid comprehensive medical
    plan in 2005 and will eliminate the referral requirement for
    specialty services. Members must use a provider who participates
    with the CDPHP UBI network to obtain coverage except for emergency
    care or when the care has been preauthorized by CDPHP UBI. A listing
    is available from CDPHP UBI Member Services at 1-877-269-2134 or on
    Find-A-Doc at our Web site, [www.cdphp.com](http://www.cdphp.com/).

-   The primary/specialist office visit copay has increased to \$20.

-   The inpatient hospital copay has changed to \$100 copay per day up
    to a maximum of \$500 per admission. For family coverage, inpatient
    copays are limited to two per calendar year. The copay will also
    apply to inpatient hospital rehabilitation, but is waived if the
    patient is admitted within one day of discharge.

-   The copay for routine annual exam for patients over age 19 including
    routine screenings has increased to \$20 per visit.

-   Physical, occupational, and speech short-term therapy are limited to
    one course each for two consecutive months for each specific
    diagnosis and related conditions per calendar year. The \$20
    specialist office visit will apply.

-   Coverage for cardiac rehabilitation is based on medical necessity.
    The \$20 office copay visit will apply.

-   The copay for local professional ambulance will increase to \$50.

-   The copay for diabetic supplies and insulin will increase to \$20
    per item.

-   The copay for diabetic durable medical equipment will increase to
    \$20 and must be preauthorized only if over \$500.

-   The copay for hospital or ambulatory surgical center will increase
    to \$50 per day.

-   The prescription drug copay has changed to \$10 generic, \$25
    preferred brand, and \$40 non-preferred brand for a 30-day supply.
    The copay for a 90-day mail order plan has been changed to \$20
    generic, \$50 preferred brand and \$80 non-preferred brand.

-   The brochure has been clarified to include new preventive guidelines
    for children and adults. See page 13 and 14.

# 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 1-877-269-2134 or write to us at     |
|                    | Patroon Creek Corporate Center, 1223 Washington |
|                    | Ave., Albany, NY 12206. You may also request    |
|                    | replacement cards through our Web site at       |
|                    | [www.cdphp.com]{.underline}.                    |
+--------------------+-------------------------------------------------+
| ### 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 set by the      |
|                    | National Committee for Quality Assurance        |
|                    | (NCQA).                                         |
|                    |                                                 |
|                    | We list Plan providers in the CDPHP UBI         |
|                    | provider directory, which we update             |
|                    | periodically. The list is also available at     |
|                    | Find-A-Doc on our Web site at                   |
|                    | [www.cdphp.com](http://www.cdphp.com/).         |
+--------------------+-------------------------------------------------+
| ##                 | 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 CDPHP UBI         |
|                    | provider directory, which we update             |
|                    | periodically. The list is also available at     |
|                    | Find-A-Doc on our Web site at                   |
|                    | [www.cdphp.com](http://www.cdphp.com/).         |
+--------------------+-------------------------------------------------+
| ###                | It depends on the type of care you need. You    |
| What you must do t | can go to any participating provider you want,  |
| o get covered care | but we must approve some care in advance.       |
+--------------------+-------------------------------------------------+
| #### Primary care  | Because all covered services must be provided   |
|                    | or arranged by CDPHP UBI participating          |
|                    | providers, you are encouraged to select a       |
|                    | personal doctor within the network to           |
|                    | coordinate your care. Your primary care         |
|                    | provider can be an internist, family            |
|                    | practitioner, general practitioner, or          |
|                    | pediatrician (for children). Alternate primary  |
|                    | care providers are obstetricians and            |
|                    | gynecologists.                                  |
+--------------------+-------------------------------------------------+
| #                  | -   Participating specialists are listed in our |
| ### Specialty care |     CDPHP UBI directory and in Find-A-Doc at    |
|                    |     our Web site at                             |
|                    |     [www.cdphp.com](http://www.cdphp.com/).     |
|                    |                                                 |
|                    | -   No referral is necessary to visit a         |
|                    |     participating specialist.                   |
|                    |                                                 |
|                    | -   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 for up to   |
|                    |     90 days after you receive notice of the     |
|                    |     change. Contact us, or if we drop out of    |
|                    |     the Program, contact your new plan.         |
|                    |                                                 |
|                    | If you are in the second or third trimester of  |
|                    | pregnancy and you lose access to your           |
|                    | specialist based on the above circumstances,    |
|                    | you can continue to see your specialist until   |
|                    | the end of your postpartum care, even if it is  |
|                    | beyond the 90 days.                             |
+--------------------+-------------------------------------------------+
| #### Hospital care | Your Plan primary care physician or specialist  |
|                    | will make necessary hospital arrangements and   |
|                    | supervise your care. This includes admission to |
|                    | a skilled nursing or other type of facility.    |
|                    |                                                 |
|                    | If you are in the hospital when your enrollment |
|                    | in our Plan begins, call our customer service   |
|                    | department immediately at 1-877-269-2134. 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              | For certain services, you or your physician     |
| ervices requiring  | must obtain approval from us. Before giving     |
| our prior approval | approval, we consider if the service is         |
|                    | covered, medically necessary, and follows       |
|                    | generally accepted medical practice.            |
|                    |                                                 |
|                    | We call this review and approval process        |
|                    | pre-certification. It is your responsibility to |
|                    | make sure this review process is followed. Your |
|                    | physician or specialist must obtain prior       |
|                    | approval for the following services:            |
|                    | hospitalization or skilled nursing facility     |
|                    | care, home health care, inpatient               |
|                    | rehabilitation unit or facility services,       |
|                    | prosthetic devices, some identified             |
|                    | medications, durable medical equipment, home    |
|                    | dialysis, and hospice care. Prior approval is   |
|                    | also required for physical therapy,             |
|                    | occupational therapy, speech therapy, mental    |
|                    | health/substance abuse, GHT, and other services |
|                    | such as off-plan referrals.                     |
|                    |                                                 |
|                    | Your physician contacts CDPHP's Resource        |
|                    | Coordination Management Department with a       |
|                    | description of the medical necessity of the     |
|                    | request.                                        |
|                    |                                                 |
|                    | A nurse reviewer reviews the request. Clinical  |
|                    | information is obtained to support the medical  |
|                    | necessity of the request. Clinical information  |
|                    | is reviewed against established criteria.       |
|                    | Decisions are based on the appropriateness of   |
|                    | care. Ultimate determinations are made by the   |
|                    | Plan's Medical Director. Upon approval you and  |
|                    | your provider are notified via telephone and    |
|                    | mail. Services that do not receive prior        |
|                    | approval will not be covered by the Plan.       |
+--------------------+-------------------------------------------------+

# 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 physician |
|                  | you pay a copayment of \$20 per office visit and  |
|                  | when you go in the hospital, you pay \$100 per    |
|                  | day, up to a maximum of \$500 per confinement.    |
+------------------+---------------------------------------------------+
| ### 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 20 percent of our allowance for |
|                  | durable medical equipment.                        |
+------------------+---------------------------------------------------+
| ### You          | We do not have a catastrophic protection          |
| r catastrophic p | out-of-pocket maximum.                            |
| rotection out-of |                                                   |
| -pocket maximum  |                                                   |
+------------------+---------------------------------------------------+

# Section 5. Benefits -- OVERVIEW *(See page 8 for how our benefits changed this year and page 52 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
(518) 641-3140 or 1-877-269-2134 or at our Web site at
[www.cdphp.com]{.underline}.

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

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

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

[Preventive care, adult 13](#preventive-care-adult)

[Preventive care, children 14](#preventive-care-children)

[Maternity care 14](#maternity-care)

[Family planning 15](#family-planning)

[Infertility services 15](#infertility-services)

[Allergy care 15](#allergy-care)

[Treatment therapies 16](#treatment-therapies)

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

[Speech therapy 16](#speech-therapy)

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

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

[Foot care 17](#foot-care)

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

[Durable medical equipment (DME) 18](#durable-medical-equipment-dme)

[Home health services 19](#home-health-services)

[Chiropractic 19](#chiropractic)

[Alternative treatments 19](#alternative-treatments)

[Educational classes and programs 19](#educational-classes-and-programs)

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

[Surgical procedures 20](#surgical-procedures)

[Reconstructive surgery 21](#reconstructive-surgery)

[Oral and maxillofacial surgery 21](#oral-and-maxillofacial-surgery)

[Organ/tissue transplants 22](#organtissue-transplants)

[Anesthesia 22](#anesthesia)

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

[Inpatient hospital 23](#inpatient-hospital)

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

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

[Hospice care 24](#hospice-care)

[Ambulance 24](#ambulance)

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

[Emergency within our service area 25](#__RefHeading___Toc78332756)

[Emergency outside our service area 26](#__RefHeading___Toc78332757)

[Ambulance 26](#__RefHeading___Toc78332758)

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

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

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

[Covered medications and supplies 30](#covered-medications-and-supplies)

[Section 5(g) Special features 31](#section-5g-special-features)

[Flexible benefits option 31](#flexible-benefits-option)

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

[Centers of excellence 31](#centers-of-excellence)

Section 5(h) Dental benefits [32](#section-5h-dental-benefits)

[Accidental injury benefit 32](#accidental-injury-benefit)

[Dental benefits 32](#dental-benefits)

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

Summary of benefits for CDPHP UBI, Inc. - 2005
[52](#summary-of-benefits-for-cdphp-ubi---2005)

2005 Rate Information for CDPHP UBI, Inc. Back cover

## 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. You pay all  |                     | * |   |
|   | P |     charges for non-participating   |                     | P |   |
|   | * |     providers.                      |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | -   Be sure to read Section 4,      |                     |   |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | * |     services*, for valuable         |                     | * |   |
|   | O |     information about how cost      |                     | O |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   | * |     Section 9 about coordinating    |                     | * |   |
|   |   |     benefits with other coverage,   |                     |   |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | * |                                     |                     | * |   |
|   | R |                                     |                     | 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 |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$20 per office     |   |   |
| r |   |                                     | visit               |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| I |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| ' |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$25 per visit      |   |   |
| r |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| I |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | Nothing             |   |   |
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|   |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$20 per office     |   |   |
|   |   |                                     | visit               |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| O |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
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| - |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| A |   |                                     | \$20 per visit      |   |   |
| t |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
| N |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| H |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| k |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
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| s |   |                                     |                     |   |   |
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| s |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

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

+------------------------------------------+---------------------------+
| ####                                     |                           |
| ## Lab, X-ray and other diagnostic tests |                           |
+------------------------------------------+---------------------------+
| Tests, such as:                          | Nothing if you receive    |
|                                          | these services at a       |
| -   Blood tests                          | preferred facility;       |
|                                          | otherwise, \$20 per       |
| -   Urinalysis                           | office visit              |
|                                          |                           |
| -   Pathology                            |                           |
|                                          |                           |
| -   X-rays                               |                           |
|                                          |                           |
| -   Non-routine Mammograms               |                           |
|                                          |                           |
| -   CAT Scans/MRI                        |                           |
|                                          |                           |
| -   Ultrasound                           |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Electrocardiogram and EEG            |                           |
+------------------------------------------+---------------------------+
| -   Non-routine Pap tests                | \$20 per office visit     |
+------------------------------------------+---------------------------+
| ###### Preventive care, adult            |                           |
+------------------------------------------+---------------------------+
| Routine screenings, such as:             | \$20 per office visit     |
|                                          |                           |
| -   Total Blood Cholesterol---Once every |                           |
|     five years                           |                           |
|                                          |                           |
| -   Colorectal Cancer Screening,         |                           |
|     including                            |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Fecal occult blood test -- every     |                           |
|     five years starting at age 50        |                           |
|                                          |                           |
| -   Sigmoidoscopy, screening -- every    |                           |
|     five years starting at age 50        |                           |
|                                          |                           |
| -   Double contrast barium enema---every |                           |
|     five years starting at age 50        |                           |
|                                          |                           |
| -   Colonoscopy---once every 10 years    |                           |
|     starting at age 50.                  |                           |
+------------------------------------------+---------------------------+
| Routine Prostate Specific Antigen (PSA)  | \$20 per office visit     |
| test -- one annually for men age 40 and  |                           |
| older                                    |                           |
+------------------------------------------+---------------------------+
| Routine pap test                         | \$20 per office visit     |
|                                          |                           |
| Note: The office visit is covered if pap |                           |
| test is received on the same day; see    |                           |
| *Diagnosis and Treatment*, above.        |                           |
+------------------------------------------+---------------------------+
| Routine mammogram -- covered for women   | Nothing                   |
| age 35 and older, as follows:            |                           |
|                                          |                           |
| -   From age 35 through 39, one during   |                           |
|     this five year period                |                           |
|                                          |                           |
| -   From age 40 through 49, one every    |                           |
|     one to two calendar years            |                           |
|                                          |                           |
| -   From age 50 to 70, annually          |                           |
|                                          |                           |
| -   Over age 71, as indicated            |                           |
+------------------------------------------+---------------------------+
| Routine immunizations, limited to:       | Nothing, office visit     |
|                                          | copay applies             |
| -   Tetanus-diphtheria (Td) booster --   |                           |
|     once every 10 years, ages 19 and     |                           |
|     over (except as provided for under   |                           |
|     Childhood immunizations)             |                           |
|                                          |                           |
| -   Influenza vaccine, annually          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Pneumococcal vaccine, age 65 and     |                           |
|     older                                |                           |
+------------------------------------------+---------------------------+
| *Not covered: Physical exams required    | *All charges.*            |
| for obtaining or continuing employment   |                           |
| or insurance, attending schools or camp, |                           |
| or travel.*                              |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Preventive care, children         |                           |
+------------------------------------------+---------------------------+
| -   Childhood immunizations recommended  | Nothing                   |
|     by the American Academy of           |                           |
|     Pediatrics                           |                           |
+------------------------------------------+---------------------------+
| -   Well-child care charges for routine  | Nothing for children to   |
|     examinations, immunizations and care | age 19.                   |
|     (up to age 22). Visits covered at 2  |                           |
|     weeks, 1 month, 2 months, 4 months,  | \$20 per visit age 19-22. |
|     6 months, 9 months, 12 months, 15    |                           |
|     months, and 18 months, then annually |                           |
|     to age 22.                           |                           |
+------------------------------------------+---------------------------+
| -   Examinations, such as:               | Nothing when performed    |
|                                          | during well child routine |
| ```{=html}                               | visits up to age 19. \$20 |
| <!-- -->                                 | per office visit,         |
| ```                                      | otherwise.                |
| -   Eye exams through age 17 to          |                           |
|     determine the need for vision        |                           |
|     correction. Limited to one every 24  |                           |
|     months.                              |                           |
|                                          |                           |
| -   Ear exams through age 17 to          |                           |
|     determine the need for hearing       |                           |
|     correction                           |                           |
|                                          |                           |
| -   Examinations done on the day of      |                           |
|     immunizations (up to age 22)         |                           |
+------------------------------------------+---------------------------+
| ###### Maternity care                    | You pay                   |
+------------------------------------------+---------------------------+
| Complete maternity (obstetrical) care,   | \$20 per office visit for |
| such as:                                 | the initial diagnosis.    |
|                                          | You pay nothing           |
| -   Prenatal care                        | thereafter.               |
+------------------------------------------+---------------------------+
| -   Delivery                             | \$100 copay per day up to |
|                                          | a maximum of \$500 per    |
| -   Postnatal care                       | admission. The copayment  |
|                                          | does not apply to         |
| Note: Here are some things to keep in    | hospital inpatient        |
| mind:                                    | charges for newborn       |
|                                          | nursery care.             |
| -   You do not need to precertify your   |                           |
|     normal delivery; see page 10 for     |                           |
|     other circumstances, such as         |                           |
|     extended stays for you or your baby. |                           |
|                                          |                           |
| -   You may remain in the hospital up to |                           |
|     48 hours after a regular delivery    |                           |
|     and 96 hours after a cesarean        |                           |
|     delivery. We will extend your        |                           |
|     inpatient stay if medically          |                           |
|     necessary.                           |                           |
|                                          |                           |
| -   We cover routine nursery care of the |                           |
|     newborn child during the covered     |                           |
|     portion of the mother's maternity    |                           |
|     stay. We will cover other care of an |                           |
|     infant who requires non-routine      |                           |
|     treatment only if we cover the       |                           |
|     infant under a Self and Family       |                           |
|     enrollment.                          |                           |
|                                          |                           |
| -   We pay hospitalization and surgeon   |                           |
|     services (delivery) the same as for  |                           |
|     illness and injury. See Hospital     |                           |
|     benefits (Section 5c) and Surgery    |                           |
|     benefits (Section 5b).               |                           |
+------------------------------------------+---------------------------+
| *Not covered: Elective sonograms to      | *All charges.*            |
| determine fetal sex.*                    |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Family planning                   |                           |
+------------------------------------------+---------------------------+
| A range of voluntary family planning     | \$20 per office visit     |
| services, limited to:                    |                           |
|                                          |                           |
| -   Voluntary sterilization (See         |                           |
|     Surgical procedures Section 5 (b))   |                           |
|                                          |                           |
| -   Genetic counseling when approved     |                           |
|                                          |                           |
| -   Visits to insert or implant covered  |                           |
|     contraceptive devices                |                           |
+------------------------------------------+---------------------------+
| Note: We cover oral contraceptives under | \$25 per covered          |
| the prescription drug benefit.           | preferred brand name drug |
|                                          | or device                 |
| -   Oral and transdermal contraceptives  |                           |
|                                          | \$40 per non-preferred    |
| -   Surgically implanted contraceptives  | drug                      |
|                                          |                           |
| -   Injectable contraceptive drugs (such | (30-day supply)           |
|     as Depo provera)                     |                           |
|                                          |                           |
| -   Intrauterine devices (IUDs)          |                           |
|                                          |                           |
| -   Diaphragms                           |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   Reversal of voluntary surgical       |                           |
|     sterilization                        |                           |
+------------------------------------------+---------------------------+
| ###### Infertility services              | You pay                   |
+------------------------------------------+---------------------------+
| Diagnosis and treatment of infertility   | \$20 per office visit     |
| such as:                                 |                           |
|                                          | \$100 copay per day up to |
| -   Artificial insemination:             | a maximum of \$500 per    |
|                                          | admission. For family     |
| ```{=html}                               | coverage, inpatient       |
| <!-- -->                                 | copays are limited to two |
| ```                                      | per calendar year         |
| -   *intravaginal insemination (IVI)*    |                           |
|                                          |                           |
| -   *intracervical insemination (ICI)*   |                           |
|                                          |                           |
| -   *intrauterine insemination (IUI)*    |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Fertility drugs                      |                           |
|                                          |                           |
| Note: Members must be at least 21 years  |                           |
| of age but no more than 44 years old to  |                           |
| be covered for infertility services.     |                           |
|                                          |                           |
| Note: We cover fertility drugs under the |                           |
| prescription drug benefit for up to six  |                           |
| cycles per lifetime.                     |                           |
+------------------------------------------+---------------------------+
| *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    |                           |
|     ART procedures*                      |                           |
|                                          |                           |
| -   *Cost of donor sperm*                |                           |
|                                          |                           |
| -   *Leuprolide Acetate when used for    |                           |
|     cessation of ovulation.*             |                           |
|                                          |                           |
| -   *Items such as ovulation predictor   |                           |
|     kits and home pregnancy kits.*       |                           |
|                                          |                           |
| -   *IVIG when utilized for infertility  |                           |
|     or pregnancy loss.*                  |                           |
+------------------------------------------+---------------------------+
| ###### Allergy care                      |                           |
+------------------------------------------+---------------------------+
| -   Testing and treatment                | \$20 per office visit     |
+------------------------------------------+---------------------------+
| -   Allergy injections                   | Nothing                   |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Allergy serum                        |                           |
+------------------------------------------+---------------------------+
| *Not covered: Provocative food testing   | *All charges.*            |
| and sublingual allergy desensitization*  |                           |
+------------------------------------------+---------------------------+
| ###### Treatment therapies               | You pay                   |
+------------------------------------------+---------------------------+
| -   Chemotherapy and radiation therapy   | \$20 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 28.                  |                           |
|                                          |                           |
| -   Respiratory and inhalation therapy   |                           |
|                                          |                           |
| -   Dialysis -- hemodialysis and         |                           |
|     peritoneal dialysis                  |                           |
+------------------------------------------+---------------------------+
| Intravenous (IV)/Infusion Therapy --     | \$20 per office visit if  |
| Home IV and antibiotic therapy           | received as an            |
|                                          | outpatient. Covered in    |
|                                          | full if part of home      |
|                                          | health care.              |
+------------------------------------------+---------------------------+
| -   Growth hormone therapy (GHT)         | \$20 per office visit     |
|                                          |                           |
| Note: We only cover GHT when we          |                           |
| preauthorize the treatment. We will ask  |                           |
| you to submit information that           |                           |
| establishes that the GHT is medically    |                           |
| necessary. If you do not ask or if we    |                           |
| determine GHT is not medically           |                           |
| necessary, we will not cover the GHT or  |                           |
| related services and supplies. See       |                           |
| *Services requiring our prior approval*  |                           |
| in Section 3.                            |                           |
+------------------------------------------+---------------------------+
| ###                                      | You pay                   |
| ### Physical and occupational therapies  |                           |
+------------------------------------------+---------------------------+
| Physical and occupational therapy are    | \$20 per office visit     |
| limited to one course each for two       |                           |
| consecutive months for each specific     | \$20 per outpatient visit |
| diagnosis and related conditions per     |                           |
| calendar year:                           | Nothing per visit during  |
|                                          | covered inpatient         |
| -   qualified physical therapists and    | admission                 |
|                                          |                           |
| -   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.                |                           |
|                                          |                           |
| -   Medically necessary cardiac          |                           |
|     rehabilitation following a heart     |                           |
|     transplant, bypass surgery or a      |                           |
|     myocardial infarction.               |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Long-term rehabilitative therapy*   |                           |
|                                          |                           |
| -   *Exercise programs*                  |                           |
|                                          |                           |
| -   *Continuous ECG monitoring and       |                           |
|     Thallium stress tests*               |                           |
|                                          |                           |
| -   *Services for chronic or maintenance |                           |
|     phase of cardiac rehabilitation*     |                           |
+------------------------------------------+---------------------------+
| ###### Speech therapy                    |                           |
+------------------------------------------+---------------------------+
| Speech therapy is limited to one course  | \$20 per office visit     |
| for two consecutive months for each      |                           |
| specific diagnosis and related           | \$20 per outpatient visit |
| conditions per calendar year.            |                           |
|                                          | Nothing per visit during  |
|                                          | covered inpatient         |
|                                          | admission.                |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Care beyond treatment period.*      |                           |
+------------------------------------------+---------------------------+
| ###### Hearing ser                       |                           |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| -   First hearing aid and testing only   | \$20 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                        | You pay                   |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| -   One pair of eyeglasses or contact    | \$20 per office visit     |
|     lenses to correct an impairment      |                           |
|     directly caused by accidental ocular |                           |
|     injury or intraocular surgery (such  |                           |
|     as for cataracts)                    |                           |
+------------------------------------------+---------------------------+
| -   Eye exam to determine the need for   | \$20 per office visit     |
|     vision correction for children       |                           |
|     through age 17 *(see Preventive      |                           |
|     Care, Children)*                     |                           |
|                                          |                           |
| -   Eye refractions once every 24 months |                           |
|                                          |                           |
| -   Eye exercises and orthoptics when    |                           |
|     approved                             |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Eyeglasses or contact lenses*       |                           |
|                                          |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
+------------------------------------------+---------------------------+
| ###### Foot care                         |                           |
+------------------------------------------+---------------------------+
| Routine foot care when you are under     | \$20 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  |                           |
+------------------------------------------+---------------------------+
| -   Artificial limbs and eyes            | 20% of charges. Must be   |
|                                          | preauthorized             |
| -   Externally worn breast prostheses    |                           |
|     and surgical bras, including         |                           |
|     necessary replacements following a   |                           |
|     mastectomy                           |                           |
+------------------------------------------+---------------------------+
| -   Internal prosthetic devices, such as | Nothing                   |
|     artificial joints, pacemakers,       |                           |
|     cochlear implants, and surgically    |                           |
|     implanted breast implant following   |                           |
|     mastectomy. Note: Internal           |                           |
|     prosthetic devices are paid as       |                           |
|     hospital benefits; see Section 5(c)  |                           |
|     for payment information. Insertion   |                           |
|     of the device is paid as surgery;    |                           |
|     see Section 5(b) for coverage of the |                           |
|     surgery to insert the device.        |                           |
+------------------------------------------+---------------------------+
| -   Corrective orthopedic appliances for | 20% of charges. Must be   |
|     non-dental treatment of              | preauthorized             |
|     temporomandibular joint (TMJ) pain   |                           |
|     dysfunction syndrome.                |                           |
|                                          |                           |
| -   Approved lumbosacral supports        |                           |
+------------------------------------------+---------------------------+
| -   Hair prosthesis. CDPHP provides      | 20% of charges.           |
|     benefits for the purchase of one     |                           |
|     medically necessary cranial          |                           |
|     prosthesis, wig, or toupee per       |                           |
|     lifetime per member for replacement  |                           |
|     of hair loss as a result of injury,  |                           |
|     disease, or treatment of a disease.  |                           |
|     You pay 20 percent of charges.       |                           |
|     Coverage is limited to a maximum     |                           |
|     amount of \$200 per prosthesis, wig  |                           |
|     or toupee. This limitation is        |                           |
|     applied to the balance remaining     |                           |
|     after the member's payment of the 20 |                           |
|     percent coinsurance.                 |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Orthopedic and corrective shoes*    |                           |
|                                          |                           |
| -   *Arch supports*                      |                           |
|                                          |                           |
| -   *Foot orthotics*                     |                           |
|                                          |                           |
| -   *Heel pads and heel cups*            |                           |
|                                          |                           |
| -   *Corsets, trusses, elastic           |                           |
|     stockings, support hose, and other   |                           |
|     supportive devices*                  |                           |
|                                          |                           |
| -   *Prosthetic replacements provided    |                           |
|     less than 3 years after the last one |                           |
|     we covered unless medically          |                           |
|     indicated*                           |                           |
|                                          |                           |
| -   *Stump hose*                         |                           |
+------------------------------------------+---------------------------+
| ###### Durable medical equipment (DME)   | You pay                   |
+------------------------------------------+---------------------------+
| Rental or purchase, at our option,       | 20% of charges. Must be   |
| including repair and adjustment, of      | preauthorized             |
| durable medical equipment prescribed by  |                           |
| your Plan physician, such as oxygen and  |                           |
| dialysis equipment. Under this benefit,  |                           |
| we also cover:                           |                           |
|                                          |                           |
| -   Hospital beds;                       |                           |
|                                          |                           |
| -   Wheelchairs                          |                           |
|                                          |                           |
| -   Crutches                             |                           |
|                                          |                           |
| -   Walkers                              |                           |
+------------------------------------------+---------------------------+
| -   Blood glucose monitors; and          | \$20 per item, must be    |
|                                          | preauthorized             |
| -   Insulin pumps.                       |                           |
|                                          |                           |
| Your Plan physician will call us for     |                           |
| authorization of this equipment. We will |                           |
| arrange with a health care provider to   |                           |
| rent or sell you durable medical         |                           |
| equipment.                               |                           |
+------------------------------------------+---------------------------+
| *Not covered: Motorized wheelchairs.*    | *All charges.*            |
+------------------------------------------+---------------------------+
| ###### Home health services              |                           |
+------------------------------------------+---------------------------+
| -   Home health care ordered by a Plan   | Nothing                   |
|     physician, approved by the Plan's    |                           |
|     medical director, and provided by a  |                           |
|     registered nurse (R.N.), licensed    |                           |
|     practical nurse (L.P.N.), licensed   |                           |
|     vocational nurse (L.V.N.), or home   |                           |
|     health aide.                         |                           |
+------------------------------------------+---------------------------+
| -   Services include oxygen therapy,     | 20% of charges.           |
|     intravenous therapy and medications. |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Nursing care requested by, or for   |                           |
|     the convenience of, the patient or   |                           |
|     the patient's family;*               |                           |
|                                          |                           |
| -   *Home care primarily for personal    |                           |
|     assistance that does not include a   |                           |
|     medical component and is not         |                           |
|     diagnostic, therapeutic, or          |                           |
|     rehabilitative*.                     |                           |
|                                          |                           |
| -   *Rest cures*                         |                           |
+------------------------------------------+---------------------------+
| ###### Chiropractic                      | You pay                   |
+------------------------------------------+---------------------------+
| -   Medically necessary care for spinal  | \$20 per office visit     |
|     manipulation                         |                           |
+------------------------------------------+---------------------------+
| ###### Alternative treatments            |                           |
+------------------------------------------+---------------------------+
| No benefit                               | *All charges*             |
+------------------------------------------+---------------------------+
| ###### Educational classes and programs  |                           |
+------------------------------------------+---------------------------+
| Coverage is limited to:                  | Nothing                   |
|                                          |                           |
| -   Smoking Cessation -- Provided at no  |                           |
|     cost to you through CDPHP UBI's      |                           |
|     wellness program.                    |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Peak Asthma Performance -- Members   |                           |
|     are encouraged to call toll-free for |                           |
|     telephonic education about asthma.   |                           |
|     Members who participate may receive  |                           |
|     a semi-annual newsletter and         |                           |
|     materials including a peak flow      |                           |
|     meter, a video on asthma, a daily    |                           |
|     diary, and medication spacer.        |                           |
|                                          |                           |
| -   PressureWise -- An interactive       |                           |
|     program for members identified as    |                           |
|     hypertensive. Members attending      |                           |
|     program receive a blood pressure     |                           |
|     monitor and information on taking    |                           |
|     their blood pressure at home.        |                           |
+------------------------------------------+---------------------------+

## **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. You pay  |                    | * |   |
|   | P |     all charges for                |                    | P |   |
|   | * |     non-participating providers.   |                    | * |   |
|   | * |                                    |                    | * |   |
|   |   | -   Be sure to read Section 4,     |                    |   |   |
|   | * |     *Your costs for covered        |                    | * |   |
|   | * |     services*, for valuable        |                    | * |   |
|   | O |     information about how cost     |                    | O |   |
|   | * |     sharing works. Also read       |                    | * |   |
|   | * |     Section 9 about coordinating   |                    | * |   |
|   |   |     benefits with other coverage,  |                    |   |   |
|   | * |     including with Medicare.       |                    | * |   |
|   | * |                                    |                    | * |   |
|   | R | -   The amounts listed below are   |                    | R |   |
|   | * |     for the charges billed by a    |                    | * |   |
|   | * |     physician or other health care |                    | * |   |
|   |   |     professional for your surgical |                    |   |   |
|   | * |     care. Look in Section 5(c) for |                    | * |   |
|   | * |     charges associated with the    |                    | * |   |
|   | T |     facility (i.e. hospital,       |                    | T |   |
|   | * |     surgical center, etc.).        |                    | * |   |
|   | * |                                    |                    | * |   |
|   |   | -   YOU MUST GET PRECERTIFICATION  |                    |   |   |
|   | * |     OF SOME SURGICAL PROCEDURES.   |                    | * |   |
|   | * |     Please refer to the            |                    | * |   |
|   | A |     precertification information   |                    | A |   |
|   | * |     shown in Section 3 to be sure  |                    | * |   |
|   | * |     which services require         |                    | * |   |
|   |   |     precertification and identify  |                    |   |   |
|   | * |     which surgeries require        |                    | * |   |
|   | * |     precertification.              |                    | * |   |
|   | N |                                    |                    | N |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
|   | T |                                    |                    | T |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
+---+---+------------------------------------+--------------------+---+---+
| B |   |                                    | You pay            |   |   |
| e |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| f |   |                                    |                    |   |   |
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| t |   |                                    |                    |   |   |
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| p |   |                                    |                    |   |   |
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| i |   |                                    |                    |   |   |
| o |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
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+---+---+------------------------------------+--------------------+---+---+
| A |   |                                    | \$20 per office    |   |   |
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+---+---+------------------------------------+--------------------+---+---+
| - |   |                                    | \$20 per office    |   |   |
|   |   |                                    | visit; nothing for |   |   |
|   |   |                                    | hospital visit     |   |   |
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+---+---+------------------------------------+--------------------+---+---+
| * |   |                                    | *All charges.*     |   |   |
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| * |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+

+------------------------------------------+---------------------------+
| ###### Reconstructive surgery            | You pay                   |
+------------------------------------------+---------------------------+
| -   Surgery to correct a functional      | \$20 per office visit;    |
|     defect                               | nothing for hospital      |
|                                          | visit                     |
| -   Surgery to correct a condition       |                           |
|     caused by injury or illness if:      |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   the condition produced a major       |                           |
|     effect on the member's appearance    |                           |
|     and                                  |                           |
|                                          |                           |
| -   the condition can reasonably be      |                           |
|     expected to be corrected by such     |                           |
|     surgery                              |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Surgery to correct a condition that  |                           |
|     existed at or from birth and is a    |                           |
|     significant deviation from the       |                           |
|     common form or norm. Examples of     |                           |
|     congenital anomalies are: protruding |                           |
|     ear deformities; cleft lip; cleft    |                           |
|     palate; birth marks; webbed fingers; |                           |
|     and webbed toes.                     |                           |
|                                          |                           |
| -   All stages of breast reconstruction  |                           |
|     surgery following a mastectomy, such |                           |
|     as:                                  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   surgery to produce a symmetrical     |                           |
|     appearance of breasts;               |                           |
|                                          |                           |
| -   treatment of any physical            |                           |
|     complications, such as lymphedemas;  |                           |
|                                          |                           |
| -   breast prostheses and surgical bras  |                           |
|     and replacements (see Prosthetic     |                           |
|     devices)                             |                           |
|                                          |                           |
| Note: If you need a mastectomy, you may  |                           |
| choose to have the procedure performed   |                           |
| on an inpatient basis and remain in the  |                           |
| hospital up to 48 hours after the        |                           |
| procedure.                               |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Cosmetic surgery -- any surgical    |                           |
|     procedure (or any portion of a       |                           |
|     procedure) performed primarily to    |                           |
|     improve physical appearance through  |                           |
|     change in bodily form, except repair |                           |
|     of accidental injury*                |                           |
|                                          |                           |
| -   *Surgeries related to sex            |                           |
|     transformation*                      |                           |
+------------------------------------------+---------------------------+
| ###### Oral and maxillofacial surgery    | You pay                   |
+------------------------------------------+---------------------------+
| Oral surgical procedures, limited to:    | \$20 per office visit;    |
|                                          | nothing for hospital      |
| -   Reduction of fractures of the jaws   | visit                     |
|     or facial bones;                     |                           |
|                                          |                           |
| -   Surgical correction of cleft lip,    |                           |
|     cleft palate or severe functional    |                           |
|     malocclusion;                        |                           |
|                                          |                           |
| -   Removal of stones from salivary      |                           |
|     ducts;                               |                           |
|                                          |                           |
| -   Excision of leukoplakia or           |                           |
|     malignancies;                        |                           |
|                                          |                           |
| -   Excision of cysts and incision of    |                           |
|     abscesses when done as independent   |                           |
|     procedures; and                      |                           |
|                                          |                           |
| -   Other surgical procedures that do    |                           |
|     not involve the teeth or their       |                           |
|     supporting structures.               |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Oral implants and transplants*      |                           |
|                                          |                           |
| -   *Procedures that involve the teeth   |                           |
|     or their supporting structures (such |                           |
|     as the periodontal membrane,         |                           |
|     gingiva, and alveolar bone)*         |                           |
|                                          |                           |
| -   *Dental work related to TMJ*         |                           |
+------------------------------------------+---------------------------+
| ###### Organ/tissue transplants          | You pay                   |
+------------------------------------------+---------------------------+
| Limited to:                              | \$20 per office visit;    |
|                                          | nothing at hospital       |
| -   Cornea                               | visit.                    |
|                                          |                           |
| -   Heart                                |                           |
|                                          |                           |
| -   Heart/lung                           |                           |
|                                          |                           |
| -   Kidney                               |                           |
|                                          |                           |
| -   Kidney/Pancreas                      |                           |
|                                          |                           |
| -   Liver                                |                           |
|                                          |                           |
| -   Lung: Single -- Double               |                           |
|                                          |                           |
| -   Pancreas                             |                           |
|                                          |                           |
| -   Allogenic donor bone marrow          |                           |
|     transplants                          |                           |
|                                          |                           |
| -   Autologous bone marrow transplants   |                           |
|     (autologous stem cell and peripheral |                           |
|     stem cell support) for the following |                           |
|     conditions: acute lymphocytic or     |                           |
|     non-lymphocytic leukemia; advanced   |                           |
|     Hodgkin's lymphoma; advanced         |                           |
|     non-Hodgkin's lymphoma; advanced     |                           |
|     neuroblastoma; breast cancer;        |                           |
|     multiple myeloma; epithelial ovarian |                           |
|     cancer; and testicular, mediastinal, |                           |
|     retroperitoneal and ovarian germ     |                           |
|     cell tumors                          |                           |
|                                          |                           |
| -   Intestinal transplants (small        |                           |
|     intestine) and the small intestine   |                           |
|     with the liver or small intestine    |                           |
|     with multiple organs such as the     |                           |
|     liver, stomach, and pancreas when    |                           |
|     medically necessary.                 |                           |
|                                          |                           |
| -   National Transplant Program (NTP) -- |                           |
|     CDPHP UBI facilitates organ          |                           |
|     transplants at a CDPHP UBI approved  |                           |
|     transplant center                    |                           |
|                                          |                           |
| Limited Benefits -- Treatment for breast |                           |
| cancer, multiple myeloma, and epithelial |                           |
| ovarian cancer may be provided in a      |                           |
| National Cancer Institute -- or National |                           |
| Institutes of Health-approved clinical   |                           |
| trial at a Plan-designated center of     |                           |
| excellence and if approved by the Plan's |                           |
| medical director in accordance with the  |                           |
| Plan's protocols.                        |                           |
|                                          |                           |
| Note: We cover related medical and       |                           |
| hospital expenses of the donor when we   |                           |
| cover the recipient.                     |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *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           |                           |
+------------------------------------------+---------------------------+
| Professional services provided in --     | \$20 per office visit     |
|                                          |                           |
| -   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. You pay all charges   |                     | * |   |
|   | * |     for non-participating           |                     | * |   |
|   |   |     providers.                      |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * | -   Be sure to read Section 4,      |                     | * |   |
|   | O |     *Your costs for covered         |                     | O |   |
|   | * |     services* for valuable          |                     | * |   |
|   | * |     information about how cost      |                     | * |   |
|   |   |     sharing works. Also read        |                     |   |   |
|   | * |     Section 9 about coordinating    |                     | * |   |
|   | * |     benefits with other coverage,   |                     | * |   |
|   | R |     including with Medicare.        |                     | R |   |
|   | * |                                     |                     | * |   |
|   | * | -   The amounts listed below are    |                     | * |   |
|   |   |     for the charges billed by the   |                     |   |   |
|   | * |     facility (i.e., hospital or     |                     | * |   |
|   | * |     surgical center) or ambulance   |                     | * |   |
|   | T |     service for your surgery or     |                     | T |   |
|   | * |     care. Any costs associated with |                     | * |   |
|   | * |     the professional charge (i.e.,  |                     | * |   |
|   |   |     physicians, etc.) are in        |                     |   |   |
|   | * |     Sections 5(a) or (b).           |                     | * |   |
|   | * |                                     |                     | * |   |
|   | A | -   **YOU MUST GET PRECERTIFICATION |                     | A |   |
|   | * |     OF HOSPITAL STAYS.** Please     |                     | * |   |
|   | * |     refer to Section 3 to be sure   |                     | * |   |
|   |   |     which services require          |                     |   |   |
|   | * |     precertification.               |                     | * |   |
|   | * |                                     |                     | * |   |
|   | N |                                     |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| R |   |                                     | \$100 copay per day |   |   |
| o |   |                                     | up to a maximum of  |   |   |
| o |   |                                     | \$500 per           |   |   |
| m |   |                                     | admission. For      |   |   |
| a |   |                                     | family coverage,    |   |   |
| n |   |                                     | inpatient copays    |   |   |
| d |   |                                     | are limited to two  |   |   |
| b |   |                                     | per calendar year.  |   |   |
| o |   |                                     | The copayment does  |   |   |
| a |   |                                     | not apply to        |   |   |
| r |   |                                     | hospital inpatient  |   |   |
| d |   |                                     | charges for newborn |   |   |
| , |   |                                     | nursery care.       |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | 20% of charges      |   |   |
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| - |   |                                     | \$20 per day        |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     | You pay             |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$50 per trip       |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
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| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

## 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.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Be sure to read Section 4,      |                     | * |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | P |     services,* for valuable         |                     | P |   |
|   | * |     information about how cost      |                     | * |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   |   |     Section 9 about coordinating    |                     |   |   |
|   | * |     benefits with other coverage,   |                     | * |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | O |                                     |                     | O |   |
|   | * | #####                               |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | R |                                     |                     | R |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
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|   | T |                                     |                     | T |   |
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|   |   |                                     |                     |   |   |
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|   | N |                                     |                     | N |   |
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|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     |                     |   |   |
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| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$25 per visit      |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| 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 |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$50 per visit      |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     | \$100 per day if    |   |   |
|   |   |                                     | admitted, up to a   |   |   |
| E |   |                                     | maximum of \$500    |   |   |
| m |   |                                     | per confinement,    |   |   |
| e |   |                                     | limited to two      |   |   |
| r |   |                                     | copayments per      |   |   |
| g |   |                                     | family per calendar |   |   |
| e |   |                                     | year.               |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
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| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
| N |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| 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 |   |                                     |                     |   |   |
| 7 |   |                                     |                     |   |   |
| 8 |   |                                     |                     |   |   |
| 3 |   |                                     |                     |   |   |
| 3 |   |                                     |                     |   |   |
| 2 |   |                                     |                     |   |   |
| 7 |   |                                     |                     |   |   |
| 5 |   |                                     |                     |   |   |
| 7 |   |                                     |                     |   |   |
| . |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| } |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$20 per visit      |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| ' |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| f |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$25 per visit      |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$50 per visit      |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     | \$100 per day if    |   |   |
|   |   |                                     | admitted, up to a   |   |   |
| E |   |                                     | maximum of \$500    |   |   |
| m |   |                                     | per confinement,    |   |   |
| e |   |                                     | limited to two      |   |   |
| r |   |                                     | copayments per      |   |   |
| g |   |                                     | family per calendar |   |   |
| e |   |                                     | year.               |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| * |   |                                     | *All charges.*      |   |   |
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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 |   |
|   | * | -   Be sure to read Section 4,    |                      | * |   |
|   | * |     *Your costs for covered       |                      | * |   |
|   |   |     services*, for valuable       |                      |   |   |
|   | * |     information about how cost    |                      | * |   |
|   | * |     sharing works. Also read      |                      | * |   |
|   | R |     Section 9 about coordinating  |                      | R |   |
|   | * |     benefits with other coverage, |                      | * |   |
|   | * |     including with Medicare.      |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * | -   **YOU MUST GET                |                      | * |   |
|   | * |     PREAUTHORIZATION OF THESE     |                      | * |   |
|   | T |     SERVICES.** See the           |                      | T |   |
|   | * |     instructions after the        |                      | * |   |
|   | * |     benefits description below.   |                      | * |   |
|   |   |     Participating providers must  |                      |   |   |
|   | * |     provide all care.             |                      | * |   |
|   | * |                                   |                      | * |   |
|   | A |                                   |                      | A |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | N |                                   |                      | N |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | T |                                   |                      | T |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
+---+---+-----------------------------------+----------------------+---+---+
| B |   |                                   | You pay              |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| f |   |                                   |                      |   |   |
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| i |   |                                   |                      |   |   |
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| n |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
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|   |   |                                   |                      |   |   |
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| s |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| A |   |                                   | Your cost sharing    |   |   |
| l |   |                                   | responsibilities are |   |   |
| l |   |                                   | no greater than for  |   |   |
| d |   |                                   | other illnesses or   |   |   |
| i |   |                                   | conditions.          |   |   |
| a |   |                                   |                      |   |   |
| g |   |                                   |                      |   |   |
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| - |   |                                   | \$20 per visit       |   |   |
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| g |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| m |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$20 per visit or    |   |   |
|   |   |                                   | test                 |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| D |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| g |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| c |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$20 outpatient      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   | \$100 copay per day  |   |   |
|   |   |                                   | up to a maximum of   |   |   |
| S |   |                                   | \$500 per admission. |   |   |
| e |   |                                   | For family coverage, |   |   |
| r |   |                                   | inpatient copays are |   |   |
| v |   |                                   | limited to two per   |   |   |
| i |   |                                   | calendar year.       |   |   |
| c |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| * |   |                                   | *All charges.*       |   |   |
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+---+---+-----------------------------------+----------------------+---+---+

+-----------------------------------------------------------------------+
| **Preauthorization** To be eligible to receive these benefits you     |
| must obtain a treatment plan and follow all of the following network  |
| authorization processes:                                              |
|                                                                       |
| Mental Health Care You have direct access to in-network mental health |
| care. A direct access toll-free telephone number, 1-800-700-4824, to  |
| ValueOptions, will connect you to a qualified mental health clinician |
| who will assist and arrange for treatment. For your convenience, the  |
| telephone number for mental health services is imprinted on your      |
| CDPHP UBI ID card.                                                    |
|                                                                       |
| Alcohol/Substance Abuse Benefits You have access to alcohol and       |
| substance abuse care. These benefits are coordinated by St. Peter's   |
| Addiction Recovery Center (SPARC). CDPHP UBI members can contact      |
| SPARC directly at 1-800-427-9025.                                     |
+-----------------------------------------------------------------------+
| **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 the next page. | * |   |
|   |   |                                                        |   |   |
|   | * | -   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.                               | * |   |
|   | * |                                                        | * |   |
|   |   | -   Be sure to read Section 4, *Your costs for covered |   |   |
|   | * |     services,* for valuable information about how cost | * |   |
|   | * |     sharing works. Also read Section 9 about           | * |   |
|   | P |     coordinating benefits with other coverage,         | P |   |
|   | * |     including with Medicare.                           | * |   |
|   | * |                                                        | * |   |
|   |   |                                                        |   |   |
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+---+---+--------------------------------------------------------+---+---+
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|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| a |   |                                                        |   |   |
| t |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| 1 |   |                                                        |   |   |
| - |   |                                                        |   |   |
| 8 |   |                                                        |   |   |
| 7 |   |                                                        |   |   |
| 7 |   |                                                        |   |   |
| - |   |                                                        |   |   |
| 2 |   |                                                        |   |   |
| 6 |   |                                                        |   |   |
| 9 |   |                                                        |   |   |
| - |   |                                                        |   |   |
| 2 |   |                                                        |   |   |
| 1 |   |                                                        |   |   |
| 3 |   |                                                        |   |   |
| 4 |   |                                                        |   |   |
| . |   |                                                        |   |   |
+---+---+--------------------------------------------------------+---+---+

*Prescription drug benefits begin on the next page*

+------------------------------------------+---------------------------+
| **Benefit Description**                  | **You pay**               |
+------------------------------------------+---------------------------+
| ###### Covered medications and supplies  |                           |
+------------------------------------------+---------------------------+
| We cover the following medications and   | \$10 generic/\$25         |
| supplies prescribed by a Plan physician  | preferred brand/\$40      |
| and obtained from a Plan pharmacy or     | non-preferred brand for a |
| through our mail order program:          | 30-day supply.            |
|                                          |                           |
| -   Drugs and medicines that by Federal  | \$20 generic/\$50         |
|     law of the United States require a   | preferred brand/\$80      |
|     physician's prescription for their   | non-preferred brand for a |
|     purchase, except those listed as     | 90-day supply by mail     |
|     *Not covered.*                       | order                     |
|                                          |                           |
| -   Self-administered injectable drugs   | Note: If there is no      |
|                                          | generic equivalent        |
| -   Implanted time-release medications.  | available, you will still |
|     There will be no refund of any       | have to pay the brand     |
|     portion of the copay if the          | name copay.               |
|     medication is removed before the end |                           |
|     of the expected life.                |                           |
|                                          |                           |
| -   Drugs for sexual dysfunction within  |                           |
|     applicable limits                    |                           |
|                                          |                           |
| -   Contraceptive drugs and devices      |                           |
|                                          |                           |
| -   Smoking cessation prescriptions up   |                           |
|     to a 12-week supply                  |                           |
|                                          |                           |
| -   Contraceptive drugs and devices      |                           |
|                                          |                           |
| -   Nutritional supplements for the      |                           |
|     therapeutic treatment of             |                           |
|     phenylketonuria (PKU).               |                           |
|                                          |                           |
| -   Infertility prescriptions available  |                           |
|     for members between 21 and 44 years  |                           |
|     of age.                              |                           |
|                                          |                           |
| -   Intravenous fluids and medication    |                           |
|     for home use.                        |                           |
|                                          |                           |
| -   Prescription drugs for certain       |                           |
|     inherited disease of amino acid and  |                           |
|     organic acid metabolism shall        |                           |
|     include modified sold food products  |                           |
|     that are low protein or which        |                           |
|     contain modified protein which are   |                           |
|     medically necessary for up to 12     |                           |
|     months. Benefit limit of \$2,500.    |                           |
+------------------------------------------+---------------------------+
| -   Insulin, oral agents to control      | \$20 per item             |
|     blood sugar, needles, test strips,   |                           |
|     lancets, and visual reading and      |                           |
|     urine test strips                    |                           |
|                                          |                           |
| -   Disposable needles and syringes for  |                           |
|     the administration of covered        |                           |
|     medication                           |                           |
|                                          |                           |
| -   Durable medical equipment for        |                           |
|     insulin dependent persons,           |                           |
|     preauthorization needed only if over |                           |
|     \$500.                               |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes*                            |                           |
|                                          |                           |
| -   *Vitamins, nutrients, and food       |                           |
|     supplements that can be purchased    |                           |
|     without a prescription*              |                           |
|                                          |                           |
| -   *Nonprescription medicines*          |                           |
|                                          |                           |
| -   *Weight loss prescriptions*          |                           |
|                                          |                           |
| -   *Drugs to enhance athletic           |                           |
|     performance*                         |                           |
|                                          |                           |
| -   *Drugs obtained at a non-Plan        |                           |
|     pharmacy; except for out-of-area     |                           |
|     emergencies*                         |                           |
+------------------------------------------+---------------------------+

## **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.                                  |
+----------------------+-----------------------------------------------+
| ###                  | If you are away at school and need medical    |
| ## Non-emergency car | care (non-preventive) for an illness or       |
| e for full-time stud | injury, coverage is available. When a medical |
| ents out of the area | situation develops, call 1-800-274-2332 prior |
|                      | to seeking care and request that CDPHP UBI    |
|                      | authorize coverage of necessary treatment by  |
|                      | a practitioner in the area.                   |
+----------------------+-----------------------------------------------+
| ####                 | The telephone system also includes a TDD      |
| # Services for deaf  | system. Members may call 1-877-261-1164 for   |
| and hearing impaired | services.                                     |
+----------------------+-----------------------------------------------+
| ##### C              | CDPHP UBI will reimburse expectant mothers 50 |
| hildbirth Education  | percent of the cost, up to \$30 per year, for |
| Reimbursement Progam | participating in and completing childbirth    |
|                      | education classes. Once you complete the      |
|                      | class, send the receipt and certificate of    |
|                      | completion to CDPHP UBI, Patroon Creek        |
|                      | Corporate Center, 1223 Washington Ave.,       |
|                      | Albany, NY 12206, for reimbursement.          |
+----------------------+-----------------------------------------------+
| ##### Ce             | CDPHP facilitates care at approved transplant |
| nters of excellence  | centers for medically necessary,              |
|                      | non-experimental treatment.                   |
+----------------------+-----------------------------------------------+

## **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 |   |
|   | * | -   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 |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | A |                                    |                     | A |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | N |                                    |                     | N |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | T |                                    |                     | T |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
+===+===+====================================+=====================+===+===+
| # |   |                                    | You pay             |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| A |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| j |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| W |   |                                    | \$20 per visit      |   |   |
| e |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
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| r |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
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| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
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| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
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| p |   |                                    |                     |   |   |
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| . |   |                                    |                     |   |   |
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| l |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| j |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| . |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| D |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| W |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| 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.**

+------------------------------+---------------------------------------+
| "The Road to Good Health"    | Through a series of wellness          |
| Wellness Workshops           | workshops, you can learn how the      |
|                              | combined power of good nutrition,     |
|                              | regular exercise, and stress          |
|                              | management can help you move toward   |
|                              | optimal health and well-being. A      |
|                              | schedule of wellness programs appears |
|                              | on our Web site,                      |
|                              | [w                                    |
|                              | ww.cdphp.com](http://www.cdphp.com/), |
|                              | and in *SmartMoves,* CDPHP's          |
|                              | quarterly member newsletter. All      |
|                              | wellness programs are free to         |
|                              | members.                              |
+------------------------------+---------------------------------------+
| Complementary and            | CDPHP will be offering at no charge,  |
| Alternative Medicine (CAM)   | an easy way to research and obtain    |
| Program                      | reputable, top-quality Complementary  |
|                              | and Alternative Medicine (CAM)        |
|                              | services and products. The program is |
|                              | being provided to CDPHP members       |
|                              | through a partnership with American   |
|                              | WholeHealth, Inc., a nationwide group |
|                              | of more than 28,000 credentialed      |
|                              | practitioners of acupuncture,         |
|                              | massage, chiropractic, and other CAM  |
|                              | disciplines. The CAM program features |
|                              | discounts on a wide variety of        |
|                              | non-covered services, including:      |
|                              | vitamins, massage therapy, fitness    |
|                              | centers, spas, personal trainers, Tai |
|                              | Chi classes, health magazine          |
|                              | subscriptions, and more. Members may  |
|                              | access it by logging in through       |
|                              | CDPHP's secure Web site function,     |
|                              | Online Health™ using member ID and    |
|                              | PIN. Areas that can be navigated      |
|                              | include:                              |
|                              |                                       |
|                              | -   Healing Centers---Look up home    |
|                              |     remedies to supplement the care   |
|                              |     your physician provides.          |
|                              |                                       |
|                              | -   Reference Library---Learn about   |
|                              |     dozens of different natural       |
|                              |     therapies.                        |
|                              |                                       |
|                              | -   Healing Kitchen---Review healthy  |
|                              |     recipes and nutrition             |
|                              |     information.                      |
|                              |                                       |
|                              | -   News and Perspectives---Read      |
|                              |     updates from the medical          |
|                              |     literature.                       |
|                              |                                       |
|                              | -   Expert Opinions---See how the     |
|                              |     experts answer frequently asked   |
|                              |     questions.                        |
|                              |                                       |
|                              | -   Find A Practitioner---Locate a    |
|                              |     participating massage therapist,  |
|                              |     acupuncturist, or holistic        |
|                              |     practitioner near you.            |
+------------------------------+---------------------------------------+
| Disease Management Programs  | -   Smoking Cessation---Classes       |
|                              |     provided at no cost to you        |
|                              |     through CDPHP's wellness program. |
|                              |                                       |
|                              | -   Peak Asthma Performance---Members |
|                              |     are encouraged to call a          |
|                              |     toll-free number to CDPHP's       |
|                              |     Wellness Line for telephonic      |
|                              |     education. They may receive a     |
|                              |     semi-annual newsletter about      |
|                              |     asthma and a kit including a peak |
|                              |     flow meter, a video on asthma, a  |
|                              |     daily diary, and a medication     |
|                              |     spacer.                           |
|                              |                                       |
|                              | -   Pressure Wise---An interactive    |
|                              |     program for members identified as |
|                              |     hypertensive. Members attending   |
|                              |     the program receive a blood       |
|                              |     pressure monitor and information  |
|                              |     on taking their blood pressure at |
|                              |     home.                             |
+------------------------------+---------------------------------------+

# 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 *Services Requiring Our Prior Approval* on page 9.**

We do not cover the following:

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

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

-   Services, drugs, or supplies not medically necessary;

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

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

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

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

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

-   Sservices, drugs, or supplies required for obtaining or continuing
    employment or insurance, attending schools or camp, or travel; 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,         | In most cases, providers and facilities file      |
| hospital, and    | claims for you. Physicians must file on the form  |
| drug benefits    | HCFA-1500, Health Insurance Claim Form. Your      |
|                  | facility will file on the UB-92 form. For claims  |
|                  | questions and assistance, call us at (518)        |
|                  | 641-3140 or 1-877-269-2134.                       |
|                  |                                                   |
|                  | 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:** CDPHP Universal        |
|                  | Benefits, Inc.\                                   |
|                  | Patroon Creek Corporate Center\                   |
|                  | 1223 Washington Avenue\                           |
|                  | Albany, NY 12206                                  |
+------------------+---------------------------------------------------+
| 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
preauthorization/prior approval:

+----+-----------------------------------------------------------------+
| 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: CDPHP UBI, Patroon Creek        |
|    |     Corporate Center, 1223 Washington Ave., Albany, NY 12206;   |
|    |     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 2, 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              |
|    | precertification or prior approval. This is the only deadline   |
|    | that may not be extended.                                       |
|    |                                                                 |
|    | OPM may disclose the information it collects during the review  |
|    | process to support their disputed claim decision. This          |
|    | information will become part of the court record.               |
+----+-----------------------------------------------------------------+
|    | You may not sue until you have completed the disputed claims    |
|    | process. Further, Federal law governs your lawsuit, benefits,   |
|    | and payment of benefits. The Federal court will base its review |
|    | on the record that was before OPM when OPM decided to uphold or |
|    | overturn our decision. You may recover only the amount of       |
|    | benefits in dispute.                                            |
+----+-----------------------------------------------------------------+

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

a)  We haven't responded yet to your initial request for care or
    preauthorization/prior approval, then call us at (518) 641-3140 or
    1-877-269-2134 and we will expedite our review; or

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

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

-   You may call OPM's Health Insurance Group 2 at (202) 606-3818
    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.                       |
+------------------+---------------------------------------------------+

[]{#__RefHeading___Toc82425548 .anchor}

+------------------+---------------------------------------------------+
| ##               | 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, |
|                  | such as preauthorization for inpatient hospital   |
|                  | stays.                                            |
+------------------+---------------------------------------------------+
|                  | **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 (518) 641-3140 or 1-877-269-2134   |
|                  |     or see our Web site at                        |
|                  |     [www.cdphp.com](http://www.cdphp.com/).       |
|                  |                                                   |
|                  | **We do not waive any costs if the Original       |
|                  | Medicare Plan is your primary payer.**            |
+------------------+---------------------------------------------------+

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 or through your |       | ****  |
|     spouse who is also an active employee          |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Have FEHB coverage through your spouse who is  | **** |        |
|     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)     |       |        |
+----------------------------------------------------+-------+--------+
| 6)  Are enrolled in Part B only, regardless of     | **** | ****  |
|     your employment status                         | for   | for    |
|                                                    | 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 |       | **     |
|     already a Medicare beneficiary and**...**      |       | **for |
|                                                    |       | 30     |
| -   This Plan was the primary payer before         |       | -month |
|     eligibility due to ESRD                        |       | coordi |
|                                                    |       | nation |
|                                                    |       | period |
+----------------------------------------------------+-------+--------+
| -   Medicare was the primary payer before          | **** |        |
|     eligibility due to ESRD                        |       |        |
+----------------------------------------------------+-------+--------+
| **C. When either you or your spouse are eligible   |       |        |
| for Medicare solely due to disability and you...** |       |        |
+----------------------------------------------------+-------+--------+
| Have FEHB coverage on your own or through your     |       | ****  |
| spouse who is also an active employee              |       |        |
+----------------------------------------------------+-------+--------+
| Have FEHB coverage on your own as an annuitant or  | **** |        |
| through a family member who is an annuitant        |       |        |
+----------------------------------------------------+-------+--------+
| **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 plan:**  |
|                    | You may enroll in our Medicare Advantage plan   |
|                    | (called Medicare Choice) and also remain        |
|                    | enrolled in our FEHB plan. In this case, we do  |
|                    | not waive cost-sharing for your FEHB coverage.  |
|                    |                                                 |
|                    | **This Plan and another plan\'s Medicare        |
|                    | 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, coinsurance,   |
|                    | or deductibles. 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.                                        |
+--------------------+-------------------------------------------------+

[]{#__RefHeading___Toc82425551 .anchor}

+--------------------+-------------------------------------------------+
| ### 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. You may also be
                      responsible for additional amounts. See page 12.

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

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

  Custodial care      Custodial care is care that does not have a direct
                      medical benefit such as house cleaning, preparing
                      meals, personal hygiene. Custodial care that lasts
                      90 days or longer is sometimes known as long-term
                      care.

  Deductible          A deductible is a fixed amount of covered expenses
                      you must incur for certain covered services and
                      supplies before the plan starts paying for those
                      services. Note: We do not have a deductible.

  Experimental or     A procedure that is not approved by the Federal
  investigational     Food and Drug Administration and/or the National
  services            Institute of Health Technology Assessment.

  Group health        Medical benefits such as hospital, surgical, and
  coverage            preventive care that are purchased on an
                      employer-sponsored basis.

  Medical necessity   A service or treatment which is appropriate and
                      consistent with the diagnosis and accepted
                      standards in the medical community.

  Plan allowance      Plan allowance is the amount we use to determine
                      our payment and your coinsurance for covered
                      services. Plans determine their allowances in
                      different ways. We determine our allowance by the
                      average community charges. Our providers accept the
                      allowances as payment in full.

  Us/We               Us and We refer to CDPHP Universal Benefits, Inc.,
                      an affiliate of Capital District Physicians' Health
                      Plan, Inc. (CDPHP).

  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 a prepaid plan     |
|                  |     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 a prepaid plan 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    |        |        |
|     FSA?         | that allows you to set aside   |        |        |
|                  | pre-tax money from your        |        |        |
|                  | paychecks to pay for a variety |        |        |
|                  | of eligible expenses. *By      |        |        |
|                  | using an FSA, you can reduce   |        |        |
|                  | your taxes while paying for    |        |        |
|                  | services you would have to pay |        |        |
|                  | for anyway, producing a        |        |        |
|                  | discount that can be over      |        |        |
|                  | 40%.*                          |        |        |
|                  |                                |        |        |
|                  | There are two types of FSAs    |        |        |
|                  | offered by FSAFEDS:            |        |        |
+------------------+--------------------------------+--------+--------+
| Health Care      | -   Covers eligible health     |        |        |
| Flexible         |     care expenses not          |        |        |
| Spending Account |     reimbursed by this Plan,   |        |        |
| (HCFSA)          |     or any other medical,      |        |        |
|                  |     dental, or vision care     |        |        |
|                  |     plan you or your           |        |        |
|                  |     dependents may have.       |        |        |
|                  |                                |        |        |
|                  | -   Eligible dependents for    |        |        |
|                  |     this account include       |        |        |
|                  |     anyone you claim on your   |        |        |
|                  |     Federal Income Tax return  |        |        |
|                  |     as a qualified dependent   |        |        |
|                  |     under the U.S. Internal    |        |        |
|                  |     Revenue Service (IRS)      |        |        |
|                  |     definition and/or with     |        |        |
|                  |     whom you jointly file your |        |        |
|                  |     Federal Income Tax return, |        |        |
|                  |     even if you don't have     |        |        |
|                  |     self and family health     |        |        |
|                  |     benefits coverage. *Note:* |        |        |
|                  |     The IRS has a broader      |        |        |
|                  |     definition 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  |        |        |
| Flexible         |     care expenses incurred so  |        |        |
| Spending Account |     you and your spouse, if    |        |        |
| (DCFSA)          |     married, can work, look    |        |        |
|                  |     for work, or attend school |        |        |
|                  |     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 child care subsidy you |        |        |
|                  |     may receive.               |        |        |
+------------------+--------------------------------+--------+--------+
| -   Enroll       | You **must make an election**  |        |        |
|     during Open  | to enroll in an FSA during the |        |        |
|     Season       | 2005 FEHB Open Season. Even if |        |        |
|                  | you 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   |        |        |
|                  | 12 and detailed throughout     |        |        |
|                  | this brochure. Your HCFSA will |        |        |
|                  | reimburse you when those costs |        |        |
|                  | are for qualified 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: inpatient hospital    |        |        |
|                  | copayments, coinsurance for    |        |        |
|                  | durable medical equipment,     |        |        |
|                  | office visit copays,           |        |        |
|                  | prescription drug copays,      |        |        |
|                  | dental services, and           |        |        |
|                  | eyeglasses.                    |        |        |
|                  |                                |        |        |
|                  | 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 | No. Section 1127 of the        |        |        |
|     me anything  | National Defense Authorization |        |        |
|     to           | Act (Public Law 108-136)       |        |        |
|     participate  | requires agencies that offer   |        |        |
|     in FSAFEDS?  | FSAFEDS to employees to cover  |        |        |
|                  | the administrative fee(s) on   |        |        |
|                  | behalf of their 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.                           |
|                  |                                                   |
|                  | -   **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.         |
|                  |                                                   |
|                  | -   **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.      |
|                  |                                                   |
|                  | -   **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.                     |
|                  |                                                   |
|                  | -   **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  |                                                   |
+------------------+---------------------------------------------------+

#   {#section-3 .unnumbered}

# Index

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

Accidental injury 17, 21, 32

Allergy tests 15

Allogeneic (donor) bone marrow transplant 22

Alternative treatments 19

Ambulance 23, 24, 26

Anesthesia 5, 20

Autologous bone marrow transplant 16, 22

Biopsy 20

Blood and blood plasma 24

Casts 23, 24

Catastrophic protection out-of-pocket maximum 53

**Changes for 2005** 7

Chemotherapy 16

Chiropractic 19

Cholesterol tests 13

Claims 8, 11, 35, 36, 40, 45, 47

Coinsurance 6, 8, 35, 43, 48

Colorectal cancer screening 13

Congenital anomalies 20, 21

Contraceptive drugs and devices 15, 30

Covered charges 39

Crutches 18

Deductible 6, 10, 48

Definitions 12, 20, 23, 25, 27, 29, 32, 43, 52

Dental care 32, 52

Diagnostic services 12, 23, 27, 52

Disputed claims review 31

Donor expenses 22

Dressings 23

Durable medical equipment 18

Educational classes and programs 19

Effective date of enrollment 9

Emergency 6, 25, 26, 34, 35, 52

Experimental or investigational 34

Eyeglasses 17

Family planning 15

Fraud 3, 4

General exclusions 34

General Exclusions 11

Hearing services 17

Home health services 19

Hospice care 24

Hospital 5, 6, 8, 9, 18, 20, 21, 22, 23, 24, 25, 27, 35, 39, 41, 42, 52

Immunizations 6, 13

Infertility 15

Inpatient hospital benefits 35

Insulin 30

Magnetic Resonance Imagings (MRIs) 13

Mammograms 13

Maternity benefits 14

Medicaid 42

Medically necessary 12, 14, 16, 20, 23, 25, 27, 29, 32, 34

Medicare 27, 38, 40

Medicare + Choice 41

Original 39, 41

Medicare Advantage 41

Members

Associate 54

Family 44

Plan 8, 33

Mental Health/Substance Abuse Benefits 27

Newborn care 14

Nurse

Licensed Practical Nurse (LPN) 19

Nurse Anesthetist (NA) 23

Occupational therapy 16

Ocular injury 17

Office visits 6, 10

Oral and maxillofacial surgical 21

Out-of-pocket expenses 38

Oxygen 18, 19, 23, 24

Pap test 13

Physician 18, 20

Precertification 37

Prescription drugs 35, 41, 52

Preventive care, adult 13

Preventive care, children 14

Preventive services 6

Prior approval 36, 37

Prosthetic devices 20

Psychologist 27

Radiation therapy 16

Room and board 23

Second surgical opinion 12

Skilled nursing facility care 9, 12, 22, 24

Smoking cessation 19

Social worker 27

Speech therapy 16

Splints 23

Subrogation 42

Substance abuse 52

Surgery 5, 14, 16, 17

Anesthesia 24

Oral 21

Outpatient 24

Reconstructive 20, 21

Syringes 30

Temporary Continuation of Coverage (TCC) 45

Transplants 16, 22

Treatment therapies 16

Vision care 52

Vision services 17

Wheelchairs 18

Workers Compensation 42

X-rays 13, 23, 24

# Summary of benefits for CDPHP UBI *-* 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           |                       |    |
| physicians:                            |                       |    |
+----------------------------------------+-----------------------+----+
| -   Diagnostic and treatment services  | Office visit copay:   | 12 |
|     provided in the office             | \$20 primary care;    |    |
|                                        | \$20 specialist       |    |
+----------------------------------------+-----------------------+----+
| Services provided by a hospital:       |                       |    |
+----------------------------------------+-----------------------+----+
| -   Inpatient                          | \$100 copay per day   | 23 |
|                                        | up to a maximum of    |    |
|                                        | \$500 per admission.  |    |
|                                        | For family coverage,  |    |
|                                        | inpatient copays are  |    |
|                                        | limited to two per    |    |
|                                        | calendar year*.*      |    |
+----------------------------------------+-----------------------+----+
| -   Outpatient                         | \$20 per visit        | 24 |
+----------------------------------------+-----------------------+----+
| Emergency benefits                     |                       |    |
+----------------------------------------+-----------------------+----+
| -   In-area                            | \$50 per visit to     | 25 |
|                                        | hospital emergency    |    |
|                                        | room; \$25 per visit  |    |
|                                        | to urgent care center |    |
+----------------------------------------+-----------------------+----+
| -   Out-of-area                        | \$50 per visit to     | 26 |
|                                        | hospital emergency    |    |
|                                        | room                  |    |
+----------------------------------------+-----------------------+----+
| Mental health and substance abuse      | Regular cost sharing  | 27 |
| treatment                              |                       |    |
+----------------------------------------+-----------------------+----+
| Prescription drugs                     | \$10 generic/\$25     | 29 |
|                                        | preferred brand/\$40  |    |
|                                        | non-preferred brand   |    |
|                                        | for a 30-day supply.  |    |
|                                        |                       |    |
|                                        | \$20 generic/\$50     |    |
|                                        | preferred brand/\$80  |    |
|                                        | non-preferred brand   |    |
|                                        | for a 90-day supply   |    |
|                                        | by mail order         |    |
+----------------------------------------+-----------------------+----+
| Dental care .                          | \$20 per visit for    | 32 |
|                                        | accidental injury     |    |
|                                        | benefit               |    |
+----------------------------------------+-----------------------+----+
| Vision care .                          | \$20 per visit for    | 17 |
|                                        | one refraction every  |    |
|                                        | 24 months.            |    |
+----------------------------------------+-----------------------+----+
| Special features:                      |                       | 31 |
|                                        |                       |    |
| Flexible benefits option               |                       |    |
|                                        |                       |    |
| Non-emergency medical care for         |                       |    |
| full-time students attending school    |                       |    |
| out of the area                        |                       |    |
|                                        |                       |    |
| Services for the deaf and hearing      |                       |    |
| impaired                               |                       |    |
|                                        |                       |    |
| Childbirth Education Reimbursement     |                       |    |
| Program                                |                       |    |
|                                        |                       |    |
| Centers of Excellence for              |                       |    |
| transplants/heart surgery              |                       |    |
+----------------------------------------+-----------------------+----+
| Protection against catastrophic costs  | We do not have an     | 10 |
|                                        | out-of-pocket maximum |    |
| (your out-of-pocket maximum)           |                       |    |
+----------------------------------------+-----------------------+----+

# 2005 Rate Information for CDPHP UBI

**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.

+---------+-------+-------+----------+-------+-------+-------+------+
|         |       | ***   |          |       |       | ***P  |      |
|         |       | Non-P |          |       |       | ostal |      |
|         |       | ostal |          |       |       | Premi |      |
|         |       | Premi |          |       |       | um*** |      |
|         |       | um*** |          |       |       |       |      |
+---------+-------+-------+----------+-------+-------+-------+------+
|         |       | *     |          | **[Mo |       | *     |      |
|         |       | *[Biw |          | nthly |       | *[Biw |      |
|         |       | eekly |          | ]{.un |       | eekly |      |
|         |       | ]{.un |          | derli |       | ]{.un |      |
|         |       | derli |          | ne}** |       | derli |      |
|         |       | ne}** |          |       |       | ne}** |      |
+---------+-------+-------+----------+-------+-------+-------+------+
| *       | **C   | **    | **Your   | **    | *     | *     | **   |
| *Type** | ode** | Gov't | Share**  | Gov't | *Your | *USPS | Your |
|         |       | Sh    |          | Sh    | Sh    | Sh    | Sha  |
| **of**  |       | are** |          | are** | are** | are** | re** |
|         |       |       |          |       |       |       |      |
| **Enrol |       |       |          |       |       |       |      |
| lment** |       |       |          |       |       |       |      |
+---------+-------+-------+----------+-------+-------+-------+------+
| **L     |       |       |          |       |       |       |      |
| ocation |       |       |          |       |       |       |      |
| Inform  |       |       |          |       |       |       |      |
| ation** |       |       |          |       |       |       |      |
| **You   |       |       |          |       |       |       |      |
| must    |       |       |          |       |       |       |      |
| live or |       |       |          |       |       |       |      |
| work in |       |       |          |       |       |       |      |
| Nassau, |       |       |          |       |       |       |      |
| Suffolk |       |       |          |       |       |       |      |
| or      |       |       |          |       |       |       |      |
| Queens  |       |       |          |       |       |       |      |
| c       |       |       |          |       |       |       |      |
| ounties |       |       |          |       |       |       |      |
| New     |       |       |          |       |       |       |      |
| York to |       |       |          |       |       |       |      |
| enroll  |       |       |          |       |       |       |      |
| in this |       |       |          |       |       |       |      |
| Plan.** |       |       |          |       |       |       |      |
+---------+-------+-------+----------+-------+-------+-------+------+
| **Self  | **    | **    | **\      | **    | *     | **    | **\  |
| Only\   | SG1** | \$116 | $38.83** | \$252 | *\$84 | \$137 | $17. |
| **      |       | .50** |          | .41** | .14** | .86** | 47** |
+---------+-------+-------+----------+-------+-------+-------+------+
| **Self  | **    | **    | **\      | **    | **    | **    | **\  |
| &       | SG2** | \$293 | $97.86** | \$636 | \$212 | \$347 | $44. |
| F       |       | .58** |          | .09** | .03** | .40** | 04** |
| amily** |       |       |          |       |       |       |      |
+---------+-------+-------+----------+-------+-------+-------+------+