**GHI Health Plan**![](media/image1.wmf){width="1.1888888888888889in"
height="0.55in"}

[http://www.ghi.com](http://www.planAddress.org/)

**2004**

**A Prepaid Comprehensive Medical Plan**

**with a High Option Point of Service Product**

![](media/image2.png){width="1.625in" height="1.4375in"}**High Option
Plan Serving:** All of New York and

Northern New Jersey

**Standard Option Plan Serving:** New York City (the Boroughs of

Manhattan, Brooklyn, Bronx

Queens, and Staten Island),

all of Nassau, Suffolk,

Rockland and Westchester

Counties

**Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 7 for requirements.**

![](media/image3.png){width="1.3541666666666667in"
height="1.4534722222222223in"}

*This Plan has full accreditation from URAC\
See the 2004 Guide for more information on accreditation.*

**Enrollment codes for this Plan:**

# 801 High Self Only 

> **802 High Self and Family**
>
> **804 Standard Self Only**
>
> **805 Standard Self and Family**

![](media/image4.png) ![](media/image5.png){width="1.1715277777777777in"
height="0.9208333333333333in"}

RI73-007

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

Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

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

![](media/image8.png){width="1.195138888888889in"
height="1.0354166666666667in"}
![](media/image5.png){width="1.1715277777777777in"
height="0.9208333333333333in"}

# Notice of the Office of Personnel Management's

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

~~\
~~

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  Table of Contents
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Introduction 3

Plain language 3

Stop Health Care Fraud! 3

Preventing Medical
Mistakes.......................................................................................................
4

Section 1. Facts about this Prepaid Plan 6

We also have Point-of-Service (POS) benefits 6

How we pay providers 6

Your rights 6

Service area 7

Section 2. How we change for 2004 8

Program-wide changes 8

Changes to this Plan 8

Section 3. How you get care 9

Identification cards 9

Where you get covered care 9

• Plan providers 9

• Plan facilities 9

What you must do to get covered care 9

• Primary care 9

• Specialty care 9

• Hospital care 10

Circumstances beyond our control 10

Services requiring our prior approval 10

Section 4. Your costs for covered services 12

• Copayments 12

• Deductible 12

• Coinsurance 12

Your catastrophic protection out-of-pocket maximum 12

Section 5. Benefits 13

Overview 13

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

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

(c) Services provided by a hospital or other facility, and ambulance
    services 38

(d) Emergency services/accidents 41

(e) Mental health and substance abuse benefits 44

(f) Prescription drug benefits 46

(g) Special features 50

• Flexible benefit options 50

• Large Case Management 50

• Customer Service AnswerLine 50

• Services for deaf and hearing impaired 50

• High risk pregnancies 50

• Centers of excellence for transplants/heart surgery/etc. 51

• Travel benefit/services overseas 51

(h) Dental benefits 52

(i) Point of service product 54

(j) Non-FEHB benefits available to Plan members 56

Section 6. General exclusions \-- things we don\'t cover 57

Section 7. Filing a claim for covered services 58

Section 8. The disputed claims process 59

Section 9. Coordinating benefits with other coverage 61

When you have other health coverage

• What is Medicare 61

• Should I enroll in Medicare? 61

• Medicare + Choice 64

• TRICARE and CHAMPVA 64

• Workers\' Compensation 64

• Medicaid 65

• Other Government agencies 65

• When others are responsible for injuries 65

Section 10. Definitions of terms we use in this brochure 66

Section 11. FEHB facts 68

Coverage information 68

• No pre-existing condition limitation 68

• Where you get information about enrolling in the FEHB Program 68

• Types of coverage available for you and your family 68

• Children's Equity Act 68

• When benefits and premiums start 68

• Your medical and claims records are confidential 69

• When you retire 69

When you lose benefits 69

• When FEHB coverage ends 70

• Spouse equity coverage 70

• Temporary Continuation of Coverage (TCC) 70

• Converting to individual coverage 70

• Getting a Certificate of Group Health Plan Coverage 71

Two new Federal Programs complement FEHB benefits 72

The Federal Flexible Spending Account Program -- *FSAFEDS* 72

The Federal Long Term Care Insurance Program 75

Index 77

Summary of benefits 78

Rates .Back cover

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  Introduction

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This brochure describes the benefits of Group Health Incorporated under
our contract (CS 1056) with the United States Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits
law. The address for GHI administrative offices is:

Group Health Incorporated

441 Ninth Avenue\
New York, NY 10001

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

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

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

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  Plain Language

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

-   Except for necessary technical terms, we use common words. For
    instance, "you" means the enrollee or family member; \"we\" means
    GHI Health Plan*.*

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

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

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

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  Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at
    1-888-456-3728 and explain the situation.

-   If we do not resolve the issue:

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

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

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

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

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

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  Preventing Medical Mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

1.  **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.

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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

    Want more information on patient safety?

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

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

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

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

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

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

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  **Section 1. Facts about this Prepaid Plan with a\
  High Option Point-of-Service product**

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This Plan offers two benefit packages. A High Option and a Standard
Option Within the Plan's network you are encouraged to select a personal
doctor who will provide or arrange your care and you will pay minimal
amounts for comprehensive benefits. The Plan is solely responsible for
the selection of these providers in your area. Contact the Plan for a
copy of their most recent provider directory.

Because the Plan emphasizes care through participating providers and
pays the cost, it seeks efficient and effective delivery of health
services. By controlling unnecessary or inappropriate care, it can
afford to offer a more comprehensive range of benefits than many
insurance plans.

In addition to providing comprehensive health services and care for
accidents, illness and injury, the Plan emphasizes preventive benefits
such as routine office visits, physicals, immunizations and well-baby
care. You are encouraged to get medical attention at the first sign of
illness. Whenever you need services, you may choose to obtain them from
your personal doctor within the Plan's provider network. Under the High
Option benefit package, you may go outside the network for treatment.
When you choose a non-Plan doctor or other non-Plan provider, you will
pay a substantial portion of the charges, and the benefits available may
be less comprehensive.

**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.**

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

Our High Option benefit package offers Point-of-Service (POS) benefits.
This means you can receive covered services from a participating
provider without a required referral, or from a non-participating
provider. These out-of-network benefits have higher out-of-pocket costs
than our in-network benefits.

How we pay providers

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

**When you use a participating hospital, keep in mind that the
professionals who provide services to you in the hospital, such as
radiologists, emergency room physicians, anesthesiologist, and
pathologist, may not all be participating providers. If they are not,
you will be reimbursed at 50% of the Plan\'s fee scheduled under the
High Option benefit package and nothing under the Standard Option
benefit package.**

**Your Rights**

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

-   GHI is URAC-accredited and is licensed under Article 43 of the New
    York State Insurance Law as a health services corporation.

-   GHI has been in continuous existence for over sixty (60) years

-   GHI is a not-for-profit New York corporation

If you want more information about us, call 212/501-4GHI (4444), or
write to GHI, PO Box 1701, New York, NY 10023-9476. You may also visit
our website at [www.ghi.com](http://www.ghi.com/).

**Service area**

To enroll with us [i]{.smallcaps}n the High Option you must live or work
in our service area. Our service area is: all of New York and the New
Jersey counties of Bergen, Essex, Hudson, Middlesex, Monmouth, Morris,
Passaic, Somerset, Sussex and Union.

To enroll with us in the Standard Option you must live or work in our
service area. Our service area is: New York City (the Boroughs of
Manhattan, Brooklyn, Bronx, Queens, and Staten Island) all of Nassau,
Suffolk, Rockland and Westchester 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.

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

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

**Program-wide changes**

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

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

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

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

**Changes to this Plan**

-   Your share of the non-Postal High Option premium will increase by
    7.40% for Self Only or 8.10% for Self and Family.

-   For 2004 we are offering two benefit packages. A High Option
    (Current Plan 801, 802) and a Standard Option (804, 805). Those
    enrollees who had GHI coverage during 2003 will remain in the High
    Option coverage unless they elect the Standard Option coverage or
    another health plan during Open season

-   Benefit Changes to the Current High Option GHI Health Plan

1.  The copay for Lab, X-ray and other diagnostic test will be increased
    from \$10 per each x-ray and laboratory test performed by a
    participating provider to \$15 per each x-ray and laboratory test
    performed by a participating provider. A maximum of two diagnostic
    copays will apply per date of service.

2.  The out-of-pocket medical expense maximum per person in any calendar
    year for covered services provided by a non-participating provider
    will be increased from \$5,000 per person in any calendar year to
    \$10,000 per person in any calendar year.

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  Section 3. How you get care
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**Identification cards** We will send you an identification (ID) card
when you enroll. You should carry your ID card with you at all times.
You must show it whenever you receive services from a Plan provider, or
fill a prescription at a Plan pharmacy. Until you receive your ID card,
use your copy of the Health Benefits Election Form, SF-2809, your health
benefits enrollment confirmation (for annuitants), or your Employee
Express confirmation letter.

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
212/501-4GHI (4444). You may also request replacement cards through the
GHI website, [www.ghi.com]{.underline}.

**Where you get covered care** You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, deductibles, and/or
coinsurance, and you will not have to file claims. If you have the High
Option Plan with our point-of-service program, you can also get care
from non-Plan providers, or from partici­pating providers without a
required referral, but it will cost you more.

**• Plan providers** Plan providers are physicians and other health care
professionals in our service area that we contract with to provide
covered services to our members. We credential Plan providers according
to national standards.\
\
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.

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

**What you must do to get**

**covered care** Within the Plan's network, you are encouraged to select
a personal doctor who will provide or arrange your care, in which case
you will pay minimal amounts for comprehensive benefits under the High
Option Plan. When you choose a non-Plan doctor or other non-Plan
provider, you will pay a substantial portion of the charges, and the
benefits available may be less comprehensive.

**• Primary care** You may seek care from a doctor, dentist, podiatrist,
qualified clinical psychologist, optometrists, chiropractor, nurse,
certified midwife, nurse practitioner/clinical specialist, or qualified
clinical social worker and any other duly-licensed, registered or
certified practitioner or privately-operated facility permitted to
perform or render care or service described in this brochure.

**• Specialty care** You may see the specialist whenever you and your
family feel you need care. Here are other things you should know about
specialty care:

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

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

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

-   Reduce our service area and you enroll in another FEHB Plan

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

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

> **• Hospital care** Your 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 212/501-4GHI (4444). 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

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

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

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

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

**Services requiring our**

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

Your physician must obtain prior approval for the following services:

-   High-tech radiology

-   High-tech nursing

-   Infusion therapy

-   Mental Health and Substance Abuse

-   Infertility Services

**What happens when you do not**

**Follow the prior approval**

**Rules** If no one contacted us, we will not pay for those services.

**Services requiring**

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

Your physician must obtain precertification for the following\
services:

-   All inpatient hospital admission for maternity care and skilled
    nursing facilities

-   Non-emergency hospital admissions

**What happens when you do not** If no one contacted us, we will decide
whether the hospital

**Follow the precertification** stay was medically necessary.

**rules**

-   If we determine that the stay was medically necessary,\
    we will pay for the covered inpatient hospital benefits\
    less the \$125 per day penalty, up to a maximum of\
    \$250 per admission

-   If we determine that it was not medically necessary for\
    you to be an inpatient, we will not pay inpatient\
    hospital benefits.

**Exceptions:** You do not need precertification in these cases

-   You have another group health insurance policy that is the primary
    payer for the hospital stay.

-   Your Medicare Part A is the primary payer for the hospital stay.
    Note: If you exhaust your Medicare hospital benefits and do not want
    to use your Medicare lifetime reserve days, then we will become the
    primary payer and you **do** need precertification.

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

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

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

+---------------------+------------------------------------------------+
| -   **Copayments**  | A copayment is a fixed amount of money you pay |
|                     | to the provider, facility, pharmacy, etc. when |
|                     | you receive services.                          |
|                     |                                                |
|                     | Example: When you see a participating provider |
|                     | you pay a copayment of \$15 per office visit   |
|                     | under the High Option and a \$25 per office    |
|                     | visit under the Standard Option and when you   |
|                     | go in the hospital, you pay nothing.           |
+---------------------+------------------------------------------------+
| -   **Deductible**  | A deductible is a fixed expense you must pay   |
|                     | for certain covered services and supplies      |
|                     | before we start paying benefits for them.      |
|                     | Copayments do not count towards any            |
|                     | deductible.                                    |
|                     |                                                |
|                     | The calendar year deductible for certain       |
|                     | services is:                                   |
|                     |                                                |
|                     | -   For nursing service, you pay an annual     |
|                     |     deductible of \$150 per individual\        |
|                     |     or family.                                 |
|                     |                                                |
|                     | -   For appliances, oxygen or equipment, you   |
|                     |     pay an annual deductible of \$100 per      |
|                     |     individual or family.                      |
|                     |                                                |
|                     | -   For referred ambulatory, laboratory tests  |
|                     |     and diagnostic x-rays, which is only       |
|                     |     available under the High Option Plan, you  |
|                     |     pay a \$25 deductible per referral.        |
|                     |                                                |
|                     | -   The Standard Option coverage has a \$50    |
|                     |     prescription drug deductible that you must |
|                     |     meet each calendar year and a \$250 per    |
|                     |     day maximum \$750 per admission hospital   |
|                     |     deductible. The hospital deductible is     |
|                     |     waived for maternity care.                 |
|                     |                                                |
|                     | > Note: If you change plans during open        |
|                     | > season, you do not have to start a new       |
|                     | > deductible under your old plan between       |
|                     | > January 1 and the effective date of your new |
|                     | > plan. If you change plans at another time    |
|                     | > during the year, you must begin a new        |
|                     | > deductible under your new plan.              |
|                     |                                                |
|                     | And, if you change options in this Plan during |
|                     | the year, we will credit the amount of covered |
|                     | expenses already applied toward the deductible |
|                     | of your old option to the deductible of your   |
|                     | new option.                                    |
+---------------------+------------------------------------------------+
| -   **Coinsurance** | Any amount in excess of 50% of the High Option |
|                     | Plan's fee schedule for POS services provided  |
|                     | by non-participating providers.                |
+---------------------+------------------------------------------------+
| ##                  | Under the High Option Plan, after your         |
|  Your catastrophic  | out-of-pocket expenses total \$10,000 per      |
| protection out-of-p | person in any calendar year for covered        |
| ocket maximum for d | services provided by a non-participating       |
| eductibles, coinsur | provider, GHI will then pay catastrophic       |
| ance,and copayments | benefits at 100% of reasonable and customary   |
|                     | charges as determined\                         |
|                     | by the Plan. Out-of-pocket expenses are        |
|                     | calculated based upon the reasonable and       |
|                     | customary charge for covered catastrophic      |
|                     | services.                                      |
|                     |                                                |
|                     | Covered catastrophic services include: 1)      |
|                     | surgery, 2) administration of anesthesia, 3)   |
|                     | chemotherapy and radiation therapy, 4) covered |
|                     | in-hospital service and diagnostic services,   |
|                     | and 5) maternity. However, expenses for the    |
|                     | following services do not count toward your    |
|                     | catastrophic protection out-of-pocket maximum: |
|                     |                                                |
|                     | -   Home and office visits and related         |
|                     |     diagnostic services                        |
|                     |                                                |
|                     | ```{=html}                                     |
|                     | <!-- -->                                       |
|                     | ```                                            |
|                     | -   Nursing, Appliances, Oxygen and Equipment  |
|                     |                                                |
|                     | ```{=html}                                     |
|                     | <!-- -->                                       |
|                     | ```                                            |
|                     | -   Dental services                            |
|                     |                                                |
|                     | ```{=html}                                     |
|                     | <!-- -->                                       |
|                     | ```                                            |
|                     | -   Vision services                            |
|                     |                                                |
|                     | -   Prescription drugs                         |
+---------------------+------------------------------------------------+

+-----------------------------------------------------------------------+
| ###### Section 5. Benefits \-- OVERVIEW                               |
|                                                                       |
| ***(See page 8 for how our benefits changed this year and page 62 for |
| a benefits summary.)***                                               |
+-----------------------------------------------------------------------+

**NOTE**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claims forms,
claims filing advice, or more information about our benefits, contact us
at 212/501- 4444 or at our website at
[www.ghi.com](http://www.ghi.com/)*.*

(a) Medical services and supplies provided by physicians and other
    health care professionals 14-31

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 31-38

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

(c) Services provided by a hospital or other facility, and ambulance
    services 38-41

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

(d) Emergency services/accidents 41-44

> • Medical emergency • Ambulance

(e) Mental health and substance abuse benefits 44-46

(f) Prescription drug benefits 46-50

(g) Special features 50

+------------------------------+---------------------------------------+
| • Flexible benefit options   | • High risk pregnancies               |
|                              |                                       |
| • Large Case Management      | • Centers of excellence for           |
|                              | transplants/heart surgery/etc.        |
| • Customer Service           |                                       |
| AnswerLine                   | • Travel benefit/services overseas    |
|                              |                                       |
| • Services for deaf and      |                                       |
| hearing impaired             |                                       |
+------------------------------+---------------------------------------+

(h) Dental benefits 52-54

(i) Point of service benefits 54-56

(j) Non-FEHB benefits available to Plan members 56

Summary of benefits 78

+---+---+-------------------------------------+-----------+---+---+----+
| > |   |                                     |           |   |   |    |
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|   |   |                                     |           |   |   |    |
| p |   |                                     |           |   |   |    |
| r |   |                                     |           |   |   |    |
| o |   |                                     |           |   |   |    |
| f |   |                                     |           |   |   |    |
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| * |   |                                     |           |   |   |    |
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+---+---+-------------------------------------+-----------+---+---+----+
|   | * | **Here are some important things to |           |   | * |    |
|   | * | keep in mind about these            |           |   | * |    |
|   | I | benefits:**                         |           |   | I |    |
|   | * |                                     |           |   | * |    |
|   | * | -   Please remember that all        |           |   | * |    |
|   |   |     benefits are subject to the     |           |   |   |    |
|   | * |     definitions, limitations, and   |           |   | * |    |
|   | * |     exclusions in this brochure and |           |   | * |    |
|   | M |     are payable only when we        |           |   | M |    |
|   | * |     determine they are medically    |           |   | * |    |
|   | * |     necessary.                      |           |   | * |    |
|   |   |                                     |           |   |   |    |
|   | * | -   Plan providers under the High   |           |   | * |    |
|   | * |     Option benefit package non-Plan |           |   | * |    |
|   | P |     providers can provide or        |           |   | P |    |
|   | * |     arrange your care. Limit        |           |   | * |    |
|   | * |     out-of-pocket costs by using    |           |   | * |    |
|   |   |     participating providers.        |           |   |   |    |
|   | * |                                     |           |   | * |    |
|   | * | -   The calendar year deductible    |           |   | * |    |
|   | O |     for certain services is:        |           |   | O |    |
|   | * |                                     |           |   | * |    |
|   | * | > • For nursing services, you pay   |           |   | * |    |
|   |   | > an annual deductible of \$150 per |           |   |   |    |
|   | * | > individual or family.             |           |   | * |    |
|   | * | >                                   |           |   | * |    |
|   | R | > • For appliances, oxygen or       |           |   | R |    |
|   | * | > equipment, you pay an annual      |           |   | * |    |
|   | * | > deductible of \$100 per           |           |   | * |    |
|   |   | >     individual or family.         |           |   |   |    |
|   | * | >                                   |           |   | * |    |
|   | * | > • For referred ambulatory         |           |   | * |    |
|   | T | > laboratory test and diagnostic    |           |   | T |    |
|   | * | > x-rays, which are available only  |           |   | * |    |
|   | * | > under the High Option Plan, you   |           |   | * |    |
|   |   | > pay a \$25 deductible per         |           |   |   |    |
|   | * | > referral.                         |           |   | * |    |
|   | * |                                     |           |   | * |    |
|   | A | We added asterisks - \* - to show   |           |   | A |    |
|   | * | when the calendar year deductible   |           |   | * |    |
|   | * | does not apply.                     |           |   | * |    |
|   |   |                                     |           |   |   |    |
|   | * | -   Be sure to read Section 4,      |           |   | * |    |
|   | * |     *Your costs for covered         |           |   | * |    |
|   | N |     services,* for valuable         |           |   | N |    |
|   | * |     information about how cost      |           |   | * |    |
|   | * |     sharing works. Also read        |           |   | * |    |
|   |   |     Section 9 about coordinating    |           |   |   |    |
|   | * |     benefits with other coverage,   |           |   | * |    |
|   | * |     including with Medicare.        |           |   | * |    |
|   | T |                                     |           |   | T |    |
|   | * |                                     |           |   | * |    |
|   | * |                                     |           |   | * |    |
+---+---+-------------------------------------+-----------+---+---+----+
| > |   |                                     | #         | * |   |    |
|   |   |                                     | ###### Hi | * |   |    |
| * |   |                                     | gh Option | S |   |    |
| * |   |                                     |           | t |   |    |
| B |   |                                     |           | a |   |    |
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| n |   |                                     |           |   |   |    |
| * |   |                                     |           |   |   |    |
| * |   |                                     |           |   |   |    |
+---+---+-------------------------------------+-----------+---+---+----+
| # |   |                                     | **You     | * |   |    |
| # |   |                                     | pay**     | * |   |    |
| # |   |                                     |           | Y |   |    |
|   |   |                                     |           | o |   |    |
| * |   |                                     |           | u |   |    |
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| D |   |                                     |           | a |   |    |
| i |   |                                     |           | y |   |    |
| a |   |                                     |           | * |   |    |
| g |   |                                     |           | * |   |    |
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| d |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
| t |   |                                     |           |   |   |    |
| r |   |                                     |           |   |   |    |
| e |   |                                     |           |   |   |    |
| a |   |                                     |           |   |   |    |
| t |   |                                     |           |   |   |    |
| m |   |                                     |           |   |   |    |
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| t |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
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| v |   |                                     |           |   |   |    |
| i |   |                                     |           |   |   |    |
| c |   |                                     |           |   |   |    |
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| s |   |                                     |           |   |   |    |
| \ |   |                                     |           |   |   |    |
| * |   |                                     |           |   |   |    |
| * |   |                                     |           |   |   |    |
| * |   |                                     |           |   |   |    |
+---+---+-------------------------------------+-----------+---+---+----+
| > |   |                                     | \$15 per  | \ |   |    |
|   |   |                                     | visit for | $ |   |    |
| P |   |                                     | part      | 2 |   |    |
| r |   |                                     | icipating | 5 |   |    |
| o |   |                                     | p         | p |   |    |
| f |   |                                     | roviders. | e |   |    |
| e |   |                                     |           | r |   |    |
| s |   |                                     | POS: 50%  | v |   |    |
| s |   |                                     | of the    | i |   |    |
| i |   |                                     | Plan's    | s |   |    |
| o |   |                                     | fee       | i |   |    |
| n |   |                                     | schedule  | t |   |    |
| a |   |                                     | for       | f |   |    |
| l |   |                                     | non-part  | o |   |    |
| > |   |                                     | icipating | r |   |    |
|   |   |                                     | p         | p |   |    |
| s |   |                                     | roviders, | a |   |    |
| e |   |                                     | and any   | r |   |    |
| r |   |                                     | d         | t |   |    |
| v |   |                                     | ifference | i |   |    |
| i |   |                                     | between   | c |   |    |
| c |   |                                     | our fee   | i |   |    |
| e |   |                                     | schedule  | p |   |    |
| s |   |                                     | and the   | a |   |    |
| > |   |                                     | billed    | t |   |    |
|   |   |                                     | amount.   | i |   |    |
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|   |   |                                     |           | . |   |    |
+---+---+-------------------------------------+-----------+---+---+----+
| > |   |                                     | \$15 per  | \ |   |    |
|   |   |                                     | visit for | $ |   |    |
| P |   |                                     | part      | 2 |   |    |
| r |   |                                     | icipating | 5 |   |    |
| o |   |                                     | p         | p |   |    |
| f |   |                                     | roviders. | e |   |    |
| e |   |                                     |           | r |   |    |
| s |   |                                     | POS: 50%  | v |   |    |
| s |   |                                     | of the    | i |   |    |
| i |   |                                     | Plan's    | s |   |    |
| o |   |                                     | fee       | i |   |    |
| n |   |                                     | schedule  | t |   |    |
| a |   |                                     | for       | f |   |    |
| l |   |                                     | non-part  | o |   |    |
| > |   |                                     | icipating | r |   |    |
|   |   |                                     | p         | p |   |    |
| s |   |                                     | roviders, | a |   |    |
| e |   |                                     | and any   | r |   |    |
| r |   |                                     | d         | t |   |    |
| v |   |                                     | ifference | i |   |    |
| i |   |                                     | between   | c |   |    |
| c |   |                                     | our fee   | i |   |    |
| e |   |                                     | schedule  | p |   |    |
| s |   |                                     | and the   | a |   |    |
| > |   |                                     | billed    | t |   |    |
|   |   |                                     | amount.   | i |   |    |
| o |   |                                     |           | n |   |    |
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|   |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
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| d |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
| s |   |                                     |           |   |   |    |
| u |   |                                     |           |   |   |    |
| r |   |                                     |           |   |   |    |
| g |   |                                     |           |   |   |    |
| i |   |                                     |           |   |   |    |
| c |   |                                     |           |   |   |    |
| a |   |                                     |           |   |   |    |
| l |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
|   |   |                                     |           |   |   |    |
| o |   |                                     |           |   |   |    |
| p |   |                                     |           |   |   |    |
| i |   |                                     |           |   |   |    |
| n |   |                                     |           |   |   |    |
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| o |   |                                     |           |   |   |    |
| n |   |                                     |           |   |   |    |
+---+---+-------------------------------------+-----------+---+---+----+

> *Diagnostic and treatment services continued on next page*

+---------------------------------------------+-----------+-----------+
| > **Diagnostic and treatment services\***   | **High\   | **        |
| > (*continued*)                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | pay**     | **You     |
|                                             |           | pay**     |
+---------------------------------------------+-----------+-----------+
| -   During a hospital stay                  | Nothing   | Nothing   |
|                                             | for       | for       |
| -   In a skilled nursing facility           | part      | part      |
|                                             | icipating | icipating |
| -   Initial examination of a newborn child  | p         | p         |
|     covered under a family enrollment       | roviders. | roviders. |
|                                             |           |           |
|                                             | POS: 50%  | All       |
|                                             | of the    | charges   |
|                                             | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| > At home                                   | \$15 per  | \$25 per  |
|                                             | visit for | visit for |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | p         | p         |
|                                             | roviders. | roviders. |
|                                             |           |           |
|                                             | POS: 50%  | All       |
|                                             | of the    | charges   |
|                                             | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| # Lab, X-ray and other diagnostic tests\*   |           |           |
+---------------------------------------------+-----------+-----------+
| > Tests, such as:                           | \$15 per  | \$25 per  |
|                                             | each      | each      |
| -   Blood tests                             | d         | d         |
|                                             | iagnostic | iagnostic |
| -   Urinalysis                              | x-ray +   | x-ray +   |
|                                             | l         | l         |
| -   Non-routine Pap tests                   | aboratory | aboratory |
|                                             | test      | test      |
| -   Pathology                               | performed | performed |
|                                             | by a      | by a      |
| -   X-rays                                  | part      | part      |
|                                             | icipating | icipating |
| -   Non-routine Mammograms                  | provider. | provider. |
|                                             | A maximum | A maximum |
| -   CAT Scans/MRI                           | of two    | of two    |
|                                             | d         | d         |
| -   Ultrasound                              | iagnostic | iagnostic |
|                                             | copays    | copays    |
| -   Electrocardiogram and EEG               | will      | will      |
|                                             | apply per | apply per |
|                                             | date of   | date of   |
|                                             | service.  | service.  |
|                                             |           |           |
|                                             | POS: For  | All       |
|                                             | non-part  | charges   |
|                                             | icipating | for       |
|                                             | p         | non-part  |
|                                             | roviders, | icipating |
|                                             | you pay   | p         |
|                                             | any       | roviders. |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+

+---------------------------------------------+-----------+-----------+
| > **Preventative care, adult\***            | **High\   | **        |
|                                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | pay**     | **You     |
|                                             |           | pay**     |
+---------------------------------------------+-----------+-----------+
| > Routine screenings, such as:              | \$15 per  | \$25 per  |
|                                             | each      | each      |
| -   Total Blood Cholesterol -- once every   | d         | d         |
|     three years                             | iagnostic | iagnostic |
|                                             | x-ray +   | x-ray +   |
| -   Colorectal Cancer Screening, including  | l         | l         |
|                                             | aboratory | aboratory |
| > -- Fecal occult blood test                | test      | test      |
|                                             | performed | performed |
| -   Osteoporosis screening                  | by a      | by a      |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | provider. | provider. |
|                                             | A maximum | A maximum |
|                                             | of two    | of two    |
|                                             | d         | d         |
|                                             | iagnostic | iagnostic |
|                                             | copays    | copays    |
|                                             | will      | will      |
|                                             | apply per | apply per |
|                                             | date of   | date of   |
|                                             | service   | service   |
|                                             |           |           |
|                                             | POS: For  | All       |
|                                             | non-part  | charges   |
|                                             | icipating | for       |
|                                             | p         | non-part  |
|                                             | roviders, | icipating |
|                                             | you pay   | p         |
|                                             | any       | roviders. |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount    |           |
+---------------------------------------------+-----------+-----------+
|                                             |           |           |
+---------------------------------------------+-----------+-----------+
| > -- Sigmoidoscopy, screening -- every five | \$15 per  | \$25 per  |
| > years starting at age 50                  | visit for | visit for |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | p         | p         |
|                                             | roviders. | roviders. |
|                                             |           |           |
|                                             | POS: 50%  | All       |
|                                             | of the    | charges   |
|                                             | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| Routine Prostate Specific Antigen (PSA)     | \$15 per  | \$25 per  |
| test -- one annually for men age 40\        | each      | each      |
| and older                                   | d         | d         |
|                                             | iagnostic | iagnostic |
|                                             | x-ray +   | x-ray +   |
|                                             | l         | l         |
|                                             | aboratory | aboratory |
|                                             | test      | test      |
|                                             | performed | performed |
|                                             | by a      | by a      |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | provider. | provider. |
|                                             | A maximum | A maximum |
|                                             | of two    | of two    |
|                                             | d         | d         |
|                                             | iagnostic | iagnostic |
|                                             | copays    | copays    |
|                                             | will      | will      |
|                                             | apply per | apply per |
|                                             | date of   | date of   |
|                                             | service   | service   |
|                                             |           |           |
|                                             | POS: For  | All       |
|                                             | non-part  | charges   |
|                                             | icipating | for       |
|                                             | p         | non-part  |
|                                             | roviders, | icipating |
|                                             | you pay   | p         |
|                                             | any       | roviders. |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount    |           |
+---------------------------------------------+-----------+-----------+
| > **Preventative care, adult\***            | **High\   | **        |
| > (*continued*)                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | pay**     | **You     |
|                                             |           | pay**     |
+---------------------------------------------+-----------+-----------+
| > Routine Pap test                          | \$15 per  | \$25 per  |
|                                             | each      | each      |
|                                             | d         | d         |
|                                             | iagnostic | iagnostic |
|                                             | x-ray +   | x-ray +   |
|                                             | l         | l         |
|                                             | aboratory | aboratory |
|                                             | test      | test      |
|                                             | performed | performed |
|                                             | by a      | by a      |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | provider. | provider. |
|                                             | A maximum | A maximum |
|                                             | of two    | of two    |
|                                             | d         | d         |
|                                             | iagnostic | iagnostic |
|                                             | copays    | copays    |
|                                             | will      | will      |
|                                             | apply per | apply per |
|                                             | date of   | date of   |
|                                             | service   | service   |
|                                             |           |           |
|                                             | POS: For  | All       |
|                                             | non-part  | charges   |
|                                             | icipating | for       |
|                                             | p         | non-part  |
|                                             | roviders, | icipating |
|                                             | you pay   | p         |
|                                             | any       | roviders. |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| > Routine mammogram --covered for women age | \$15 per  | \$25 per  |
| > 35 and older, as follows:                 | each      | each      |
|                                             | d         | d         |
| -   From age 35 through 39, one during this | iagnostic | iagnostic |
|     five year period                        | x-ray +   | x-ray +   |
|                                             | l         | l         |
| -   From age 40 through 64, one every       | aboratory | aboratory |
|     calendar year                           | test      | test      |
|                                             | performed | performed |
| -   At age 65 and older, one every two      | by a      | by a      |
|     consecutive calendar years              | part      | part      |
|                                             | icipating | icipating |
|                                             | provider. | provider. |
|                                             | A maximum | A maximum |
|                                             | of two    | of two    |
|                                             | d         | d         |
|                                             | iagnostic | iagnostic |
|                                             | copays    | copays    |
|                                             | will      | will      |
|                                             | apply per | apply per |
|                                             | date of   | date of   |
|                                             | service   | service   |
|                                             |           |           |
|                                             | POS: For  | All       |
|                                             | non-part  | charges   |
|                                             | icipating | for       |
|                                             | p         | non-part  |
|                                             | roviders, | icipating |
|                                             | you pay   | p         |
|                                             | any       | roviders. |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| > *Not covered: Physical exams required for | *All      | *All      |
| > obtaining or continuing employment or     | charges*  | charges*  |
| > insurance, attending schools or camp, or  |           |           |
| > travel.*                                  |           |           |
+---------------------------------------------+-----------+-----------+
| > Routine immunizations, limited to:        | \$15 per  | \$25 per  |
|                                             | visit for | visit for |
| -   Tetanus-diptheria (Td) booster -- once  | part      | part      |
|     every 10 years, ages 19 and over        | icipating | icipating |
|     (except as provided for under Childhood | p         | p         |
|     immunizations)                          | roviders. | roviders. |
|                                             |           |           |
| -   Influenza vaccine annually              | POS: 50%  | All       |
|                                             | of the    | charges   |
| -   Pneumococcal vaccine, age 65 and over   | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+

+---------------------------------------------+-----------+-----------+
| > **Preventative care, children\***         | **High\   | **        |
|                                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | pay**     | **You     |
|                                             |           | pay**     |
+---------------------------------------------+-----------+-----------+
| -   Childhood immunizations recommended by  | Nothing   | Nothing   |
|     the American Academy of Pediatrics      | for       | for       |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | p         | p         |
|                                             | roviders. | roviders. |
|                                             |           |           |
|                                             | POS: 50%  | All       |
|                                             | of the    | charges   |
|                                             | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount    |           |
+---------------------------------------------+-----------+-----------+
| -   Well-child care charges for routine     | Nothing   | Nothing   |
|     examinations, immunizations and care    | for       | for       |
|     (up to age 22)                          | part      | part      |
|                                             | icipating | icipating |
|                                             | p         | p         |
|                                             | roviders. | roviders. |
|                                             |           |           |
|                                             | 50% of    | All       |
|                                             | the       | charges   |
|                                             | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| -   Examinations, such as:                  | \$15 per  | \$25 per  |
|                                             | visit for | visit for |
| > \- Eye exams to determine the need for    | part      | part      |
| > vision correction                         | icipating | icipating |
| >                                           | p         | p         |
| > \- Ear exams to determine the need for    | roviders. | roviders. |
| > hearing correction                        |           |           |
|                                             | POS: 50%  | All       |
|                                             | of the    | charges   |
|                                             | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount..  |           |
+---------------------------------------------+-----------+-----------+

> *Preventive care, children continued on next page*

+---------------------------------------------+-----------+-----------+
| > **Preventative care, children\***         | **High\   | **        |
| > *(continued)*                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | pay**     | **You     |
|                                             |           | pay**     |
+---------------------------------------------+-----------+-----------+
| -   Examinations done on the day of         | Nothing   | Nothing   |
|     immunizations (up to age 22)            | for       | for       |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | p         | p         |
|                                             | roviders. | roviders. |
|                                             |           |           |
|                                             | POS: 50%  | All       |
|                                             | of the    | charges   |
|                                             | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| ######## Maternity care\*                   |           |           |
+---------------------------------------------+-----------+-----------+
| > Complete maternity (obstetrical) care,    | A single  | A single  |
| > such as:                                  | \$15      | \$25      |
|                                             | copay for | copay for |
| -   Prenatal care                           | all pre-  | all pre-  |
|                                             | and       | and       |
| -   Delivery                                | p         | p         |
|                                             | ost-natal | ost-natal |
| -   Postnatal care                          | care from | care from |
|                                             | a         | a         |
| > Note: Here are some things to keep in     | part      | part      |
| > mind:                                     | icipating | icipating |
|                                             | provider. | provider. |
| -   You must precertify your normal         |           |           |
|     delivery. Maternity admissions should   | POS: 50%  | All       |
|     be precertified no later than the       | of the    | charges   |
|     second trimester.                       | Plan's    | for       |
|                                             | fee       | non-part  |
| -   You may remain in the hospital up to 48 | schedule  | icipating |
|     hours after a regular delivery and 96   | for       | p         |
|     hours after a cesarean delivery. We     | non-part  | roviders. |
|     will extend your inpatient stay if      | icipating |           |
|     medically necessary.                    | p         |           |
|                                             | roviders, |           |
| -   We cover routine nursery care of the    | and any   |           |
|     newborn child during the covered        | d         |           |
|     portion of the mother's maternity stay. | ifference |           |
|     We will cover other care of an infant   | between   |           |
|     who requires non-routine treatment only | our fee   |           |
|     if we cover the infant under a Self and | schedule  |           |
|     Family enrollment. Surgical Benefits,   | and the   |           |
|     not maternity benefits, apply to        | billed    |           |
|     circumcision if this is the case.       | amount.   |           |
|                                             |           |           |
| -   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: Routine sonograms to          | > *All    | > *All    |
| determine fetal age, size or sex.*          | >         | >         |
|                                             |  charges* |  charges* |
+---------------------------------------------+-----------+-----------+

+---------------------------------------------+-----------+-----------+
| > **Family planning\***                     | **High\   | **        |
|                                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | pay**     | **You     |
|                                             |           | pay**     |
+---------------------------------------------+-----------+-----------+
| > A range of voluntary family planning      | \$15 per  | \$25 per  |
| > services, limited to:                     | visit for | visit for |
|                                             | part      | part      |
| Voluntary sterilization (See Surgical       | icipating | icipating |
| procedures Section 5b)                      | p         | p         |
|                                             | roviders. | roviders. |
| -   Surgically implanted contraceptives     |           |           |
|     (such as Norplant)                      | POS: 50%  | All       |
|                                             | of the    | charges   |
| -   Injectable contraceptive drugs (such as | Plan's    | for       |
|     Depo provera)                           | fee       | non-part  |
|                                             | schedule  | icipating |
| -   Intrauterine devices (IUDs)             | for       | p         |
|                                             | non-part  | roviders. |
| -   Diaphragms                              | icipating |           |
|                                             | p         |           |
| > Note: We cover oral contraceptives under  | roviders, |           |
| > the prescription drug benefit.            | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| > *Not covered: reversal of voluntary       | *All      | *All      |
| > surgical sterilization, genetic           | charges*  | charges*  |
| > counseling.*                              |           |           |
+---------------------------------------------+-----------+-----------+
| ######## Infertility services\*             |           |           |
+---------------------------------------------+-----------+-----------+
| > Diagnosis and treatment of infertility,   | \$15 per  | \$25 per  |
| > such as**:**                              | visit for | visit for |
|                                             | part      | part      |
| -   In vitro fertilization (limited to      | icipating | icipating |
|     three transfers per lifetime)           | p         | p         |
|                                             | roviders. | roviders. |
| -   Embryo transfer                         |           |           |
|                                             | POS: 50%  | All       |
| -   Artificial insemination                 | of the    | charges   |
|                                             | Plan's    | for       |
| ```{=html}                                  | fee       | non-part  |
| <!-- -->                                    | schedule  | icipating |
| ```                                         | for       | p         |
| -   Intravaginal insemination (IVI)         | non-part  | roviders. |
|                                             | icipating |           |
| -   Intracervical insemination (ICI)        | p         |           |
|                                             | roviders, |           |
| -   Intrauterinal insemination (IUI)        | and any   |           |
|                                             | d         |           |
| ```{=html}                                  | ifference |           |
| <!-- -->                                    | between   |           |
| ```                                         | our fee   |           |
| -   Fertility drugs                         | schedule  |           |
|                                             | and the   |           |
| Note: We cover injectable fertility drugs   | billed    |           |
| under medical benefits and oral fertility   | amount.   |           |
| drugs under the prescription drug benefit.  |           |           |
+---------------------------------------------+-----------+-----------+
| *Not covered: Cost of donor sperm*          | *All      | *All      |
|                                             | charges*  | charge*   |
+---------------------------------------------+-----------+-----------+

+---------------------------------------------+-----------+-----------+
| > **Allergy care\***                        | **High\   | **        |
|                                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | pay**     | **You     |
|                                             |           | pay**     |
+---------------------------------------------+-----------+-----------+
| > Testing and treatment                     | \$15 per  | \$25 per  |
| >                                           | visit for | visit for |
| > Allergy injections                        | part      | part      |
| >                                           | icipating | icipating |
| > Treatment materials (such as allergy      | p         | p         |
| > serum)                                    | roviders. | roviders. |
|                                             |           |           |
|                                             | POS: 50%  | All       |
|                                             | of the    | charges   |
|                                             | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| > *Not covered: Provocative food testing    | *All      | *All      |
| > and sublingual allergy desensitization*   | charges*  | charges*  |
+---------------------------------------------+-----------+-----------+
| ######## Treatment therapies\*              |           |           |
+---------------------------------------------+-----------+-----------+
| -   Chemotherapy and radiation therapy      | In a      | In a      |
|                                             | doctor's  | doctor's  |
| > Note: High dose chemotherapy in           | office,   | office,   |
| > association with autologous bone marrow   | nothing   | nothing   |
| > transplants are limited to those          | for a     | for a     |
| > transplants listed under Organ/Tissue     | part      | part      |
| > Transplants on page 35.                   | icipating | icipating |
|                                             | provider. | provider. |
| -   Respiratory and inhalation therapy      |           |           |
|                                             | POS: In a | All       |
| ```{=html}                                  | doctors   | charges   |
| <!-- -->                                    | office,   | for       |
| ```                                         | 50% of    | non-part  |
| -   Dialysis -- hemodialysis and peritoneal | the       | icipating |
|     dialysis                                | Plan's    | p         |
|                                             | fee       | roviders. |
|                                             | schedule, |           |
|                                             | for       |           |
|                                             | non-part  |           |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| -   High-tech nursing and infusion therapy  | > Nothing | > Nothing |
|                                             | > for a   | > for a   |
| \- IV infusion therapy                      | > part    | > part    |
|                                             | icipating | icipating |
| \- Parenteral and enteral therapy           | >         | >         |
|                                             | provider. | provider. |
| \- Other home IV therapies                  | >         | >         |
|                                             | > POS:    | > All     |
| > Note: Contact us at (212) 615-4662 prior  | > All     | > charges |
| > to receiving services to ensure coverage. | > charges | > for     |
|                                             | > for     | >         |
| -   Intermittent home nursing service       | >         |  non-part |
|                                             |  non-part | icipating |
| > \- Provided by a Registered Nurse or      | icipating | > p       |
| > Licensed Practitioner                     | > p       | roviders. |
| >                                           | roviders. |           |
| > \- Authorized and supervised by a doctor  |           |           |
| >                                           |           |           |
| > \- Intermittent visits less than 2 hours  |           |           |
| > per day                                   |           |           |
+---------------------------------------------+-----------+-----------+

> *Treatment therapies continued on next page*

+---------------------------------------------+-----------+-----------+
| > **Treatment therapies\*** (*continued*)   | **High\   | **        |
|                                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | pay**     | **You     |
|                                             |           | pay**     |
+---------------------------------------------+-----------+-----------+
| -   Growth hormone therapy (GHT). This      | > Generic | > After a |
|     benefit is provided under our           | > drug:   | > \$50    |
|     Prescription Drug Benefits. You must    | > \$10    | > annual  |
|     fill the prescription at a pharmacy     | > copay   | > d       |
|     that participates under the program     | > per     | eductible |
|     Express Scripts PERxCare Retail         | > pre     | > per     |
|     Pharmacy Program.                       | scription | > person  |
|                                             | > or      | >         |
|                                             | > refill  | > Generic |
|                                             | >         | > drug:   |
|                                             | > Name    | > \$10    |
|                                             | > brand   | > copay   |
|                                             | > drug,   | > per     |
|                                             | > listed  | > pre     |
|                                             | > on      | scription |
|                                             | > f       | > or      |
|                                             | ormulary: | > refill  |
|                                             | > \$20    | >         |
|                                             | > copay   | > Name    |
|                                             | > per     | > brand   |
|                                             | > pre     | > drug,   |
|                                             | scription | > listed  |
|                                             | > or      | > on      |
|                                             | > refill  | > f       |
|                                             | >         | ormulary: |
|                                             | > Name    | > \$25    |
|                                             | > brand   | > copay   |
|                                             | > drug    | > per     |
|                                             | > not on  | > pre     |
|                                             | > fo      | scription |
|                                             | rmulary:\ | > or      |
|                                             | > \$50    | > refill  |
|                                             | > copay   | >         |
|                                             | > per     | > Name    |
|                                             | > pre     | > brand   |
|                                             | scription | > drug    |
|                                             | > or      | > not on  |
|                                             | > refill  | > fo      |
|                                             |           | rmulary:\ |
|                                             |           | > \$50    |
|                                             |           | > copay   |
|                                             |           | > per     |
|                                             |           | > pre     |
|                                             |           | scription |
|                                             |           | > or      |
|                                             |           | > refill  |
+---------------------------------------------+-----------+-----------+
| > *Not covered:*                            | *All      | *All      |
|                                             | charges*  | charges*  |
| -   *Treatment for experimental or          |           |           |
|     investigational procedures.*            |           |           |
|                                             |           |           |
| -   *Therapy necessary for transsexual      |           |           |
|     surgery.*                               |           |           |
+---------------------------------------------+-----------+-----------+
| > **Physical and occupational therapies\*** |           |           |
+---------------------------------------------+-----------+-----------+
| -   60 visits per condition for the         | \$15 per  | \$25 per  |
|     services of each of the following:      | visit for | visit for |
|                                             | part      | part      |
| ```{=html}                                  | icipating | icipating |
| <!-- -->                                    | p         | p         |
| ```                                         | roviders. | roviders. |
| -   qualified physical therapist;           |           |           |
|                                             | > POS:    | > All     |
| -   occupational therapist.                 | > 50% of  | > charges |
|                                             | > the     | > for     |
| > Note: We only cover therapy to restore    | > Plan's  | >         |
| > bodily function when there has been a     | > fee     |  non-part |
| > total or partial loss of bodily function  | >         | icipating |
| > due to illness or injury. Occupational    |  schedule | > p       |
| > therapy is limited to services that       | > for     | roviders. |
| > assist the member to achieve and maintain | >         |           |
| > self-care and improved functioning in     |  non-part |           |
| > other daily living activities.            | icipating |           |
| >                                           | > p       |           |
| > Cardiac rehabilitation following a heart  | roviders, |           |
| > transplant, bypass surgery or a           | > and any |           |
| > myocardial infarction.                    | > d       |           |
|                                             | ifference |           |
|                                             | > between |           |
|                                             | > our fee |           |
|                                             | >         |           |
|                                             |  schedule |           |
|                                             | > and the |           |
|                                             | > billed  |           |
|                                             | > amount. |           |
+---------------------------------------------+-----------+-----------+
| > **Physical and occupational therapies\*** |           |           |
| > (*continued*)                             |           |           |
+---------------------------------------------+-----------+-----------+
| > *Not covered:*                            | *All      | *All      |
|                                             | charges*  | charges*  |
| -   *long-term rehabilitative therapy*      |           |           |
|                                             |           |           |
| -   *exercise programs*                     |           |           |
+---------------------------------------------+-----------+-----------+
| > **Speech therapy**                        | **High\   | **        |
|                                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | pay**     | **You     |
|                                             |           | pay**     |
+---------------------------------------------+-----------+-----------+
| -   60 visits per condition                 | \$15 per  | \$25 per  |
|                                             | visit for | visit for |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | p         | p         |
|                                             | roviders. | roviders. |
|                                             |           |           |
|                                             | POS: 50%  | All       |
|                                             | of the    | charges   |
|                                             | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| > **Hearing services (testing, treatment,   |           |           |
| > and supplies)\***                         |           |           |
+---------------------------------------------+-----------+-----------+
| -   Hearing testing                         | \$15 per  | \$25 per  |
|                                             | visit for | visit for |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | p         | p         |
|                                             | roviders. | roviders. |
|                                             |           |           |
|                                             | POS: 50%  | All       |
|                                             | of the    | charges   |
|                                             | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| > *Not covered: hearing aids, testing and   | > *All    | > *All    |
| > examinations for them*                    | >         | >         |
|                                             |  charges* |  charges* |
+---------------------------------------------+-----------+-----------+

+---------------------------------------------+-----------+-----------+
| > **Vision services (testing, treatment,    | **High\   | **        |
| > and supplies)\***                         | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | Pay**     | **You     |
|                                             |           | Pay**     |
+---------------------------------------------+-----------+-----------+
| -   Medical and surgical benefits for       | \$15 per  | \$25 per  |
|     diagnosis and treatment of diseases of  | visit for | visit for |
|     the eye.                                | part      | part      |
|                                             | icipating | icipating |
|                                             | provider. | provider. |
|                                             |           |           |
|                                             | For       | All       |
|                                             | non-part  | charges   |
|                                             | icipating | for       |
|                                             | p         | non-part  |
|                                             | roviders, | icipating |
|                                             | you pay   | p         |
|                                             | 50% of    | roviders. |
|                                             | the       |           |
|                                             | Plan's    |           |
|                                             | fee       |           |
|                                             | schedule  |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| -   Examination of the eyes to determine if | Nothing   | Nothing   |
|     glasses are required: once each         | for       | for       |
|     calendar year.                          | services  | services  |
|                                             | provided  | provided  |
| ```{=html}                                  | by        | by        |
| <!-- -->                                    | part      | part      |
| ```                                         | icipating | icipating |
| -   One set of single vision or bifocal     | o         | o         |
|     lenses (toric kryptok or flat top       | pticians, | pticians, |
|     22mm): once each calendar year.         | opt       | opt       |
|                                             | ometrists | ometrists |
| -   One pair of basic frames from available | and       | and       |
|     styles: one every two years.            | vision    | vision    |
|                                             | centers.  | centers.  |
| -   Contact lenses for certain unusual      |           |           |
|     medical conditions (such as post        | POS: For  | All       |
|     cataract surgery or keratoconus         | non-part  | charges   |
|     treatment).                             | icipating | for       |
|                                             | p         | non-part  |
| -   Replacement of broken lenses with       | roviders, | icipating |
|     lenses of the same prescription and     | you pay   | p         |
|     material originally supplied.           | any       | roviders. |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| > *Not covered:*                            | *All      | *All      |
|                                             | charges*  | charges*  |
| -   *Frames at any time unless lenses are   |           |           |
|     also provided.*                         |           |           |
|                                             |           |           |
| -   *Replacement or repair of frames.*      |           |           |
|                                             |           |           |
| -   *Certain bifocals and trifocals,        |           |           |
|     tinted, plastic and oversized lenses    |           |           |
|     and sunglasses and frames other than    |           |           |
|     basic frames; contact lenses for        |           |           |
|     cosmetic purposes.*                     |           |           |
|                                             |           |           |
| -   *Charges in excess of the maximum GHI   |           |           |
|     allowance.*                             |           |           |
+---------------------------------------------+-----------+-----------+

+---------------------------------------------+-----------+-----------+
| > **Foot care\***                           | **High\   | **        |
|                                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | Pay**     | **You     |
|                                             |           | Pay**     |
+---------------------------------------------+-----------+-----------+
| > Podiatric services, including the routine | \$15 per  | \$25 per  |
| > treatment of corns, calluses, and         | visit for | visit for |
| > bunions, and the partial removal of       | part      | part      |
| > toenails, are limited to 4 visits per     | icipating | icipating |
| > calendar year.                            | provider. | provider. |
|                                             |           |           |
|                                             | For       | All       |
|                                             | non-part  | charges   |
|                                             | icipating | for       |
|                                             | p         | non-part  |
|                                             | roviders, | icipating |
|                                             | you pay   | p         |
|                                             | 50% of    | roviders. |
|                                             | the       |           |
|                                             | Plan's    |           |
|                                             | fee       |           |
|                                             | schedule  |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| > *Not covered:*                            | *All      | *All      |
|                                             | charges*  | charges*  |
| -   *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)*                  |           |           |
|                                             |           |           |
| -   *Orthotics devices for the feet.*       |           |           |
+---------------------------------------------+-----------+-----------+

+---------------------------------------------+-----------+-----------+
| > **Orthopedic and prosthetic devices**     | **High\   | *         |
|                                             | Option**  | *Standard |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | Pay**     | **You     |
|                                             |           | Pay**     |
+---------------------------------------------+-----------+-----------+
| -   Artificial limbs and eyes; stump hose.  | > 20% of  | > 20% of  |
|                                             | > the     | > the     |
| -   Externally worn breast prostheses and   | > Plan's  | > Plan's  |
|     surgical bras, including necessary      | > fee     | > fee     |
|     replacements, following a mastectomy.   | >         | >         |
|                                             |  schedule |  schedule |
| ```{=html}                                  | > for a   | > for a   |
| <!-- -->                                    | > part    | > part    |
| ```                                         | icipating | icipating |
| -   Orthopedic devices, such as braces.     | >         | >         |
|                                             | provider. | provider. |
| ```{=html}                                  | >         | >         |
| <!-- -->                                    | > POS:    | > All     |
| ```                                         | > 50% of  | > charges |
| -   Ostomy supplies.                        | > the     | > for     |
|                                             | > Plan's  | >         |
| ```{=html}                                  | > fee     |  non-part |
| <!-- -->                                    | >         | icipating |
| ```                                         |  schedule | > p       |
| -   Internal prosthetic devices, such as    | > and any | roviders. |
|     artificial joints, pacemakers, cochlear | > d       |           |
|     implants, and surgically implanted      | ifference | Note:     |
|     breast implant following mastectomy.    | > between | \$100     |
|                                             | > our     | d         |
|                                             | >         | eductible |
|                                             | allowance | applies   |
|                                             | > and the | per       |
|                                             | > billed  | i         |
|                                             | > amount  | ndividual |
|                                             | > for a   | or        |
|                                             | >         | family.   |
|                                             |  non-part | There is  |
|                                             | icipating | a         |
|                                             | >         | combined  |
|                                             | provider. | maximum   |
|                                             | >         | of        |
|                                             | > Note:   | \$25,000  |
|                                             | > \$100   | per year  |
|                                             | > d       | per       |
|                                             | eductible | person    |
|                                             | > applies | with      |
|                                             | > per     | these     |
|                                             | > i       | benefits  |
|                                             | ndividual | and       |
|                                             | > or      | private   |
|                                             | > family. | duty      |
|                                             | > There   | nursing.  |
|                                             | > is a    |           |
|                                             | >         |           |
|                                             |  combined |           |
|                                             | > maximum |           |
|                                             | > of      |           |
|                                             | >         |           |
|                                             |  \$25,000 |           |
|                                             | > per     |           |
|                                             | > year    |           |
|                                             | > per     |           |
|                                             | > person  |           |
|                                             | > with    |           |
|                                             | > these   |           |
|                                             | >         |           |
|                                             |  benefits |           |
|                                             | > and     |           |
|                                             | > private |           |
|                                             | > duty    |           |
|                                             | >         |           |
|                                             |  nursing. |           |
+---------------------------------------------+-----------+-----------+
| > *Not covered:*                            | *All      | *All      |
|                                             | charges*  | charges*  |
| -   *orthopedic and corrective shoes*       |           |           |
|                                             |           |           |
| -   *arch supports*                         |           |           |
|                                             |           |           |
| -   *foot orthotics*                        |           |           |
|                                             |           |           |
| -   *heel pads and heel cups*               |           |           |
|                                             |           |           |
| -   *lumbosacral supports*                  |           |           |
|                                             |           |           |
| -   *corsets, trusses, elastic stockings,   |           |           |
|     support hose, and other supportive      |           |           |
|     devices*                                |           |           |
|                                             |           |           |
| -   *corrective appliances for treatment of |           |           |
|     tempormandibular joint (TMJ) pain       |           |           |
|     dysfunction syndrome.*                  |           |           |
+---------------------------------------------+-----------+-----------+
| ######## Durable medical equipment (DME)    | **High\   | **        |
|                                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | Pay**     | **You     |
|                                             |           | Pay**     |
+---------------------------------------------+-----------+-----------+
| > Rental or purchase, at our option,        | > 20% of  | > 20% of  |
| > including repair and adjustment, of       | > the     | > the     |
| > durable medical equipment prescribed by   | > Plan's  | > Plan's  |
| > your Plan physician, such as oxygen and   | > fee     | > fee     |
| > dialysis equipment. Under this benefit,   | >         | >         |
| > we also cover:                            | scheduled | scheduled |
|                                             | > for a   | > for a   |
| -   hospital beds;                          | > part    | > part    |
|                                             | icipating | icipating |
| -   wheelchairs;                            | >         | >         |
|                                             | provider. | provider. |
| -   crutches;                               | >         | >         |
|                                             | > POS:    | > All     |
| -   walkers;                                | > 50% of  | > charges |
|                                             | > the     | > for     |
| -   blood glucose monitors; and             | > Plan's  | >         |
|                                             | > fee     |  non-part |
| -   insulin pumps.                          | >         | icipating |
|                                             |  schedule | > p       |
| > Note: Call us at (212) 615-4662 as soon   | > and any | roviders. |
| > as your Plan physician prescribes this    | > d       |           |
| > equipment. We will arrange with a         | ifference | Note:     |
| > healthcare provider to rent or sell you   | > between | \$100     |
| > durable medical equipment at discounted   | > our     | d         |
| > rates and will tell you more about this   | >         | eductible |
| > service when you call.                    | allowance | applies   |
|                                             | > and the | per       |
|                                             | > billed  | i         |
|                                             | > amount  | ndividual |
|                                             | > for a   | or        |
|                                             | >         | family.   |
|                                             |  non-part | There is  |
|                                             | icipating | a         |
|                                             | >         | combined  |
|                                             | provider. | maximum   |
|                                             | >         | of        |
|                                             | > Note:   | \$25,000  |
|                                             | > \$100   | per year  |
|                                             | > d       | per       |
|                                             | eductible | person    |
|                                             | > applies | with      |
|                                             | > per     | these     |
|                                             | > i       | benefits  |
|                                             | ndividual | and       |
|                                             | > or      | private   |
|                                             | > family. | duty      |
|                                             | > There   | nursing.  |
|                                             | > is a    |           |
|                                             | >         |           |
|                                             |  combined |           |
|                                             | > maximum |           |
|                                             | > of      |           |
|                                             | >         |           |
|                                             |  \$25,000 |           |
|                                             | > per     |           |
|                                             | > year    |           |
|                                             | > per     |           |
|                                             | > person  |           |
|                                             | > with    |           |
|                                             | > these   |           |
|                                             | >         |           |
|                                             |  benefits |           |
|                                             | > and     |           |
|                                             | > private |           |
|                                             | > duty    |           |
|                                             | >         |           |
|                                             |  nursing. |           |
+---------------------------------------------+-----------+-----------+
| *Not covered*                               | *All      | *All      |
|                                             | charges*  | charges*  |
| -   *Hearing aids and air purification      |           |           |
|     devices*                                |           |           |
|                                             |           |           |
| -   *Alarm and Alert Services*              |           |           |
+---------------------------------------------+-----------+-----------+
| ######## Home health services\*             | **High\   | **        |
|                                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | Pay**     | **You     |
|                                             |           | Pay**     |
+---------------------------------------------+-----------+-----------+
| > The following conditions must be met:     | Nothing   | Nothing   |
|                                             | for a     | for a     |
| -   Home health care must be provided and   | part      | part      |
|     billed by a certified home health       | icipating | icipating |
|     agency, which has an agreement with GHI | provider. | provider. |
|     to provide home health care services.   |           |           |
|                                             | POS: All  | All       |
| -   You must remain under the care of a     | charges   | charges   |
|     medical doctor.                         | for a     | for a     |
|                                             | non-part  | non-part  |
| -   The services are provided according to  | icipating | icipating |
|     a plan of treatment approved by the     | provider. | provider. |
|     attending medical doctor.               |           |           |
|                                             |           |           |
| -   Medical evidence substantiates that you |           |           |
|     would have required further inpatient   |           |           |
|     care had the home health care not been  |           |           |
|     available.                              |           |           |
|                                             |           |           |
| ####### The following services are covered: |           |           |
|                                             |           |           |
| -   Part-time or intermittent nursing care  |           |           |
|     by a registered professional nurse      |           |           |
|     (R.N.) or a home health aide under the  |           |           |
|     supervision of a registered             |           |           |
|     professional nurse.                     |           |           |
|                                             |           |           |
| -   Physical therapy.                       |           |           |
|                                             |           |           |
| -   Respiration or inhalation therapy.      |           |           |
|                                             |           |           |
| -   Prescription drugs.                     |           |           |
|                                             |           |           |
| -   Medical supplies which serve a specific |           |           |
|     therapeutic or diagnostic purpose.      |           |           |
|                                             |           |           |
| -   Other medically necessary services or   |           |           |
|     supplies that would have been provided  |           |           |
|     by a hospital if the subscriber were    |           |           |
|     still hospitalized.                     |           |           |
+---------------------------------------------+-----------+-----------+
| -   Private Duty Nursing services rendered  | > Nothing | > Nothing |
|     at home or in the hospital by a         | > for a   | > for a   |
|     registered nurse (R.N.) or when an R.N. | > part    | > part    |
|     is not available by a licensed          | icipating | icipating |
|     practical nurse (L.P.N).                | >         | >         |
|                                             | provider. | provider. |
|                                             | >         | >         |
|                                             | > POS:    | > All     |
|                                             | > 50% of  | > charges |
|                                             | > the     | > for     |
|                                             | > Plan's  | >         |
|                                             | > fee     |  non-part |
|                                             | >         | icipating |
|                                             |  schedule | > p       |
|                                             | > and any | roviders. |
|                                             | > d       | >         |
|                                             | ifference | > Note:   |
|                                             | > between | > \$150   |
|                                             | > our     | > annual  |
|                                             | >         | > d       |
|                                             | allowance | eductible |
|                                             | > and the | > applies |
|                                             | > billed  | > per     |
|                                             | > amount  | > person  |
|                                             | > for a   | > or      |
|                                             | >         | > family. |
|                                             |  non-part | > There   |
|                                             | icipating | > is a    |
|                                             | >         | >         |
|                                             | provider. |  combined |
|                                             | >         | > maximum |
|                                             | > Note:   | > of      |
|                                             | > \$150   | >         |
|                                             | > annual  |  \$25,000 |
|                                             | > d       | > per     |
|                                             | eductible | >         |
|                                             | > applies |  calendar |
|                                             | > per     | > year    |
|                                             | > person  | > per     |
|                                             | > or      | > person  |
|                                             | > family. | > with    |
|                                             | > There   | > these   |
|                                             | > is a    | >         |
|                                             | >         |  benefits |
|                                             |  combined | > and     |
|                                             | > maximum | > Durable |
|                                             | > of      | > Medical |
|                                             | >         | > E       |
|                                             |  \$25,000 | quipment. |
|                                             | > per     |           |
|                                             | >         |           |
|                                             |  calendar |           |
|                                             | > year    |           |
|                                             | > per     |           |
|                                             | > person  |           |
|                                             | > with    |           |
|                                             | > these   |           |
|                                             | >         |           |
|                                             |  benefits |           |
|                                             | > and     |           |
|                                             | > Durable |           |
|                                             | > Medical |           |
|                                             | > E       |           |
|                                             | quipment. |           |
+---------------------------------------------+-----------+-----------+

> Home health services continued on next page

+---------------------------------------------+-----------+-----------+
| ##                                          | **High\   | **        |
| ###### Home health services\* (*continued*) | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | Pay**     | **You     |
|                                             |           | Pay**     |
+---------------------------------------------+-----------+-----------+
| > Not covered:                              | *All      | *All      |
|                                             | charges*  | charges*  |
| -   *Homemaking services, including         |           |           |
|     housekeeping, preparing meals, or       |           |           |
|     acting as a companion or sitter.*       |           |           |
|                                             |           |           |
| -   *Services and supplies related to       |           |           |
|     normal maternity care.*                 |           |           |
|                                             |           |           |
| -   *Services and supplies provided         |           |           |
|     following a noncovered hospital         |           |           |
|     admission or admission to a facility    |           |           |
|     that is not a participating facility.*  |           |           |
|                                             |           |           |
| -   *Services and supplies provided when    |           |           |
|     the subscriber would not have required  |           |           |
|     continued inpatient care.*              |           |           |
|                                             |           |           |
| -   *Services and supplies provided by a    |           |           |
|     non-participating facility for home     |           |           |
|     health care.*                           |           |           |
|                                             |           |           |
| -   *High-tech nursing and infusion         |           |           |
|     therapy*.                               |           |           |
+---------------------------------------------+-----------+-----------+
| ######## Chiropractic\*                     |           |           |
+---------------------------------------------+-----------+-----------+
| -   Manipulation of the spine and           | \$15 per  | \$25 per  |
|     extremities                             | visit for | visit for |
|                                             | part      | part      |
| -   Adjustment procedures such as           | icipating | icipating |
|     ultrasound, electrical muscle           | p         | p         |
|     stimulation, vibratory therapy, and     | roviders. | roviders. |
|     cold pack application.                  |           |           |
|                                             | POS: 50%  | All       |
|                                             | of the    | charges   |
|                                             | Plan's    | for       |
|                                             | fee       | non-part  |
|                                             | schedule  | icipating |
|                                             | for       | p         |
|                                             | non-part  | roviders. |
|                                             | icipating |           |
|                                             | p         |           |
|                                             | roviders, |           |
|                                             | and any   |           |
|                                             | d         |           |
|                                             | ifference |           |
|                                             | between   |           |
|                                             | our fee   |           |
|                                             | schedule  |           |
|                                             | and the   |           |
|                                             | billed    |           |
|                                             | amount.   |           |
+---------------------------------------------+-----------+-----------+
| ## *Not covered:*                           | > *All    | > *All    |
|                                             | >         | >         |
| -   *naturopathic services*                 |  charges* |  charges* |
|                                             |           |           |
| -   *hypnotherapy*                          |           |           |
|                                             |           |           |
| -   *biofeedback*                           |           |           |
+---------------------------------------------+-----------+-----------+
| ######## Alternative treatments\*           |           |           |
+---------------------------------------------+-----------+-----------+
| -   Acupuncture -- After 5 visits a         | *All      | \$20 per  |
|     treatment plan must be approved by      | charges*  | visit for |
|                                             |           | part      |
| > GHI in order for additional visits to be  |           | icipating |
| > covered                                   |           | p         |
|                                             |           | roviders. |
|                                             |           |           |
|                                             |           | All       |
|                                             |           | charges   |
|                                             |           | for       |
|                                             |           | non-part  |
|                                             |           | icipating |
|                                             |           | p         |
|                                             |           | roviders. |
+---------------------------------------------+-----------+-----------+
| ######## Educational classes and programs   | **High\   | **        |
|                                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | Pay**     | **You     |
|                                             |           | Pay**     |
+---------------------------------------------+-----------+-----------+
| > Coverage is limited to:                   | > Nothing | > Nothing |
|                                             | >         | >         |
| -   Diabetes self-management                | > For     | > For     |
|                                             | >         | >         |
| -   Cholesterol Management                  |  diabetes |  diabetes |
|                                             | > self    | > self    |
| -   Arthritis                               | > m       | > m       |
|                                             | anagement | anagement |
| -   Asthma                                  | > call    | > call    |
|                                             | >         | >         |
| -   Hepatitis C                             |  Diabetes |  Diabetes |
|                                             | > Health  | > Health  |
| -   Multiple Sclerosis                      | >         | >         |
|                                             | Solutions | Solutions |
| -   Depression                              | > at      | > at      |
|                                             | > (800)   | > (800)   |
| -   Osteoporosis                            | >         | >         |
|                                             |  881-4008 |  881-4008 |
|                                             | >         | >         |
|                                             | > For     | > For     |
|                                             | >         | >         |
|                                             | arthritis | arthritis |
|                                             | > and     | > and     |
|                                             | > ost     | > ost     |
|                                             | eoporosis | eoporosis |
|                                             | > in      | > in      |
|                                             | formation | formation |
|                                             | > call    | > call    |
|                                             | >         | >         |
|                                             | Arthritis | Arthritis |
|                                             | > F       | > F       |
|                                             | oundation | oundation |
|                                             | > NYC     | > NYC     |
|                                             | > Chapter | > Chapter |
|                                             | > at      | > at      |
|                                             | > (212)   | > (212)   |
|                                             | >         | >         |
|                                             |  984-8713 |  984-8713 |
|                                             | >         | >         |
|                                             | > To      | > To      |
|                                             | > enroll  | > enroll  |
|                                             | > in our  | > in our  |
|                                             | > Asthma  | > Asthma  |
|                                             | > Ch      | > program |
|                                             | olesterol | > call    |
|                                             | > Ma      | > (212)   |
|                                             | nagement, | >         |
|                                             | >         |  615-0363 |
|                                             | Hepatitis |           |
|                                             | > C       |           |
|                                             | >         |           |
|                                             |  Multiple |           |
|                                             | >         |           |
|                                             | Sclerosis |           |
|                                             | > &       |           |
|                                             | > D       |           |
|                                             | epression |           |
|                                             | > program |           |
|                                             | > call    |           |
|                                             | > GHI     |           |
|                                             | > Disease |           |
|                                             | > M       |           |
|                                             | anagement |           |
|                                             | > Line    |           |
|                                             | > (212)   |           |
|                                             | >         |           |
|                                             |  615-0363 |           |
+---------------------------------------------+-----------+-----------+
| -   Smoking Cessation                       | > All     | > All     |
|                                             | > charges | > charges |
|                                             | > in      | > in      |
|                                             | > excess  | > excess  |
|                                             | > of      | > of      |
|                                             | > \$100   | > \$100   |
+---------------------------------------------+-----------+-----------+

+---+---+-------------------------------------+-----------+---+---+---+
| * |   |                                     |           |   |   |   |
| * |   |                                     |           |   |   |   |
| S |   |                                     |           |   |   |   |
| e |   |                                     |           |   |   |   |
| c |   |                                     |           |   |   |   |
| t |   |                                     |           |   |   |   |
| i |   |                                     |           |   |   |   |
| o |   |                                     |           |   |   |   |
| n |   |                                     |           |   |   |   |
| 5 |   |                                     |           |   |   |   |
| ( |   |                                     |           |   |   |   |
| b |   |                                     |           |   |   |   |
| ) |   |                                     |           |   |   |   |
| . |   |                                     |           |   |   |   |
| S |   |                                     |           |   |   |   |
| u |   |                                     |           |   |   |   |
| r |   |                                     |           |   |   |   |
| g |   |                                     |           |   |   |   |
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| c |   |                                     |           |   |   |   |
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| * |   |                                     |           |   |   |   |
| * |   |                                     |           |   |   |   |
+---+---+-------------------------------------+-----------+---+---+---+
|   | * | **Here are some important things to |           |   | * |   |
|   | * | keep in mind about these            |           |   | * |   |
|   | I | benefits:**                         |           |   | I |   |
|   | * |                                     |           |   | * |   |
|   | * | -   Please remember that all        |           |   | * |   |
|   |   |     benefits are subject to the     |           |   |   |   |
|   | * |     definitions, limitations, and   |           |   | * |   |
|   | * |     exclusions in this brochure 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 |   |
|   | * | ```{=html}                          |           |   | * |   |
|   | * | <!-- -->                            |           |   | * |   |
|   |   | ```                                 |           |   |   |   |
|   | * | -   The amounts listed below are    |           |   | * |   |
|   | * |     for the charges billed by a     |           |   | * |   |
|   | R |     physician or other health care  |           |   | R |   |
|   | * |     professional for your surgical  |           |   | * |   |
|   | * |     care. Look at Section 5 (c) for |           |   | * |   |
|   |   |     charges associated with         |           |   |   |   |
|   | * |     facility (i.e., hospital,       |           |   | * |   |
|   | * |     surgical center, etc.).         |           |   | * |   |
|   | T |                                     |           |   | T |   |
|   | * | -   **YOU MUST GET PRECERTIFICATION |           |   | * |   |
|   | * |     OF SOME SURGICAL PROCEDURES.**  |           |   | * |   |
|   |   |     Please refer to the             |           |   |   |   |
|   | * |     precertification information    |           |   | * |   |
|   | * |     shown in Section 3 to be sure   |           |   | * |   |
|   | A |     which services require          |           |   | A |   |
|   | * |     precertification and identify   |           |   | * |   |
|   | * |     which surgeries require         |           |   | * |   |
|   |   |     precertification.               |           |   |   |   |
|   | * |                                     |           |   | * |   |
|   | * |                                     |           |   | * |   |
|   | N |                                     |           |   | N |   |
|   | * |                                     |           |   | * |   |
|   | * |                                     |           |   | * |   |
|   |   |                                     |           |   |   |   |
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|   | T |                                     |           |   | T |   |
|   | * |                                     |           |   | * |   |
|   | * |                                     |           |   | * |   |
+---+---+-------------------------------------+-----------+---+---+---+
| > |   |                                     | **High    | * |   |   |
|   |   |                                     | Option**  | * |   |   |
| * |   |                                     |           | S |   |   |
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+---+---+-------------------------------------+-----------+---+---+---+
| > |   |                                     | > **You   | > |   |   |
|   |   |                                     | > Pay**   |   |   |   |
| * |   |                                     |           | * |   |   |
| * |   |                                     |           | * |   |   |
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| * |   |                                     |           |   |   |   |
+---+---+-------------------------------------+-----------+---+---+---+
| > |   |                                     | \$15 per  | \ |   |   |
|   |   |                                     | office    | $ |   |   |
| A |   |                                     | procedure | 2 |   |   |
| > |   |                                     | for a     | 5 |   |   |
|   |   |                                     | part      | p |   |   |
| c |   |                                     | icipating | e |   |   |
| o |   |                                     | provider. | r |   |   |
| m |   |                                     |           | o |   |   |
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| e |   |                                     | provider  | e |   |   |
| n |   |                                     | in a      | p |   |   |
| s |   |                                     | hospital  | r |   |   |
| i |   |                                     | or a      | o |   |   |
| v |   |                                     | part      | c |   |   |
| e |   |                                     | icipating | e |   |   |
| > |   |                                     | a         | d |   |   |
|   |   |                                     | mbulatory | u |   |   |
| r |   |                                     | surgery   | r |   |   |
| a |   |                                     | center.   | e |   |   |
| n |   |                                     |           | f |   |   |
| g |   |                                     | POS: 50%  | o |   |   |
| e |   |                                     | of the    | r |   |   |
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|   |   |                                     | fee       | p |   |   |
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| e |   |                                     | our fee   | i |   |   |
| r |   |                                     | schedule  | p |   |   |
| v |   |                                     | and the   | a |   |   |
| i |   |                                     | billed    | t |   |   |
| c |   |                                     | amount    | i |   |   |
| e |   |                                     | for       | n |   |   |
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| , |   |                                     | icipating | p |   |   |
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|   |   |                                     | roviders. | o |   |   |
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| s |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
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| o |   |                                     |           |   |   |   |
| r |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
| d |   |                                     |           |   |   |   |
| e |   |                                     |           |   |   |   |
| v |   |                                     |           |   |   |   |
| i |   |                                     |           |   |   |   |
| c |   |                                     |           |   |   |   |
| e |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
| c |   |                                     |           |   |   |   |
| o |   |                                     |           |   |   |   |
| v |   |                                     |           |   |   |   |
| e |   |                                     |           |   |   |   |
| r |   |                                     |           |   |   |   |
| a |   |                                     |           |   |   |   |
| g |   |                                     |           |   |   |   |
| e |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
|   |   |                                     |           |   |   |   |
| i |   |                                     |           |   |   |   |
| n |   |                                     |           |   |   |   |
| f |   |                                     |           |   |   |   |
| o |   |                                     |           |   |   |   |
| r |   |                                     |           |   |   |   |
| m |   |                                     |           |   |   |   |
| a |   |                                     |           |   |   |   |
| t |   |                                     |           |   |   |   |
| i |   |                                     |           |   |   |   |
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| . |   |                                     |           |   |   |   |
+---+---+-------------------------------------+-----------+---+---+---+

+--------------------------------------------+-----------+------------+
| > **Surgical procedures** (*continued*)    | **High\   | *          |
|                                            | Option**  | *Standard\ |
|                                            |           | Option**   |
|                                            | **You     |            |
|                                            | Pay**     | **You      |
|                                            |           | Pay**      |
+--------------------------------------------+-----------+------------+
| -   Voluntary sterilization (e.g., Tubal   | \$15 per  | \$25 per   |
|     ligation, Vasectomy)                   | office    | office     |
|                                            | procedure | procedure  |
| -   Treatment of burns                     | for       | for        |
|                                            | part      | par        |
|                                            | icipating | ticipating |
|                                            | p         | providers. |
|                                            | roviders. |            |
|                                            |           | Nothing    |
|                                            | Nothing   | for a      |
|                                            | for a     | par        |
|                                            | part      | ticipating |
|                                            | icipating | provider   |
|                                            | provider  | in the     |
|                                            | in the    | hospital   |
|                                            | hospital  | or a       |
|                                            | or a      | par        |
|                                            | part      | ticipating |
|                                            | icipating | ambulatory |
|                                            | a         | surgery    |
|                                            | mbulatory | center.    |
|                                            | surgery   |            |
|                                            | center.   | > All      |
|                                            |           | > charges  |
|                                            | POS: 50%  | > for      |
|                                            | of the    | > non-par  |
|                                            | Plan's    | ticipating |
|                                            | fee       | >          |
|                                            | schedule  | providers. |
|                                            | and any   |            |
|                                            | d         |            |
|                                            | ifference |            |
|                                            | between   |            |
|                                            | our fee   |            |
|                                            | schedule  |            |
|                                            | and the   |            |
|                                            | billed    |            |
|                                            | amount    |            |
|                                            | for       |            |
|                                            | non-part  |            |
|                                            | icipating |            |
|                                            | p         |            |
|                                            | roviders. |            |
+--------------------------------------------+-----------+------------+
| > *Not covered:*                           | > *All    | > *All     |
|                                            | >         | > charges* |
| -   *Reversal of voluntary sterilization.* |  charges* |            |
|                                            |           |            |
| -   *Stand-by services.*                   |           |            |
+--------------------------------------------+-----------+------------+

+--------------------------------------------+-----------+------------+
| > **Reconstructive surgery**               | **High\   | *          |
|                                            | Option**  | *Standard\ |
|                                            |           | Option**   |
|                                            | **You     |            |
|                                            | Pay**     | **You      |
|                                            |           | Pay**      |
+--------------------------------------------+-----------+------------+
| -   Surgery to correct a functional defect | \$15 per  | \$25 per   |
|                                            | office    | office     |
| -   Surgery to correct a condition caused  | procedure | procedure  |
|     by injury or illness if:               | for       | for        |
|                                            | part      | par        |
| ```{=html}                                 | icipating | ticipating |
| <!-- -->                                   | p         | providers. |
| ```                                        | roviders. |            |
| -   the condition produced a major effect  |           | Nothing    |
|     on the member's appearance and         | Nothing   | for a      |
|                                            | for a     | par        |
| -   the condition can reasonably be        | part      | ticipating |
|     expected to be corrected by such       | icipating | provider   |
|     surgery.                               | provider  | in the     |
|                                            | in the    | hospital   |
| ```{=html}                                 | hospital  | or a       |
| <!-- -->                                   | or a      | par        |
| ```                                        | part      | ticipating |
| -   Surgery to correct a condition that    | icipating | ambulatory |
|     existed at or from birth and is a      | a         | surgery    |
|     significant deviation from the common  | mbulatory | center.    |
|     form or norm. Examples of congenital   | surgery   |            |
|     anomalies are: protruding ear          | center.   | > All      |
|     deformities; cleft lip; cleft palate;  |           | > charges  |
|     birth marks; webbed fingers; and       | POS: 50%  | > for      |
|     webbed toes.                           | of the    | > non-par  |
|                                            | Plan's    | ticipating |
|                                            | fee       | >          |
|                                            | schedule  | providers. |
|                                            | and any   |            |
|                                            | d         |            |
|                                            | ifference |            |
|                                            | between   |            |
|                                            | our fee   |            |
|                                            | schedule  |            |
|                                            | and the   |            |
|                                            | billed    |            |
|                                            | amount    |            |
|                                            | for       |            |
|                                            | non-part  |            |
|                                            | icipating |            |
|                                            | p         |            |
|                                            | roviders. |            |
+--------------------------------------------+-----------+------------+
| -   All stages of breast reconstruction    | \$15 per  | \$25 per   |
|     surgery following a mastectomy, such   | office    | office     |
|     as:                                    | procedure | procedure  |
|                                            | for       | for        |
| > \- surgery to produce a symmetrical      | part      | par        |
| > appearance on the other breast           | icipating | ticipating |
| >                                          | p         | providers. |
| > \- treatment of any physical             | roviders. |            |
| > complications, such as lymphedemas       |           | Nothing    |
| >                                          | Nothing   | for a      |
| > \- breast prostheses and surgical bras   | for a     | par        |
| > and replacements (see Prosthetic         | part      | ticipating |
| > devices).                                | icipating | provider\  |
| >                                          | provider\ | in the     |
| > Note: If you need a mastectomy, you may  | in the    | hospital   |
| > choose to have the procedure performed   | hospital  | or a       |
| > on an inpatient basis and remain in the  | or a      | par        |
| > hospital up to 48 hours after the        | part      | ticipating |
| > procedure.                               | icipating | ambulatory |
|                                            | a         | surgery    |
|                                            | mbulatory | center.    |
|                                            | surgery   |            |
|                                            | center.   | > All      |
|                                            |           | > charges  |
|                                            | POS: 50%  | > for      |
|                                            | of the    | > non-par  |
|                                            | Plan's    | ticipating |
|                                            | fee       | >          |
|                                            | schedule  | providers. |
|                                            | and any   |            |
|                                            | d         |            |
|                                            | ifference |            |
|                                            | between   |            |
|                                            | our fee   |            |
|                                            | schedule  |            |
|                                            | and the   |            |
|                                            | billed    |            |
|                                            | amount    |            |
|                                            | for       |            |
|                                            | non-part  |            |
|                                            | icipating |            |
|                                            | p         |            |
|                                            | roviders. |            |
+--------------------------------------------+-----------+------------+
| > *Not covered:*                           | > *All    | > *All     |
|                                            | >         | > charges* |
| -   *Cosmetic surgery -- any surgical      |  charges* |            |
|     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**       | **High\   | *          |   |
|                                            | Option**  | *Standard\ |   |
|                                            |           | Option**   |   |
|                                            | **You     |            |   |
|                                            | Pay**     | **You      |   |
|                                            |           | Pay**      |   |
+--------------------------------------------+-----------+------------+---+
| > Oral surgical procedures, limited to:    | \$15 per  | \$25 per   |   |
|                                            | office    | office     |   |
| -   Reduction of fractures of the jaws or  | procedure | procedure  |   |
|     facial bones                           | for       | for        |   |
|                                            | part      | par        |   |
| -   Surgical correction of cleft lip,      | icipating | ticipating |   |
|     cleft palate or severe functional      | p         | providers. |   |
|     malocclusion                           | roviders. |            |   |
|                                            |           | Nothing    |   |
| -   Removal of stones from salivary ducts  | Nothing   | for a      |   |
|                                            | for a     | par        |   |
| -   Excision of leukoplakia or             | part      | ticipating |   |
|     malignancies                           | icipating | provider   |   |
|                                            | provider  | in the     |   |
| -   Excision of cysts and incision of      | in the    | hospital   |   |
|     abscesses when done as independent     | hospital  | or a       |   |
|     procedures, and                        | or a      | par        |   |
|                                            | part      | ticipating |   |
| -   Removal of impacted teeth              | icipating | a          |   |
|                                            | am        | mbulatory\ |   |
| -   Other surgical procedures that do not  | bulatory\ | surgery    |   |
|     involve the teeth or their supporting  | surgery   | center.    |   |
|     structures.                            | center.   |            |   |
|                                            |           | > All      |   |
|                                            | POS: 50%  | > charges  |   |
|                                            | of the    | > for      |   |
|                                            | Plan's    | > non-par  |   |
|                                            | fee       | ticipating |   |
|                                            | schedule  | >          |   |
|                                            | and any   | providers. |   |
|                                            | d         |            |   |
|                                            | ifference |            |   |
|                                            | between   |            |   |
|                                            | our fee   |            |   |
|                                            | schedule  |            |   |
|                                            | and the   |            |   |
|                                            | billed    |            |   |
|                                            | amount    |            |   |
|                                            | for       |            |   |
|                                            | non-part  |            |   |
|                                            | icipating |            |   |
|                                            | pr        |            |   |
|                                            | oviders.. |            |   |
+--------------------------------------------+-----------+------------+---+
| > *Not covered:*                           | > *All    | > *All     |   |
|                                            | >         | > charges* |   |
| -   *Oral implants and transplants*        |  charges* |            |   |
|                                            |           |            |   |
| -   *Procedures that involve the teeth or  |           |            |   |
|     their supporting structures (such as   |           |            |   |
|     the periodontal membrane, gingiva, and |           |            |   |
|     alveolar bone)*                        |           |            |   |
|                                            |           |            |   |
| -   *All other procedures involving the    |           |            |   |
|     teeth or intra-oral areas surrounding  |           |            |   |
|     the teeth are not covered, including   |           |            |   |
|     any dental care involved in the        |           |            |   |
|     treatment of teporomandibular joint    |           |            |   |
|     (TMJ) pain dysfunction syndrome.*      |           |            |   |
+--------------------------------------------+-----------+------------+---+

+--------------------------------------------+-----------+------------+---+
| > **Organ/tissue transplants**             | **High\   | *          |   |
|                                            | Option**  | *Standard\ |   |
|                                            |           | Option**   |   |
|                                            | **You     |            |   |
|                                            | Pay**     | **You      |   |
|                                            |           | Pay**      |   |
+--------------------------------------------+-----------+------------+---+
| > Limited to:                              | \$15 per  | \$25 per   |   |
|                                            | office    | office     |   |
| -   Cornea                                 | procedure | procedure  |   |
|                                            | for       | for        |   |
| -   Human Heart                            | part      | par        |   |
|                                            | icipating | ticipating |   |
| -   Heart/lung                             | p         | providers. |   |
|                                            | roviders. |            |   |
| -   Kidney                                 |           | Nothing    |   |
|                                            | Nothing   | for a      |   |
| -   Kidney/Pancreas                        | for a     | par        |   |
|                                            | part      | ticipating |   |
| -   Liver                                  | icipating | provider\  |   |
|                                            | provider\ | in the     |   |
| -   Lung: Single --Double                  | in the    | hospital   |   |
|                                            | hospital  | or a       |   |
| -   Pancreas                               | or a      | par        |   |
|                                            | part      | ticipating |   |
| -   Allogeneic (donor) bone marrow         | icipating | ambulatory |   |
|     transplants                            | a         | surgery    |   |
|                                            | mbulatory | center.    |   |
| -   Autologous bone marrow transplants     | surgery   |            |   |
|     (autologous stem cell and peripheral   | center.   | All        |   |
|     stem cell support) for the following   |           | charges    |   |
|     conditions: acute lymphocytic or       | POS: 50%  | for        |   |
|     non-lymphocytic leukemia; advanced     | of the    | non-par    |   |
|     Hodgkin\'s lymphoma; advanced          | Plan's    | ticipating |   |
|     non-Hodgkin\'s lymphoma; advanced      | fee       | providers. |   |
|     neuroblastoma; breast cancer; multiple | schedule  |            |   |
|     myeloma; epithelial ovarian cancer;    | and any   |            |   |
|     and testicular, mediastinal,           | d         |            |   |
|     retroperitoneal and ovarian germ cell  | ifference |            |   |
|     tumors                                 | between   |            |   |
|                                            | our fee   |            |   |
| -   Intestinal transplants (small          | schedule  |            |   |
|     intestine) and the small intestine     | and the   |            |   |
|     with the liver or small intestine with | billed    |            |   |
|     multiple organs such as the liver,     | amount    |            |   |
|     stomach, and pancreas.                 | for       |            |   |
|                                            | non-part  |            |   |
| ```{=html}                                 | icipating |            |   |
| <!-- -->                                   | p         |            |   |
| ```                                        | roviders. |            |   |
| -   National Transplant Program (NTP) --   |           |            |   |
|     We will cover transplants approved as  |           |            |   |
|     safe and effective for a specific      |           |            |   |
|     disease by the Federal Drug            |           |            |   |
|     Administration (FDA) or National       |           |            |   |
|     Institute of Health, or which our      |           |            |   |
|     Medical Director determines is         |           |            |   |
|     medically necessary, appropriate and   |           |            |   |
|     advisable on a case-by-case basis. We  |           |            |   |
|     will cover the medical and hospital    |           |            |   |
|     services, and related organ            |           |            |   |
|     acquisition costs. Eligibility for     |           |            |   |
|     transplants will be determined and     |           |            |   |
|     approved in advance solely by our      |           |            |   |
|     Medical Director upon recommendation   |           |            |   |
|     of your PCP. Additionally, all         |           |            |   |
|     transplants must be performed at       |           |            |   |
|     hospitals specifically approved and    |           |            |   |
|     designated by us to perform these      |           |            |   |
|     procedures. Specialty physician        |           |            |   |
|     experts from our designated centers of |           |            |   |
|     excellence will provide clinical       |           |            |   |
|     review and support to the Medical      |           |            |   |
|     Director's decision.                   |           |            |   |
|                                            |           |            |   |
| Limited Benefits -- Treatment for breast   |           |            |   |
| cancer, multiple myeloma, and epithelial   |           |            |   |
| ovarian cancer may be provided in an NCI-  |           |            |   |
| or NIH-approved clinical trial at a        |           |            |   |
| Plan-designated center of excellence and   |           |            |   |
| if approved by the Plan's medical director |           |            |   |
| in accordance with the Plan's protocols.   |           |            |   |
+--------------------------------------------+-----------+------------+---+

> *Organ/tissue transplants continued on next page*

+--------------------------------------------+-----------+------------+---+
| > **Organ/tissue transplants**             | **High\   | *          |   |
| > (*continued*)                            | Option**  | *Standard\ |   |
|                                            |           | Option**   |   |
|                                            | **You     |            |   |
|                                            | Pay**     | **You      |   |
|                                            |           | Pay**      |   |
+--------------------------------------------+-----------+------------+---+
| > We cover:                                | > See     | > See      |   |
|                                            | >         | > previous |   |
| -   We cover related medical and hospital  |  previous | > page.    |   |
|     expenses of the donor when we cover    | > page.   |            |   |
|     the recipient up to a maximum of       |           |            |   |
|     \$10,000 per transplant.               |           |            |   |
|                                            |           |            |   |
| -   Travel expenses up to a maximum of     |           |            |   |
|     \$150 per person per day and \$10,000  |           |            |   |
|     per lifetime of the recipient if the   |           |            |   |
|     recipient patient lives more than 75   |           |            |   |
|     miles from the transplant center. This |           |            |   |
|     includes food and lodging for the      |           |            |   |
|     recipient patient and one adult family |           |            |   |
|     member (two, if the recipient is a     |           |            |   |
|     minor) to the city where the           |           |            |   |
|     transplant takes place.                |           |            |   |
|                                            |           |            |   |
| > Note: The benefit period begins five (5) |           |            |   |
| > days prior to surgery and extends for a  |           |            |   |
| > period of up to one year from the date   |           |            |   |
| > of surgery. There is a separate lifetime |           |            |   |
| > maximum benefit up to \$1,000,000 per    |           |            |   |
| > recipient for each type of covered       |           |            |   |
| > transplant.                              |           |            |   |
+--------------------------------------------+-----------+------------+---+
| > *Not covered:*                           | *All      | *All       |   |
|                                            | charges*  | 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   | Nothing    |   |
|                                            | for a     | for a      |   |
| -   Hospital (inpatient)                   | part      | par        |   |
|                                            | icipating | ticipating |   |
|                                            | provider\ | provider\  |   |
|                                            | in the    | in the     |   |
|                                            | hospital  | hospital   |   |
|                                            | or a      | or a       |   |
|                                            | part      | par        |   |
|                                            | icipating | ticipating |   |
|                                            | a         | ambulatory |   |
|                                            | mbulatory | surgery    |   |
|                                            | surgery   | center.    |   |
|                                            | center.   |            |   |
|                                            |           | All        |   |
|                                            | POS: Any  | charges    |   |
|                                            | d         | for        |   |
|                                            | ifference | non-par    |   |
|                                            | between   | ticipating |   |
|                                            | our fee   | providers. |   |
|                                            | schedule  |            |   |
|                                            | and the   |            |   |
|                                            | billed    |            |   |
|                                            | amount    |            |   |
|                                            | for       |            |   |
|                                            | non-part  |            |   |
|                                            | icipating |            |   |
|                                            | providers |            |   |
+--------------------------------------------+-----------+------------+---+

> Anesthesia continued on next page

+--------------------------------------------+-----------+------------+
| > **Anesthesia** (*continued*)             | **High\   | *          |
|                                            | Option**  | *Standard\ |
|                                            |           | Option**   |
|                                            | **You     |            |
|                                            | Pay**     | **You      |
|                                            |           | Pay**      |
+--------------------------------------------+-----------+------------+
| Professional services provided in --       | Nothing   | Nothing    |
|                                            | for a     | for a      |
| -   Hospital outpatient department         | part      | par        |
|                                            | icipating | ticipating |
| -   Skilled nursing facility               | provider\ | provider\  |
|                                            | in the    | in the     |
| -   Hospital ambulatory surgical center    | hospital  | hospital   |
|                                            | or a      | or a       |
| -   Office                                 | part      | par        |
|                                            | icipating | ticipating |
|                                            | a         | ambulatory |
|                                            | mbulatory | surgery    |
|                                            | surgery   | center.    |
|                                            | center.   |            |
|                                            |           | All        |
|                                            | POS: Any  | charges    |
|                                            | d         | for        |
|                                            | ifference | non-par    |
|                                            | between   | ticipating |
|                                            | our fee   | providers. |
|                                            | schedule  |            |
|                                            | and the   |            |
|                                            | billed    |            |
|                                            | amount    |            |
|                                            | for       |            |
|                                            | non-part  |            |
|                                            | icipating |            |
|                                            | p         |            |
|                                            | roviders. |            |
+--------------------------------------------+-----------+------------+
| *Not covered:*                             | > *All    | > *All     |
|                                            | >         | > charges* |
| -   *Services administered by the same     |  charges* |            |
|     practitioner performing surgery*       |           |            |
+--------------------------------------------+-----------+------------+

+----+---+------------------------------------+-----------+---+---+------+
| >  |   |                                    |           |   |   |      |
|  * |   |                                    |           |   |   |      |
| *S |   |                                    |           |   |   |      |
| ec |   |                                    |           |   |   |      |
| ti |   |                                    |           |   |   |      |
| on |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  5 |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| (c |   |                                    |           |   |   |      |
| ). |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| Se |   |                                    |           |   |   |      |
| rv |   |                                    |           |   |   |      |
| ic |   |                                    |           |   |   |      |
| es |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| pr |   |                                    |           |   |   |      |
| ov |   |                                    |           |   |   |      |
| id |   |                                    |           |   |   |      |
| ed |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| by |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| ho |   |                                    |           |   |   |      |
| sp |   |                                    |           |   |   |      |
| it |   |                                    |           |   |   |      |
| al |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| or |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  o |   |                                    |           |   |   |      |
| th |   |                                    |           |   |   |      |
| er |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  f |   |                                    |           |   |   |      |
| ac |   |                                    |           |   |   |      |
| il |   |                                    |           |   |   |      |
| it |   |                                    |           |   |   |      |
| y, |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| nd |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| mb |   |                                    |           |   |   |      |
| ul |   |                                    |           |   |   |      |
| an |   |                                    |           |   |   |      |
| ce |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| se |   |                                    |           |   |   |      |
| rv |   |                                    |           |   |   |      |
| ic |   |                                    |           |   |   |      |
| es |   |                                    |           |   |   |      |
| ** |   |                                    |           |   |   |      |
+----+---+------------------------------------+-----------+---+---+------+
|    | * | > **Here are some important things |           |   | * |      |
|    | * | > to remember about these          |           |   | * |      |
|    | I | > benefits:**                      |           |   | I |      |
|    | * |                                    |           |   | * |      |
|    | * | -   Please remember that all       |           |   | * |      |
|    |   |     benefits are subject to the    |           |   |   |      |
|    | * |     definitions, limitations, and  |           |   | * |      |
|    | * |     exclusions in this brochure    |           |   | * |      |
|    | M |     and are payable only when we   |           |   | M |      |
|    | * |     determine they are medically   |           |   | * |      |
|    | * |     necessary.                     |           |   | * |      |
|    |   |                                    |           |   |   |      |
|    | * | -   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 |      |
|    | * | -   The amounts listed below are   |           |   | * |      |
|    | * |     for the facility charges       |           |   | * |      |
|    |   |     billed by the facility (i.e.,  |           |   |   |      |
|    | * |     hospital or surgical center)   |           |   | * |      |
|    | * |     or ambulance service for your  |           |   | * |      |
|    | R |     surgery or care. Any costs     |           |   | R |      |
|    | * |     associated with the            |           |   | * |      |
|    | * |     professional charge (i.e.,     |           |   | * |      |
|    |   |     physicians, etc.) are          |           |   |   |      |
|    | * |     addressed in Section 5(a) or   |           |   | * |      |
|    | * |     (b).                           |           |   | * |      |
|    | T |                                    |           |   | T |      |
|    | * | ```{=html}                         |           |   | * |      |
|    | * | <!-- -->                           |           |   | * |      |
|    |   | ```                                |           |   |   |      |
|    | * | -   **YOU MUST GET                 |           |   | * |      |
|    | * |     PRECERTIFICATION OF HOSPITAL   |           |   | * |      |
|    | A |     STAYS.** Please refer to       |           |   | A |      |
|    | * |     Section 3 to be sure which     |           |   | * |      |
|    | * |     services require               |           |   | * |      |
|    |   |     precertification.              |           |   |   |      |
|    | * |                                    |           |   | * |      |
|    | * |                                    |           |   | * |      |
|    | N |                                    |           |   | N |      |
|    | * |                                    |           |   | * |      |
|    | * |                                    |           |   | * |      |
|    |   |                                    |           |   |   |      |
|    | * |                                    |           |   | * |      |
|    | * |                                    |           |   | * |      |
|    | T |                                    |           |   | T |      |
|    | * |                                    |           |   | * |      |
|    | * |                                    |           |   | * |      |
+----+---+------------------------------------+-----------+---+---+------+
| >  |   |                                    | **High    | * |   |      |
|  * |   |                                    | Option**  | * |   |      |
| *B |   |                                    |           | S |   |      |
| en |   |                                    |           | t |   |      |
| ef |   |                                    |           | a |   |      |
| it |   |                                    |           | n |   |      |
| >  |   |                                    |           | d |   |      |
|  D |   |                                    |           | a |   |      |
| es |   |                                    |           | r |   |      |
| cr |   |                                    |           | d |   |      |
| ip |   |                                    |           | O |   |      |
| ti |   |                                    |           | p |   |      |
| on |   |                                    |           | t |   |      |
| ** |   |                                    |           | i |   |      |
|    |   |                                    |           | o |   |      |
|    |   |                                    |           | n |   |      |
|    |   |                                    |           | * |   |      |
|    |   |                                    |           | * |   |      |
+----+---+------------------------------------+-----------+---+---+------+
| >  |   |                                    | > **You   | > |   |      |
|  * |   |                                    | > Pay**   |   |   |      |
| *I |   |                                    |           | * |   |      |
| np |   |                                    |           | * |   |      |
| at |   |                                    |           | Y |   |      |
| ie |   |                                    |           | o |   |      |
| nt |   |                                    |           | u |   |      |
| >  |   |                                    |           | > |   |      |
| ho |   |                                    |           |   |   |      |
| sp |   |                                    |           | P |   |      |
| it |   |                                    |           | a |   |      |
| al |   |                                    |           | y |   |      |
| ** |   |                                    |           | * |   |      |
|    |   |                                    |           | * |   |      |
+----+---+------------------------------------+-----------+---+---+------+
| >  |   |                                    | > Nothing | > |   |      |
| Ro |   |                                    | > for a   |   |   |      |
| om |   |                                    | > Plan    | \ |   |      |
| >  |   |                                    | >         | $ |   |      |
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| nd |   |                                    |           | 5 |   |      |
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| wh |   |                                    |           |   |   |      |
| en |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| it |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| is |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  n |   |                                    |           |   |   |      |
| ot |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  m |   |                                    |           |   |   |      |
| ed |   |                                    |           |   |   |      |
| ic |   |                                    |           |   |   |      |
| al |   |                                    |           |   |   |      |
| ly |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| ne |   |                                    |           |   |   |      |
| ce |   |                                    |           |   |   |      |
| ss |   |                                    |           |   |   |      |
| ar |   |                                    |           |   |   |      |
| y, |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  y |   |                                    |           |   |   |      |
| ou |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  p |   |                                    |           |   |   |      |
| ay |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  t |   |                                    |           |   |   |      |
| he |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| ad |   |                                    |           |   |   |      |
| di |   |                                    |           |   |   |      |
| ti |   |                                    |           |   |   |      |
| on |   |                                    |           |   |   |      |
| al |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| ch |   |                                    |           |   |   |      |
| ar |   |                                    |           |   |   |      |
| ge |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| bo |   |                                    |           |   |   |      |
| ve |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  t |   |                                    |           |   |   |      |
| he |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  s |   |                                    |           |   |   |      |
| em |   |                                    |           |   |   |      |
| ip |   |                                    |           |   |   |      |
| ri |   |                                    |           |   |   |      |
| va |   |                                    |           |   |   |      |
| te |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| ro |   |                                    |           |   |   |      |
| om |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  r |   |                                    |           |   |   |      |
| at |   |                                    |           |   |   |      |
| e. |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  ( |   |                                    |           |   |   |      |
| Ho |   |                                    |           |   |   |      |
| sp |   |                                    |           |   |   |      |
| it |   |                                    |           |   |   |      |
| al |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| de |   |                                    |           |   |   |      |
| du |   |                                    |           |   |   |      |
| ct |   |                                    |           |   |   |      |
| ib |   |                                    |           |   |   |      |
| le |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| is |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
| wa |   |                                    |           |   |   |      |
| iv |   |                                    |           |   |   |      |
| ed |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  f |   |                                    |           |   |   |      |
| or |   |                                    |           |   |   |      |
| >  |   |                                    |           |   |   |      |
|  m |   |                                    |           |   |   |      |
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| ty |   |                                    |           |   |   |      |
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| ca |   |                                    |           |   |   |      |
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+----+---+------------------------------------+-----------+---+---+------+
| #  |   |                                    | > Nothing | > |   |      |
| ## |   |                                    | > for a   |   |   |      |
| #  |   |                                    | > Plan    | N |   |      |
| Ot |   |                                    | >         | o |   |      |
| he |   |                                    |  facility | t |   |      |
| r  |   |                                    |           | h |   |      |
| ho |   |                                    |           | i |   |      |
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| it |   |                                    |           | g |   |      |
| al |   |                                    |           | > |   |      |
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| ce |   |                                    |           | n |   |      |
| s  |   |                                    |           | c |   |      |
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| d  |   |                                    |           | u |   |      |
| su |   |                                    |           | d |   |      |
| pp |   |                                    |           | e |   |      |
| li |   |                                    |           | d |   |      |
| es |   |                                    |           | > |   |      |
| ,  |   |                                    |           |   |   |      |
| su |   |                                    |           | i |   |      |
| ch |   |                                    |           | n |   |      |
|  a |   |                                    |           | > |   |      |
| s: |   |                                    |           |   |   |      |
|    |   |                                    |           | \ |   |      |
| -  |   |                                    |           | $ |   |      |
|    |   |                                    |           | 2 |   |      |
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| at |   |                                    |           | > |   |      |
| in |   |                                    |           |   |   |      |
| g, |   |                                    |           | p |   |      |
|    |   |                                    |           | e |   |      |
|    |   |                                    |           | r |   |      |
|  r |   |                                    |           | > |   |      |
| ec |   |                                    |           |   |   |      |
| ov |   |                                    |           | d |   |      |
| er |   |                                    |           | a |   |      |
| y, |   |                                    |           | y |   |      |
|    |   |                                    |           | > |   |      |
|    |   |                                    |           |   |   |      |
| ma |   |                                    |           | p |   |      |
| te |   |                                    |           | e |   |      |
| rn |   |                                    |           | r |   |      |
| it |   |                                    |           | > |   |      |
| y, |   |                                    |           |   |   |      |
|    |   |                                    |           | i |   |      |
|    |   |                                    |           | m |   |      |
|  a |   |                                    |           | p |   |      |
| nd |   |                                    |           | a |   |      |
|    |   |                                    |           | t |   |      |
|    |   |                                    |           | i |   |      |
|  o |   |                                    |           | e |   |      |
| th |   |                                    |           | n |   |      |
| er |   |                                    |           | t |   |      |
|    |   |                                    |           | > |   |      |
|    |   |                                    |           |   |   |      |
|  t |   |                                    |           | a |   |      |
| re |   |                                    |           | d |   |      |
| at |   |                                    |           | m |   |      |
| me |   |                                    |           | i |   |      |
| nt |   |                                    |           | s |   |      |
|    |   |                                    |           | s |   |      |
|    |   |                                    |           | i |   |      |
|  r |   |                                    |           | o |   |      |
| oo |   |                                    |           | n |   |      |
| ms |   |                                    |           | > |   |      |
|    |   |                                    |           |   |   |      |
| -  |   |                                    |           | t |   |      |
|    |   |                                    |           | o |   |      |
| Pr |   |                                    |           | > |   |      |
| es |   |                                    |           |   |   |      |
| cr |   |                                    |           | a |   |      |
| ib |   |                                    |           | > |   |      |
| ed |   |                                    |           |   |   |      |
|    |   |                                    |           | m |   |      |
|    |   |                                    |           | a |   |      |
|  d |   |                                    |           | x |   |      |
| ru |   |                                    |           | i |   |      |
| gs |   |                                    |           | m |   |      |
|    |   |                                    |           | u |   |      |
|    |   |                                    |           | m |   |      |
|  a |   |                                    |           | > |   |      |
| nd |   |                                    |           |   |   |      |
|    |   |                                    |           | o |   |      |
|    |   |                                    |           | f |   |      |
|  m |   |                                    |           | > |   |      |
| ed |   |                                    |           |   |   |      |
| ic |   |                                    |           | \ |   |      |
| in |   |                                    |           | $ |   |      |
| es |   |                                    |           | 7 |   |      |
|    |   |                                    |           | 5 |   |      |
| -  |   |                                    |           | 0 |   |      |
|    |   |                                    |           | > |   |      |
| Di |   |                                    |           |   |   |      |
| ag |   |                                    |           | p |   |      |
| no |   |                                    |           | e |   |      |
| st |   |                                    |           | r |   |      |
| ic |   |                                    |           | > |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           | i |   |      |
| la |   |                                    |           | n |   |      |
| bo |   |                                    |           | p |   |      |
| ra |   |                                    |           | a |   |      |
| to |   |                                    |           | t |   |      |
| ry |   |                                    |           | i |   |      |
|    |   |                                    |           | e |   |      |
|    |   |                                    |           | n |   |      |
|  t |   |                                    |           | t |   |      |
| es |   |                                    |           | > |   |      |
| ts |   |                                    |           |   |   |      |
|    |   |                                    |           | a |   |      |
|    |   |                                    |           | d |   |      |
|  a |   |                                    |           | m |   |      |
| nd |   |                                    |           | i |   |      |
|    |   |                                    |           | s |   |      |
|    |   |                                    |           | s |   |      |
| X- |   |                                    |           | i |   |      |
| ra |   |                                    |           | o |   |      |
| ys |   |                                    |           | n |   |      |
|    |   |                                    |           |   |   |      |
| -  |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| Ad |   |                                    |           |   |   |      |
| mi |   |                                    |           |   |   |      |
| ni |   |                                    |           |   |   |      |
| st |   |                                    |           |   |   |      |
| ra |   |                                    |           |   |   |      |
| ti |   |                                    |           |   |   |      |
| on |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| of |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  b |   |                                    |           |   |   |      |
| lo |   |                                    |           |   |   |      |
| od |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| nd |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  b |   |                                    |           |   |   |      |
| lo |   |                                    |           |   |   |      |
| od |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| pr |   |                                    |           |   |   |      |
| od |   |                                    |           |   |   |      |
| uc |   |                                    |           |   |   |      |
| ts |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| -  |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  B |   |                                    |           |   |   |      |
| lo |   |                                    |           |   |   |      |
| od |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| or |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  b |   |                                    |           |   |   |      |
| lo |   |                                    |           |   |   |      |
| od |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  p |   |                                    |           |   |   |      |
| la |   |                                    |           |   |   |      |
| sm |   |                                    |           |   |   |      |
| a, |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| if |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  n |   |                                    |           |   |   |      |
| ot |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  d |   |                                    |           |   |   |      |
| on |   |                                    |           |   |   |      |
| at |   |                                    |           |   |   |      |
| ed |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| or |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| re |   |                                    |           |   |   |      |
| pl |   |                                    |           |   |   |      |
| ac |   |                                    |           |   |   |      |
| ed |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| -  |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| Dr |   |                                    |           |   |   |      |
| es |   |                                    |           |   |   |      |
| si |   |                                    |           |   |   |      |
| ng |   |                                    |           |   |   |      |
| s, |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| sp |   |                                    |           |   |   |      |
| li |   |                                    |           |   |   |      |
| nt |   |                                    |           |   |   |      |
| s, |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| ca |   |                                    |           |   |   |      |
| st |   |                                    |           |   |   |      |
| s, |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| nd |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  s |   |                                    |           |   |   |      |
| te |   |                                    |           |   |   |      |
| ri |   |                                    |           |   |   |      |
| le |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| tr |   |                                    |           |   |   |      |
| ay |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| se |   |                                    |           |   |   |      |
| rv |   |                                    |           |   |   |      |
| ic |   |                                    |           |   |   |      |
| es |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| -  |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  M |   |                                    |           |   |   |      |
| ed |   |                                    |           |   |   |      |
| ic |   |                                    |           |   |   |      |
| al |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| su |   |                                    |           |   |   |      |
| pp |   |                                    |           |   |   |      |
| li |   |                                    |           |   |   |      |
| es |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| nd |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| eq |   |                                    |           |   |   |      |
| ui |   |                                    |           |   |   |      |
| pm |   |                                    |           |   |   |      |
| en |   |                                    |           |   |   |      |
| t, |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  i |   |                                    |           |   |   |      |
| nc |   |                                    |           |   |   |      |
| lu |   |                                    |           |   |   |      |
| di |   |                                    |           |   |   |      |
| ng |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| ox |   |                                    |           |   |   |      |
| yg |   |                                    |           |   |   |      |
| en |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| -  |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| An |   |                                    |           |   |   |      |
| es |   |                                    |           |   |   |      |
| th |   |                                    |           |   |   |      |
| et |   |                                    |           |   |   |      |
| ic |   |                                    |           |   |   |      |
| s, |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  i |   |                                    |           |   |   |      |
| nc |   |                                    |           |   |   |      |
| lu |   |                                    |           |   |   |      |
| di |   |                                    |           |   |   |      |
| ng |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  n |   |                                    |           |   |   |      |
| ur |   |                                    |           |   |   |      |
| se |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| ne |   |                                    |           |   |   |      |
| st |   |                                    |           |   |   |      |
| he |   |                                    |           |   |   |      |
| ti |   |                                    |           |   |   |      |
| st |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| se |   |                                    |           |   |   |      |
| rv |   |                                    |           |   |   |      |
| ic |   |                                    |           |   |   |      |
| es |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| -  |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  T |   |                                    |           |   |   |      |
| ak |   |                                    |           |   |   |      |
| e- |   |                                    |           |   |   |      |
| ho |   |                                    |           |   |   |      |
| me |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  i |   |                                    |           |   |   |      |
| te |   |                                    |           |   |   |      |
| ms |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| -  |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  M |   |                                    |           |   |   |      |
| ed |   |                                    |           |   |   |      |
| ic |   |                                    |           |   |   |      |
| al |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  s |   |                                    |           |   |   |      |
| up |   |                                    |           |   |   |      |
| pl |   |                                    |           |   |   |      |
| ie |   |                                    |           |   |   |      |
| s, |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| pp |   |                                    |           |   |   |      |
| li |   |                                    |           |   |   |      |
| an |   |                                    |           |   |   |      |
| ce |   |                                    |           |   |   |      |
| s, |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  m |   |                                    |           |   |   |      |
| ed |   |                                    |           |   |   |      |
| ic |   |                                    |           |   |   |      |
| al |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| eq |   |                                    |           |   |   |      |
| ui |   |                                    |           |   |   |      |
| pm |   |                                    |           |   |   |      |
| en |   |                                    |           |   |   |      |
| t, |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| nd |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| ny |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  c |   |                                    |           |   |   |      |
| ov |   |                                    |           |   |   |      |
| er |   |                                    |           |   |   |      |
| ed |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  i |   |                                    |           |   |   |      |
| te |   |                                    |           |   |   |      |
| ms |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| bi |   |                                    |           |   |   |      |
| ll |   |                                    |           |   |   |      |
| ed |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| by |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| ho |   |                                    |           |   |   |      |
| sp |   |                                    |           |   |   |      |
| it |   |                                    |           |   |   |      |
| al |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  f |   |                                    |           |   |   |      |
| or |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  u |   |                                    |           |   |   |      |
| se |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| at |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| ho |   |                                    |           |   |   |      |
| me |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| (N |   |                                    |           |   |   |      |
| ot |   |                                    |           |   |   |      |
| e: |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| ca |   |                                    |           |   |   |      |
| le |   |                                    |           |   |   |      |
| nd |   |                                    |           |   |   |      |
| ar |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| ye |   |                                    |           |   |   |      |
| ar |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
| de |   |                                    |           |   |   |      |
| du |   |                                    |           |   |   |      |
| ct |   |                                    |           |   |   |      |
| ib |   |                                    |           |   |   |      |
| le |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|    |   |                                    |           |   |   |      |
|  a |   |                                    |           |   |   |      |
| pp |   |                                    |           |   |   |      |
| li |   |                                    |           |   |   |      |
| es |   |                                    |           |   |   |      |
| .) |   |                                    |           |   |   |      |
+----+---+------------------------------------+-----------+---+---+------+

> *Inpatient hospital continued on next page*

+---------------------------------------------+-----------+-----------+---+
| > **Inpatient hospital** (*continued*)      | **High\   | **        |   |
|                                             | Option**  | Standard\ |   |
|                                             |           | Option**  |   |
|                                             | **You     |           |   |
|                                             | Pay**     | **You     |   |
|                                             |           | Pay**     |   |
+---------------------------------------------+-----------+-----------+---+
| > *Not covered:*                            | > *All    | > *All    |   |
|                                             | >         | >         |   |
| -   *Custodial care, rest cures,            |  charges* |  charges* |   |
|     domiciliary or convalescent care*       |           |           |   |
|                                             |           |           |   |
| -   *Non-covered facilities, such as        |           |           |   |
|     nursing homes and schools*              |           |           |   |
|                                             |           |           |   |
| -   *Personal comfort items, such as        |           |           |   |
|     telephone, television, barber services, |           |           |   |
|     guest meals and beds*                   |           |           |   |
|                                             |           |           |   |
| -   *Private nursing care*                  |           |           |   |
|                                             |           |           |   |
| -   *Long term rehabilitation*              |           |           |   |
+---------------------------------------------+-----------+-----------+---+
| #### **Outpatie                             | ####      |           |   |
| nt hospital or ambulatory surgical center** |           |           |   |
+---------------------------------------------+-----------+-----------+---+
| -   Operating, recovery, and other          | > Nothing | > Nothing |   |
|     treatment rooms                         | > for a   | > for a   |   |
|                                             | > Plan    | > Plan    |   |
| -   Prescribed drugs and medicines          | >         | >         |   |
|                                             | facility. | facility. |   |
| -   Administration of blood, blood plasma,  |           |           |   |
|     and other biologicals                   |           |           |   |
|                                             |           |           |   |
| -   Pre-surgical testing                    |           |           |   |
|                                             |           |           |   |
| -   Dressings, casts, and sterile tray      |           |           |   |
|     services                                |           |           |   |
|                                             |           |           |   |
| -   Medical supplies, including oxygen      |           |           |   |
|                                             |           |           |   |
| -   Anesthetics and anesthesia service      |           |           |   |
+---------------------------------------------+-----------+-----------+---+
| -   Diagnostic laboratory tests, X-rays,    | > \$25    | > All     |   |
|     and pathology services                  | >         | > Charges |   |
|                                             | copayment |           |   |
+---------------------------------------------+-----------+-----------+---+
| -   Chemotherapy and radiation              | > Nothing | > Nothing |   |
|                                             | > for     | > for     |   |
|                                             | > che     | > che     |   |
|                                             | motherapy | motherapy |   |
|                                             | > and     | > and     |   |
|                                             | >         | >         |   |
|                                             | radiation | radiation |   |
|                                             | >         | >         |   |
|                                             |  provided |  provided |   |
|                                             | > in a    | > in a    |   |
|                                             | > part    | > part    |   |
|                                             | icipating | icipating |   |
|                                             | >         | >         |   |
|                                             | facility. | facility. |   |
|                                             | >         | >         |   |
|                                             | > POS:    | > All     |   |
|                                             | > 50% of  | > charges |   |
|                                             | > the     | > for     |   |
|                                             | > Plan's  | >         |   |
|                                             | > fee     |  non-part |   |
|                                             | >         | icipating |   |
|                                             |  schedule | > p       |   |
|                                             | > and any | roviders. |   |
|                                             | > d       |           |   |
|                                             | ifference |           |   |
|                                             | > between |           |   |
|                                             | > our fee |           |   |
|                                             | >         |           |   |
|                                             |  schedule |           |   |
|                                             | > and the |           |   |
|                                             | > billed  |           |   |
|                                             | > amount  |           |   |
|                                             | > for     |           |   |
|                                             | >         |           |   |
|                                             |  non-part |           |   |
|                                             | icipating |           |   |
|                                             | > p       |           |   |
|                                             | roviders. |           |   |
+---------------------------------------------+-----------+-----------+---+

> Outpatient hospital continued on next page

+---------------------------------------------+-----------+------------+
| > **Outpatient hospital** (*continued*)     | **High\   | *          |
|                                             | Option**  | *Standard\ |
|                                             |           | Option**   |
|                                             | **You     |            |
|                                             | Pay**     | **You      |
|                                             |           | Pay**      |
+---------------------------------------------+-----------+------------+
| > Note: We cover hospital services and      |           |            |
| > supplies related to dental procedures     |           |            |
| > when necessitated by a non-dental         |           |            |
| > physical impairment. We do not cover the  |           |            |
| > dental procedures. Conditions for which   |           |            |
| > hospitalization would be covered include  |           |            |
| > hemophilia, impacted teeth, and heart     |           |            |
| > disease; the need for anesthesia, by      |           |            |
| > itself, is not such a condition.          |           |            |
+---------------------------------------------+-----------+------------+
| *Not covered: blood and blood derivatives   | *All      | *All       |
| not replaced by the member*                 | charges*  | charges*   |
+---------------------------------------------+-----------+------------+
| #### **Extended care benefi                 | **High    | **Standard |
| ts/skilled nursing care facility benefits** | Option**  | Option**   |
+---------------------------------------------+-----------+------------+
| > Skilled nursing facility (SNF):           | > Nothing | > Nothing  |
| >                                           | > for a   | > for a    |
| > Limited to 30 days:                       | > part    | > par      |
|                                             | icipating | ticipating |
| -   Bed, board and general nursing care     | >         | >          |
|                                             | provider. |  provider. |
| -   Drugs, biologicals, supplied and        | >         | >          |
|     equipment ordinarily provided or        | > POS:    | > All      |
|     arranged by the skilled nursing         | > All     | > charges  |
|     facility when prescribed by your doctor | > charges | > for a    |
|     as governed by Medicare guidelines.     | > for a   | > non-par  |
|                                             | >         | ticipating |
|                                             |  non-part | >          |
|                                             | icipating |  provider. |
|                                             | >         |            |
|                                             | provider. |            |
+---------------------------------------------+-----------+------------+
| > *Not covered:*                            | *All      | *All       |
|                                             | charges*  | charges*   |
| -   *custodial care*                        |           |            |
+---------------------------------------------+-----------+------------+
| #### **Hospice care**                       | ####      |            |
+---------------------------------------------+-----------+------------+
| > Supportive and palliative care for a      | > Nothing | > Nothing  |
| > terminally ill member in the home or      |           |            |
| > hospice facility. Services include:       |           |            |
|                                             |           |            |
| -   inpatient/outpatient care; and          |           |            |
|                                             |           |            |
| -   family counseling under the direction   |           |            |
|     of a doctor.                            |           |            |
|                                             |           |            |
| > Note: Your provider must certify that you |           |            |
| > are in the terminal stages of illness,    |           |            |
| > with a life expectancy of approximately   |           |            |
| > six months or less. The hospice must have |           |            |
| > an agreement with us or recognized by     |           |            |
| > Medicare as a hospice.                    |           |            |
+---------------------------------------------+-----------+------------+
| > *Not covered: Independent nursing,        | *All      | *All       |
| > homemaker services*                       | charges*  | charges*   |
+---------------------------------------------+-----------+------------+
| ######## Ambulance                          | ########  |            |
+---------------------------------------------+-----------+------------+
| -   Ambulance services for each trip to or  | > All     | > All      |
|     from a hospital for medically necessary | > charges | > charges  |
|     services. This includes the use of an   | > in      | > in       |
|     ambulance for emergency outpatient care | > excess  | > excess   |
|     and maternity care, to the nearest      | > of      | > of       |
|     facility.                               | > \$100.  | > \$100.   |
+---------------------------------------------+-----------+------------+
| > *Not covered:*                            | *All      | *All       |
|                                             | charges*  | charges*   |
| -   *Air ambulance*                         |           |            |
|                                             |           |            |
| -   *Ambullette services*                   |           |            |
+---------------------------------------------+-----------+------------+

+---+---+------------------------------------------------------+---+---+
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
|   |   |                                                      |   |   |
| S |   |                                                      |   |   |
| e |   |                                                      |   |   |
| c |   |                                                      |   |   |
| t |   |                                                      |   |   |
| i |   |                                                      |   |   |
| o |   |                                                      |   |   |
| n |   |                                                      |   |   |
|   |   |                                                      |   |   |
| 5 |   |                                                      |   |   |
|   |   |                                                      |   |   |
| ( |   |                                                      |   |   |
| d |   |                                                      |   |   |
| ) |   |                                                      |   |   |
| . |   |                                                      |   |   |
|   |   |                                                      |   |   |
| E |   |                                                      |   |   |
| m |   |                                                      |   |   |
| e |   |                                                      |   |   |
| r |   |                                                      |   |   |
| g |   |                                                      |   |   |
| e |   |                                                      |   |   |
| n |   |                                                      |   |   |
| c |   |                                                      |   |   |
| y |   |                                                      |   |   |
|   |   |                                                      |   |   |
| s |   |                                                      |   |   |
| e |   |                                                      |   |   |
| r |   |                                                      |   |   |
| v |   |                                                      |   |   |
| i |   |                                                      |   |   |
| c |   |                                                      |   |   |
| e |   |                                                      |   |   |
| s |   |                                                      |   |   |
| / |   |                                                      |   |   |
| a |   |                                                      |   |   |
| c |   |                                                      |   |   |
| c |   |                                                      |   |   |
| i |   |                                                      |   |   |
| d |   |                                                      |   |   |
| e |   |                                                      |   |   |
| n |   |                                                      |   |   |
| t |   |                                                      |   |   |
| s |   |                                                      |   |   |
+---+---+------------------------------------------------------+---+---+
|   | * | **Here are some important things to keep in mind     | * | # |
|   | * | about these benefits:**                              | * | # |
|   | I |                                                      | I | # |
|   | * | -   Please remember that all benefits are subject to | * | # |
|   | * |     the definitions, limitations, and exclusions in  | * | # |
|   |   |     this brochure and are payable only when we       |   |   |
|   | * |     determine they are medically necessary.          | * |   |
|   | * |                                                      | * |   |
|   | M | -   Be sure to read Section 4, *Your costs for       | M |   |
|   | * |     covered services,* for valuable information      | * |   |
|   | * |     about how cost sharing works. Also read Section  | * |   |
|   |   |     9 about coordinating benefits with other         |   |   |
|   | * |     coverage, including with Medicare.               | * |   |
|   | * |                                                      | * |   |
|   | P | #####                                                | P |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | O |                                                      | O |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | R |                                                      | R |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | T |                                                      | T |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | A |                                                      | A |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | N |                                                      | N |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   | T |                                                      | T |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
+---+---+------------------------------------------------------+---+---+
| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| * |   |                                                      |   |   |
| * |   |                                                      |   |   |
| W |   |                                                      |   |   |
| h |   |                                                      |   |   |
| a |   |                                                      |   |   |
| t |   |                                                      |   |   |
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|   |   |                                                      |   |   |
| i |   |                                                      |   |   |
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|   |   |                                                      |   |   |
| a |   |                                                      |   |   |
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|   |   |                                                      |   |   |
| m |   |                                                      |   |   |
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| d |   |                                                      |   |   |
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|   |   |                                                      |   |   |
| e |   |                                                      |   |   |
| m |   |                                                      |   |   |
| e |   |                                                      |   |   |
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| g |   |                                                      |   |   |
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| ' |   |                                                      |   |   |
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|   |   |                                                      |   |   |
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+---+---+------------------------------------------------------+---+---+

+-----------------------------------------------+----------+----------+
| > **Benefit Description**                     | **High   | **       |
|                                               | Option** | Standard |
|                                               |          | Option** |
+-----------------------------------------------+----------+----------+
| > **Emergency within our service area**       | > **You  | > **You  |
|                                               | > Pay**  | > Pay**  |
+-----------------------------------------------+----------+----------+
| -   Emergency medical/surgical care at a      | \$15 per | \$25 per |
|     doctor\'s office                          | office   | office   |
|                                               | visit    | visit    |
| -   Emergency medical/surgical care at an     | for a    | for a    |
|     urgent care center                        | parti    | parti    |
|                                               | cipating | cipating |
| ```{=html}                                    | p        | p        |
| <!-- -->                                      | rovider. | rovider. |
| ```                                           |          |          |
| -   Emergency care as an outpatient or        | POS: Any | Any      |
|     inpatient at a hospital, including        | di       | di       |
|     doctors\' services                        | fference | fference |
|                                               | between  | between  |
| > Note: Copay waived if admitted to the       | our fee  | our fee  |
| > hospital. If private physicians who are not | schedule | schedule |
| > hospital employees provide the emergency    | and the  | and the  |
| > care, you may receive a separate bill for   | billed   | billed   |
| > these services, which we will process as a  | amount   | amount   |
| > medical benefit.                            | for a    | for a    |
|                                               | no       | no       |
|                                               | n-partic | n-partic |
|                                               | ipat-ing | ipat-ing |
|                                               | p        | p        |
|                                               | rovider. | rovider. |
|                                               |          |          |
|                                               | \$50     | \$75     |
|                                               | copay    | copay    |
|                                               | and any  | and any  |
|                                               | charges  | charges  |
|                                               | that     | that     |
|                                               | exceed   | exceed   |
|                                               | the      | the      |
|                                               | e        | e        |
|                                               | mergency | mergency |
|                                               | fee      | fee      |
|                                               | schedule | s        |
|                                               |          | chedule. |
+-----------------------------------------------+----------+----------+
| > *Not covered: Elective care or              | *All     | *All     |
| > non-emergency care*                         | charge*  | charges* |
+-----------------------------------------------+----------+----------+
| ######## Emergency outside our service area   |          |          |
+-----------------------------------------------+----------+----------+
| -   Emergency medical/surgical care at a      | \$15 per | \$25 per |
|     doctor\'s office                          | visit    | visit    |
|                                               | for a    | for a    |
| -   Emergency medical/surgical care at an     | parti    | parti    |
|     urgent care center                        | cipating | cipating |
|                                               | p        | p        |
|                                               | rovider. | rovider. |
|                                               |          |          |
|                                               | POS: Any | Any      |
|                                               | di       | di       |
|                                               | fference | fference |
|                                               | between  | between  |
|                                               | our fee  | our fee  |
|                                               | schedule | schedule |
|                                               | and the  | and the  |
|                                               | billed   | billed   |
|                                               | amount   | amount   |
|                                               | for a    | for a    |
|                                               | n        | n        |
|                                               | on-parti | on-parti |
|                                               | cipating | cipating |
|                                               | p        |          |
|                                               | rovider. |          |
+-----------------------------------------------+----------+----------+

> Emergency outside our service area continued on next page

+-----------------------------------------------+----------+----------+
| > **Emergency outside our service area**      | **High\  | **S      |
| > (*continued*)                               | Option** | tandard\ |
|                                               |          | Option** |
|                                               | **You    |          |
|                                               | Pay**    | **You    |
|                                               |          | Pay**    |
+-----------------------------------------------+----------+----------+
| -   Emergency care as an outpatient or        | POS: Any | Any      |
|     inpatient at a hospital, including        | di       | di       |
|     doctors\' services                        | fference | fference |
|                                               | between  | between  |
| > Note: Copay waived if admitted to the       | our fee  | our fee  |
| > hospital. If private physicians who are not | schedule | schedule |
| > hospital employees provide the emergency    | and the  | and the  |
| > care, you may receive a separate bill for   | billed   | billed   |
| > these services, which we will process as a  | amount   | amount   |
| > medical benefit.                            | for a    | for a    |
|                                               | n        | n        |
|                                               | on-parti | on-parti |
|                                               | cipating | cipating |
|                                               | p        | p        |
|                                               | rovider. | rovider. |
|                                               |          |          |
|                                               | Note:    | Note:    |
|                                               | For      | For      |
|                                               | e        | e        |
|                                               | mergency | mergency |
|                                               | services | services |
|                                               | billed   | billed   |
|                                               | for by a | for by a |
|                                               | doctor,  | doctor,  |
|                                               | you pay  | you pay  |
|                                               | any      | any      |
|                                               | di       | di       |
|                                               | fference | fference |
|                                               | between  | between  |
|                                               | our fee  | our fee  |
|                                               | schedule | schedule |
|                                               | and the  | and the  |
|                                               | billed   | billed   |
|                                               | amount   | amount   |
+-----------------------------------------------+----------+----------+
| > *Not covered:*                              | *All     | *All     |
|                                               | charges* | charges* |
| -   *Elective care or non-emergency care*     |          |          |
+-----------------------------------------------+----------+----------+
| > **Ambulance**                               |          |          |
+-----------------------------------------------+----------+----------+
| > Professional ambulance service to or from a | All      | All      |
| > hospital for medically necessary services.  | charges  | charges  |
| > This includes the use of an ambulance for   | in       | in       |
| > emergency outpatient care and maternity     | excess   | excess   |
| > care, to the nearest facility.              | of       | of       |
| >                                             | \$100.   | \$100.   |
| > See 5(c) for non-emergency service.         |          |          |
+-----------------------------------------------+----------+----------+
| *Not covered: air ambulance and ambullette    | > *All   | > *All   |
| services*                                     | >        | >        |
|                                               | charges* | charges* |
+-----------------------------------------------+----------+----------+

+---+---+---------------------------------------+----------+---+---+------+
| * |   |                                       |          |   |   |      |
| * |   |                                       |          |   |   |      |
| S |   |                                       |          |   |   |      |
| e |   |                                       |          |   |   |      |
| c |   |                                       |          |   |   |      |
| t |   |                                       |          |   |   |      |
| i |   |                                       |          |   |   |      |
| o |   |                                       |          |   |   |      |
| n |   |                                       |          |   |   |      |
| 5 |   |                                       |          |   |   |      |
| ( |   |                                       |          |   |   |      |
| e |   |                                       |          |   |   |      |
| ) |   |                                       |          |   |   |      |
| . |   |                                       |          |   |   |      |
| M |   |                                       |          |   |   |      |
| e |   |                                       |          |   |   |      |
| n |   |                                       |          |   |   |      |
| t |   |                                       |          |   |   |      |
| a |   |                                       |          |   |   |      |
| l |   |                                       |          |   |   |      |
| h |   |                                       |          |   |   |      |
| e |   |                                       |          |   |   |      |
| a |   |                                       |          |   |   |      |
| l |   |                                       |          |   |   |      |
| t |   |                                       |          |   |   |      |
| h |   |                                       |          |   |   |      |
| a |   |                                       |          |   |   |      |
| n |   |                                       |          |   |   |      |
| d |   |                                       |          |   |   |      |
| s |   |                                       |          |   |   |      |
| u |   |                                       |          |   |   |      |
| b |   |                                       |          |   |   |      |
| s |   |                                       |          |   |   |      |
| t |   |                                       |          |   |   |      |
| a |   |                                       |          |   |   |      |
| n |   |                                       |          |   |   |      |
| c |   |                                       |          |   |   |      |
| e |   |                                       |          |   |   |      |
| a |   |                                       |          |   |   |      |
| b |   |                                       |          |   |   |      |
| u |   |                                       |          |   |   |      |
| s |   |                                       |          |   |   |      |
| e |   |                                       |          |   |   |      |
| b |   |                                       |          |   |   |      |
| e |   |                                       |          |   |   |      |
| n |   |                                       |          |   |   |      |
| e |   |                                       |          |   |   |      |
| f |   |                                       |          |   |   |      |
| i |   |                                       |          |   |   |      |
| t |   |                                       |          |   |   |      |
| s |   |                                       |          |   |   |      |
| * |   |                                       |          |   |   |      |
| * |   |                                       |          |   |   |      |
+---+---+---------------------------------------+----------+---+---+------+
|   | * | > When you get our approval for       |          |   | * | ##   |
|   | * | > services and follow a treatment     |          |   | * | ###  |
|   | I | > plan we approve, cost-sharing and   |          |   | I |      |
|   | * | > limitations for Plan mental health  |          |   | * |      |
|   | * | > and substance abuse benefits will   |          |   | * |      |
|   |   | > be no greater than for similar      |          |   |   |      |
|   | * | > benefits for other illnesses and    |          |   | * |      |
|   | * | > conditions.                         |          |   | * |      |
|   | M | >                                     |          |   | M |      |
|   | * | > **Here are some important things to |          |   | * |      |
|   | * | > keep in mind about these            |          |   | * |      |
|   |   | > benefits:**                         |          |   |   |      |
|   | * |                                       |          |   | * |      |
|   | * | -   Please remember that all benefits |          |   | * |      |
|   | P |     are subject to the definitions,   |          |   | P |      |
|   | * |     limitations, and exclusions in    |          |   | * |      |
|   | * |     this brochure and are payable     |          |   | * |      |
|   |   |     only when we determine they are   |          |   |   |      |
|   | * |     medically necessary.              |          |   | * |      |
|   | * |                                       |          |   | * |      |
|   | O | -   Be sure to read Section 4, *Your  |          |   | O |      |
|   | * |     costs for covered services,* for  |          |   | * |      |
|   | * |     valuable information about how    |          |   | * |      |
|   |   |     cost sharing works. Also read     |          |   |   |      |
|   | * |     Section 9 about coordinating      |          |   | * |      |
|   | * |     benefits with other coverage,     |          |   | * |      |
|   | R |     including with Medicare.          |          |   | R |      |
|   | * |                                       |          |   | * |      |
|   | * | -   **YOU MUST GET PREAUTHORIZATION   |          |   | * |      |
|   |   |     OF THESE SERVICES.** See the      |          |   |   |      |
|   | * |     instructions after the benefits   |          |   | * |      |
|   | * |     description below.                |          |   | * |      |
|   | T |                                       |          |   | T |      |
|   | * | -   Participating providers must      |          |   | * |      |
|   | * |     provide all care.                 |          |   | * |      |
|   |   |                                       |          |   |   |      |
|   | * |                                       |          |   | * |      |
|   | * |                                       |          |   | * |      |
|   | A |                                       |          |   | A |      |
|   | * |                                       |          |   | * |      |
|   | * |                                       |          |   | * |      |
|   |   |                                       |          |   |   |      |
|   | * |                                       |          |   | * |      |
|   | * |                                       |          |   | * |      |
|   | N |                                       |          |   | N |      |
|   | * |                                       |          |   | * |      |
|   | * |                                       |          |   | * |      |
|   |   |                                       |          |   |   |      |
|   | * |                                       |          |   | * |      |
|   | * |                                       |          |   | * |      |
|   | T |                                       |          |   | T |      |
|   | * |                                       |          |   | * |      |
|   | * |                                       |          |   | * |      |
+---+---+---------------------------------------+----------+---+---+------+
| * |   |                                       | **High   | * |   |      |
| * |   |                                       | Option** | * |   |      |
| B |   |                                       |          | S |   |      |
| e |   |                                       |          | t |   |      |
| n |   |                                       |          | a |   |      |
| e |   |                                       |          | n |   |      |
| f |   |                                       |          | d |   |      |
| i |   |                                       |          | a |   |      |
| t |   |                                       |          | r |   |      |
| D |   |                                       |          | d |   |      |
| e |   |                                       |          | \ |   |      |
| s |   |                                       |          | O |   |      |
| c |   |                                       |          | p |   |      |
| r |   |                                       |          | t |   |      |
| i |   |                                       |          | i |   |      |
| p |   |                                       |          | o |   |      |
| t |   |                                       |          | n |   |      |
| i |   |                                       |          | * |   |      |
| o |   |                                       |          | * |   |      |
| n |   |                                       |          |   |   |      |
| * |   |                                       |          |   |   |      |
| * |   |                                       |          |   |   |      |
+---+---+---------------------------------------+----------+---+---+------+
| # |   |                                       | ### **Y  | # |   |      |
| # |   |                                       | ou Pay** | # |   |      |
| # |   |                                       |          | # |   |      |
|   |   |                                       |          |   |   |      |
| * |   |                                       |          | * |   |      |
| * |   |                                       |          | * |   |      |
| M |   |                                       |          | Y |   |      |
| e |   |                                       |          | o |   |      |
| n |   |                                       |          | u |   |      |
| t |   |                                       |          |   |   |      |
| a |   |                                       |          | P |   |      |
| l |   |                                       |          | a |   |      |
|   |   |                                       |          | y |   |      |
| h |   |                                       |          | * |   |      |
| e |   |                                       |          | * |   |      |
| a |   |                                       |          |   |   |      |
| l |   |                                       |          |   |   |      |
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+---+---+---------------------------------------+----------+---+---+------+

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

+-----------------------------------------------+----------+-----------+
| > **Mental health and substance abuse         | **High\  | **        |
| > benefits** *(continued)*                    | Option** | Standard\ |
|                                               |          | Option**  |
|                                               | **You    |           |
|                                               | Pay**    | **You     |
|                                               |          | Pay**     |
+-----------------------------------------------+----------+-----------+
| *Not covered:*                                | > *All   | > *All    |
|                                               | >        | >         |
| -   *Services we have not approved.*          | charges* |  charges* |
|                                               |          |           |
| ```{=html}                                    |          |           |
| <!-- -->                                      |          |           |
| ```                                           |          |           |
| -   *Facility charges of a non-participating  |          |           |
|     general hospital or facility.*            |          |           |
|                                               |          |           |
| -   *Treatment by a non-participating         |          |           |
|     provider.*                                |          |           |
|                                               |          |           |
| > *Note: OPM will base its review of disputes |          |           |
| > about treatment plans on the treatment      |          |           |
| > plan's clinical appropriateness. OPM will   |          |           |
| > generally not order us to pay or provide    |          |           |
| > one clinically appropriate treatment plan   |          |           |
| > in favor of another.*                       |          |           |
+-----------------------------------------------+----------+-----------+
| **Preauthorization** To be eligible to        |          |           |
| receive these benefits you must follow your   |          |           |
| treatment plan and all of our network         |          |           |
| authorization processes on pages 10 and 38.   |          |           |
| Contact us at 1-(800) 692-7311                |          |           |
+-----------------------------------------------+----------+-----------+
| **Limitation** There are no benefits if you   |          |           |
| do not obtain a treatment plan.               |          |           |
+-----------------------------------------------+----------+-----------+

<table>
<colgroup>
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 72%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 0%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="10"><strong>Section 5 (f). Prescription drug
benefits</strong></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"><p><strong>I</strong></p>
<p><strong>M</strong></p>
<p><strong>P</strong></p>
<p><strong>O</strong></p>
<p><strong>R</strong></p>
<p><strong>T</strong></p>
<p><strong>A</strong></p>
<p><strong>N</strong></p>
<p><strong>T</strong></p></td>
<td><p><strong>Here are some important things to keep in mind about
these benefits:</strong></p>
<ul>
<li><p>We cover prescribed drugs and medications, as described in the
chart beginning on the next page.</p></li>
<li><p>All benefits are subject to the definitions, limitations and
exclusions in this brochure and are payable only when we determine they
are medically necessary.</p></li>
<li><p>Be sure to read Section 4, <em>Your costs for covered
services,</em> for valuable information about how cost sharing works,
with special sections for members who are age 65 or over. Also read
Section 9 about coordinating benefits with other coverage, including
with Medicare.</p></li>
</ul></td>
<td><p><strong>I</strong></p>
<p><strong>M</strong></p>
<p><strong>P</strong></p>
<p><strong>O</strong></p>
<p><strong>R</strong></p>
<p><strong>T</strong></p>
<p><strong>A</strong></p>
<p><strong>N</strong></p>
<p><strong>T</strong></p></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"><blockquote>
<p><strong>There are important features you should be aware of.</strong>
These include:</p>
</blockquote>
<ul>
<li><p><strong>Who can write your prescription.</strong> A licensed
doctor must write the prescription.</p></li>
</ul>
<ul>
<li><p><strong>Where you can obtain them.</strong> You may fill the
prescription at a pharmacy that participates under the program through
Express Scripts PERxCare Retail Pharmacy Program. You must fill the
prescription at a Plan pharmacy, or by mail for a maintenance
medication.</p></li>
</ul>
<ul>
<li><p><strong>We use a formulary.</strong> The formulary is a list of
preferred, clinically effective prescription drugs that are also
cost-effective. Express Scripts acts on behalf of GHI to provide
affordable access to clinically sound, high quality pharmacy benefits
for you. The formulary is developed using an evaluation process. The
process begins with an assessment of the drug’s clinical effectiveness
by an independent panel of physicians and pharmacists, also known as the
Pharmacy and Therapeutics Committee. If the panel determines that the
drug is clinically effective, the drug is further evaluated on an
economic basis.<br />
<br />
We have an open formulary. If your physician believes a name brand
product is necessary or there is no generic available, your physician
may prescribe a name brand drug from a formulary list. This list of name
brand drugs is a preferred list of drugs that we selected to meet
patient needs at a lower cost. To order a prescription drug brochure,
call 1-877- 534-3682.</p></li>
</ul>
<ul>
<li><p><strong>These are the dispensing limitations.</strong>
Prescription drugs prescribed by a doctor and obtained at a pharmacy
that participates under the program through Express Scripts PERxCare
Retail Pharmacy Program. Drugs are prescribed by doctors and dispensed
in accordance with the Plan’s drug formulary. Under the High Optio, you
pay a $10 copay for a generic drug, a $20 copay per prescription unit or
refill for a name brand drug listed on the preferred prescriptions drug
formulary and a $50 copay per prescription unit or refill for a name
brand drug not listed on the preferred prescription drug formulary.
Under the Standard Option benefit package, you pay a $10 copay for a
generic drug, a $25 copay per prescription unit or refill for a name
brand drug listed on the preferred prescriptions drug formulary and a
$50 copay per prescription unit or refill for a name brand drug not
listed on the preferred prescription drug formulary once a $50
deductable is met . A generic equivalent will be dispensed if it is
available, unless your physician specifically requires a name brand. If
you receive a name brand drug when a Federally-approved generic drug is
available, and your physician has not specified "dispense as written"
for the name brand drug, you have to pay the brand name copay.</p></li>
</ul>
<ul>
<li><p><strong>Mandatory Mail</strong>: Your prescription coverage also
includes a mandatory mail program. All maintenance medications must be
sent to Express Scripts Mail Service Pharmacy. Two refills per
prescription will be allowed at any local “preferred” Express Scripts
PERxCare Pharmacy. When a new maintenance medication is prescribed the
patient should request 2 prescriptions. The initial for a 31-day supply
to be filled at a retail pharmacy, and the second, for up to a 90-day
supply, to be submitted to Express Scripts Mail Service Pharmacy. For
all existing maintenance medications at a retail pharmacy, the patient
is required to obtain a new prescription, for up to a 90-day supply, to
be sent to Express Scripts Mail Service Pharmacy.<strong><br />
</strong></p></li>
</ul></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="6"><strong>Prescription drug benefits</strong>
<em>(Continued)</em></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3"><ul>
<li></li>
</ul></td>
<td colspan="6"><ul>
<li><p><strong>Maintenance Drug Program</strong>: The maintenance drug
program permits long-term prescriptions to be filled for up to a 90-day
supply. Under the High Option, you pay a $20 copay for a generic drug, a
$40 copay per prescription unit or refill for a name brand drug listed
on the preferred prescriptions drug formulary and a $60 copay per
prescription unit or refill for a name brand drug not listed on the
preferred prescription drug formulary. Under the Standard Option benefit
package, you pay a $25 copay for a generic drug, a $50 copay per
prescription unit or refill for a name brand drug listed on the
preferred prescriptions drug formulary and a $80 copay per prescription
unit or refill for a name brand drug not listed on the preferred
prescription drug formulary.</p></li>
</ul>
<ul>
<li><p><strong>Why use a generic drug?</strong></p>
<ul>
<li><p>Generic drugs may have unfamiliar names, but they are safe and
effective.</p></li>
<li><p>Generic drugs contain the same active ingredients, in the same
dosage form as their brand name counterparts, and are manufactured
according to the same strict federal regulations.</p></li>
<li><p>Generic drugs may differ in color, size, or shape, but they have
the same strength, purity, and quality as the brand-name
alternatives.</p></li>
<li><p>Prescriptions filled with generic drugs often have lower
co-payments. Therefore, you may be able to get the same health benefits
at a lower cost. You should ask your physician or pharmacist whether a
generic version of your medications is available. By using a generic
drug, you may be able to receive the same high-quality medication but
reduce your expenses.</p></li>
</ul></li>
</ul>
<ul>
<li><p><strong>When you have to file a claim.</strong> In an emergency,
a direct reimbursement claim form must be filed for prescriptions that
you obtained through a non-participating retail pharmacy. Upon filling
your prescriptions through non-participating pharmacies:</p>
<ul>
<li><p>You must pay the full cost of the prescription.</p></li>
<li><p>You must complete a direct reimbursement claims form, and submit
it to Express Scripts. This form can be obtained by calling Express
Scripts at 1-877-534-3682.</p></li>
<li><p>Express Scripts will reimburse you for the amount the medication
would have cost your benefits plan at a participating pharmacy, minus
the co-payment you would have paid.</p></li>
</ul></li>
</ul></td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

+-----------------------------------------------+---------+------------+
| > **Benefit Description**                     | **High  | **Standard |
|                                               | O       | Option**   |
|                                               | ption** |            |
+-----------------------------------------------+---------+------------+
| > **Covered medications and supplies**        | **You   | > **You    |
|                                               | Pay**   | > Pay**    |
+-----------------------------------------------+---------+------------+
| Each new enrollee will receive a description  | >       | > After a  |
| of our prescription drug program, a combined  | Network | > \$50 per |
| prescription drug/Plan identification card, a | >       | > person   |
| mail order form/patient profile and a         | Retail: | > calendar |
| preaddressed reply envelope.                  | >       | > year     |
|                                               | > \$10  | >          |
| We cover the following medications and        | >       | deductable |
| supplies prescribed by a physician and        | generic | > is met:  |
| obtained from either a Plan pharmacy or by    | >       | >          |
| mail. Note: Mandatory mail requirements apply | > \$20  | > Network  |
| for maintenance drugs:                        | > brand | > Retail:  |
|                                               | > name  | >          |
| -   Drugs for which a prescription is         | >       | > \$10     |
|     required by law.                          |  listed | > generic  |
|                                               | > on    | >          |
| ```{=html}                                    | > the   | > \$25     |
| <!-- -->                                      | > pr    | > brand    |
| ```                                           | eferred | > name     |
| -   FDA-approved prescription drugs and       | > presc | > listed   |
|     devices for birth control.                | ription | > on the   |
|                                               | > drug  | >          |
| ```{=html}                                    | > fo    |  preferred |
| <!-- -->                                      | rmulary | > pr       |
| ```                                           | >       | escription |
| -   Fertility drugs.                          | > \$50  | > drug     |
|                                               | > brand | >          |
| ```{=html}                                    | > name  |  formulary |
| <!-- -->                                      | > drug  | >          |
| ```                                           | > not   | > \$50     |
| -   Drugs to treat sexual dysfunction (Viagra | >       | > brand    |
|     is limited to six tablets per every       |  listed | > name     |
|     thirty-one days).                         | > on    | > drug not |
|                                               | > the   | > listed   |
| ```{=html}                                    | > pr    | > on the   |
| <!-- -->                                      | eferred | >          |
| ```                                           | > presc |  preferred |
| -   Diabetic supplies, including insulin      | ription | > pr       |
|     syringes, needles, glucose test tablets   | > drug  | escription |
|     and test tape.                            | > for   | > drug     |
|                                               | mulary. | >          |
| ```{=html}                                    | >       | formulary. |
| <!-- -->                                      | >       | >          |
| ```                                           | Network | > Network  |
| -   Disposable needles and syringes needed    | > Mail  | > Mail     |
|     for injection of covered prescribed       | >       | > Order:   |
|     medication.                               |  Order: | >          |
|                                               | >       | > \$25     |
| ```{=html}                                    | > \$20  | > generic  |
| <!-- -->                                      | >       | >          |
| ```                                           | generic | > \$50     |
| -   Smoking cessation drugs and medication,   | >       | > brand    |
|     including nicotine patches\               | > \$40  | > name     |
|     (up to 90-day supply).                    | > brand | > listed   |
|                                               | > name  | > on the   |
| -   Intravenous fluids and medications for    | >       | >          |
|     home use through our Participating        |  listed |  preferred |
|     Provider network for home infusion        | > on    | > pr       |
|     therapy                                   | > the   | escription |
|                                               | > pr    | > drug     |
|                                               | eferred | >          |
|                                               | > presc |  formulary |
|                                               | ription | >          |
|                                               | > drug  | > \$80     |
|                                               | > fo    | > brand    |
|                                               | rmulary | > name     |
|                                               | >       | > drug not |
|                                               | > \$60  | > listed   |
|                                               | > brand | > on the   |
|                                               | > name  | >          |
|                                               | > drug  |  preferred |
|                                               | > not   | > pr       |
|                                               | >       | escription |
|                                               |  listed | > drug     |
|                                               | > on    | >          |
|                                               | > the   | formulary. |
|                                               | > pr    |            |
|                                               | eferred |            |
|                                               | > presc |            |
|                                               | ription |            |
|                                               | > drug  |            |
|                                               | > for   |            |
|                                               | mulary. |            |
+-----------------------------------------------+---------+------------+

*Covered medications and supplies continued on next page.*

+-----------------------------------------------+----------+---+----------+
| > **Covered medications and supplies**        | **High\  |   | **S      |
| > *(continued)*                               | Option** |   | tandard\ |
|                                               |          |   | Option** |
|                                               | **You    |   |          |
|                                               | Pay**    |   | **You    |
|                                               |          |   | Pay**    |
+-----------------------------------------------+----------+---+----------+
| -   A generic equivalent will be dispensed if |          |   |          |
|     it is available, unless your physician    |          |   |          |
|     specifically requires a name brand. If    |          |   |          |
|     you receive a name brand drug when a      |          |   |          |
|     Federally-approved generic drug is        |          |   |          |
|     available, and your physician has not     |          |   |          |
|     specified \"dispense as written\" for the |          |   |          |
|     name brand drug, you have to pay the      |          |   |          |
|     brand name copay.                         |          |   |          |
|                                               |          |   |          |
| ```{=html}                                    |          |   |          |
| <!-- -->                                      |          |   |          |
| ```                                           |          |   |          |
| -   We administer an open formulary. If your  |          |   |          |
|     physician believes a name brand product   |          |   |          |
|     is necessary or there is no generic       |          |   |          |
|     available, your physician may prescribe a |          |   |          |
|     name brand drug from a formulary list.    |          |   |          |
|     This list of name brand drugs is a        |          |   |          |
|     preferred list of drugs that we selected  |          |   |          |
|     to meet patient needs at a lower cost. To |          |   |          |
|     order a prescription drug brochure, call  |          |   |          |
|     Express Scripts at 1-877-534-3682.        |          |   |          |
+-----------------------------------------------+----------+---+----------+
| *Not covered:*                                | *All     | * |          |
|                                               | Charges* | A |          |
| -   *Nonprescription medications*             |          | l |          |
|                                               |          | l |          |
| -   *Drugs obtained at a non-participating    |          | C |          |
|     pharmacy, except for emergencies.*        |          | h |          |
|                                               |          | a |          |
| -   *Vitamins and nutritional substances that |          | r |          |
|     can be purchased without a prescription.* |          | g |          |
|                                               |          | e |          |
| -   *Medical supplies such as dressings and   |          | s |          |
|     antiseptics.*                             |          | * |          |
|                                               |          |   |          |
| -   *Drugs for cosmetic purposes.*            |          |   |          |
|                                               |          |   |          |
| -   *Drugs to enhance athletic performance.*  |          |   |          |
+-----------------------------------------------+----------+---+----------+

+----------------------+-----------------------------------------------+
| > **Section 5 (g).   |                                               |
| > Special features** |                                               |
+----------------------+-----------------------------------------------+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| > **Flexible         | > Under the flexible benefits option, we      |
| > benefits option**  | > determine the most effective way to provide |
|                      | > services.                                   |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| > **Large Case       | > The Plan provides a large case management   |
| > Management**       | > program that seeks to provide alternatives  |
|                      | > for improving the quality and cost          |
|                      | > effectiveness of care. The large case       |
|                      | > management program focuses on catastrophic  |
|                      | > illnesses --- for example, major head       |
|                      | > injury, high-risk infancy, stroke and       |
|                      | > severe amputations. The large case          |
|                      | > management process begins when we are       |
|                      | > notified that you or covered family member  |
|                      | > has experienced a specific illness or       |
|                      | > injury with potential long-term effects or  |
|                      | > changes in lifestyle. Case Managers         |
|                      | > evaluate individual needs, and the full     |
|                      | > range of treatment and financial exposures, |
|                      | > from the onset of a condition or illness to |
|                      | > recovery or stabilization. They review the  |
|                      | > efforts of the health care team and family  |
|                      | > with the goal of helping the patient return |
|                      | > to pre-illness/injury functioning or of     |
|                      | > lessening the burden of a chronic or        |
|                      | > terminal condition. Case Managers provide   |
|                      | > the family with support and advice ranging  |
|                      | > from referral to family counseling. If it   |
|                      | > is determined that involvement of a Case    |
|                      | > Manager would be both care- and             |
|                      | > cost-effective, we will obtain the          |
|                      | > necessary authorization from the patient to |
|                      | > proceed. Throughout the process, we will    |
|                      | > maintain strict confidentiality.            |
+----------------------+-----------------------------------------------+
| > **Customer Service | > For information and assistance 24 hours a   |
| > AnswerLine**       | > day, 7 days a week, access our automated    |
|                      | > telephone AnswerLine at 212/501-4GHI        |
|                      | > (4444).                                     |
+----------------------+-----------------------------------------------+
| > **Services for     | > If you have a question concerning Plan      |
| > deaf and hearing   | > benefits or how to arrange for care,        |
| > impaired**         | > contact (212) 721-4962 (Hearing impaired    |
|                      | > --- TDD) or you may write to us at Post     |
|                      | > Office Box 1701, New York, NY 10023-9476 or |
|                      | > contact our office nearest you. You may     |
|                      | > also contact the Plan at its website at     |
|                      | > [http://www.ghi.com](http://www.ghi.com/).  |
+----------------------+-----------------------------------------------+
| > **High risk        | > The Plan provides an intensive large case   |
| > pregnancies**      | > management program as described above.      |
+----------------------+-----------------------------------------------+
| > **Centers of       | > We have a special network of hospitals that |
| > excellence**       | > perform a broad range of cardiac care and   |
|                      | > organ transplants. These centers are        |
|                      | > recognized leaders in their respective      |
|                      | > specialties and their services are          |
|                      | > available to you at no out-of-pocket        |
|                      | > expense. Call GHI Managed Care at least 10  |
|                      | > days before the hospital admission to       |
|                      | > pre-certify coverage and for details on how |
|                      | > to use this program.                        |
+----------------------+-----------------------------------------------+
| > **Travel benefit/  | > As a GHI subscriber under the High Option   |
| > services           | > Plan benefit package, you are not           |
| > overseas**         | > restricted to just using members of our     |
|                      | > provider network. However, if you go        |
|                      | > outside the network, your out-of-pocket     |
|                      | > expenses will increase significantly. You   |
|                      | > will receive 50% of our fee schedule if you |
|                      | > use a non-participating provider --- you    |
|                      | > are responsible for the balance of the      |
|                      | > provider's charge. Also, unlike when you    |
|                      | > use a network provider, you are responsible |
|                      | > for paying the non-participating provider   |
|                      | > up front and filing a claim form with us    |
|                      | > for reimbursement.                          |
+----------------------+-----------------------------------------------+

+---+---+---------------------------------------+----------+---+---+--------+
| > |   |                                       |          |   |   |        |
|   |   |                                       |          |   |   |        |
| S |   |                                       |          |   |   |        |
| e |   |                                       |          |   |   |        |
| c |   |                                       |          |   |   |        |
| t |   |                                       |          |   |   |        |
| i |   |                                       |          |   |   |        |
| o |   |                                       |          |   |   |        |
| n |   |                                       |          |   |   |        |
| > |   |                                       |          |   |   |        |
|   |   |                                       |          |   |   |        |
| 5 |   |                                       |          |   |   |        |
| > |   |                                       |          |   |   |        |
|   |   |                                       |          |   |   |        |
| ( |   |                                       |          |   |   |        |
| h |   |                                       |          |   |   |        |
| ) |   |                                       |          |   |   |        |
| . |   |                                       |          |   |   |        |
| > |   |                                       |          |   |   |        |
|   |   |                                       |          |   |   |        |
| D |   |                                       |          |   |   |        |
| e |   |                                       |          |   |   |        |
| n |   |                                       |          |   |   |        |
| t |   |                                       |          |   |   |        |
| a |   |                                       |          |   |   |        |
| l |   |                                       |          |   |   |        |
| > |   |                                       |          |   |   |        |
|   |   |                                       |          |   |   |        |
| b |   |                                       |          |   |   |        |
| e |   |                                       |          |   |   |        |
| n |   |                                       |          |   |   |        |
| e |   |                                       |          |   |   |        |
| f |   |                                       |          |   |   |        |
| i |   |                                       |          |   |   |        |
| t |   |                                       |          |   |   |        |
| s |   |                                       |          |   |   |        |
+---+---+---------------------------------------+----------+---+---+--------+
|   | * | **Here are some important things to   |          | * |   |        |
|   | * | keep in mind about these benefits:**  |          | * |   |        |
|   | I |                                       |          | I |   |        |
|   | * | -   Please remember that all benefits |          | * |   |        |
|   | * |     are subject to the definitions,   |          | * |   |        |
|   |   |     limitations, and exclusions in    |          |   |   |        |
|   | * |     this brochure and are payable     |          | * |   |        |
|   | * |     only when we determine they are   |          | * |   |        |
|   | M |     medically necessary.              |          | M |   |        |
|   | * |                                       |          | * |   |        |
|   | * | -   We cover hospitalization for      |          | * |   |        |
|   |   |     certain dental procedures only    |          |   |   |        |
|   | * |     when a non-dental physical        |          | * |   |        |
|   | * |     impairment exists which makes     |          | * |   |        |
|   | P |     hospitalization necessary to      |          | P |   |        |
|   | * |     safeguard\                        |          | * |   |        |
|   | * |     the health of the patient; see    |          | * |   |        |
|   |   |     section 5(c) for inpatient        |          |   |   |        |
|   | * |     hospital benefits. We do not      |          | * |   |        |
|   | * |     cover the dental procedure unless |          | * |   |        |
|   | O |     it is described below. We will    |          | O |   |        |
|   | * |     cover the hospitalization, but    |          | * |   |        |
|   | * |     not the cost of the professional  |          | * |   |        |
|   |   |     dental services. Conditions for   |          |   |   |        |
|   | * |     which hospitalization would be    |          | * |   |        |
|   | * |     covered include hemophilia,       |          | * |   |        |
|   | R |     impacted teeth, and heart         |          | R |   |        |
|   | * |     disease; the need for anesthesia, |          | * |   |        |
|   | * |     by itself, is not such a          |          | * |   |        |
|   |   |     condition.                        |          |   |   |        |
|   | * |                                       |          | * |   |        |
|   | * | ```{=html}                            |          | * |   |        |
|   | T | <!-- -->                              |          | T |   |        |
|   | * | ```                                   |          | * |   |        |
|   | * | -   Be sure to read Section 4, *Your  |          | * |   |        |
|   |   |     costs for covered services,* for  |          |   |   |        |
|   | * |     valuable information about how    |          | * |   |        |
|   | * |     cost sharing works. Also read     |          | * |   |        |
|   | A |     Section 9 about coordinating      |          | A |   |        |
|   | * |     benefits with other coverage,     |          | * |   |        |
|   | * |     including with Medicare.          |          | * |   |        |
|   |   |                                       |          |   |   |        |
|   | * |                                       |          | * |   |        |
|   | * |                                       |          | * |   |        |
|   | N |                                       |          | N |   |        |
|   | * |                                       |          | * |   |        |
|   | * |                                       |          | * |   |        |
|   |   |                                       |          |   |   |        |
|   | * |                                       |          | * |   |        |
|   | * |                                       |          | * |   |        |
|   | T |                                       |          | T |   |        |
|   | * |                                       |          | * |   |        |
|   | * |                                       |          | * |   |        |
+---+---+---------------------------------------+----------+---+---+--------+
| > |   |                                       | **High\  |   | * |        |
|   |   |                                       | Option** |   | * |        |
| * |   |                                       |          |   | S |        |
| * |   |                                       | **You    |   | t |        |
| A |   |                                       | Pay**    |   | a |        |
| c |   |                                       |          |   | n |        |
| c |   |                                       |          |   | d |        |
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|   |   |                                       |          |   | o |        |
| i |   |                                       |          |   | n |        |
| n |   |                                       |          |   | * |        |
| j |   |                                       |          |   | * |        |
| u |   |                                       |          |   |   |        |
| r |   |                                       |          |   | * |        |
| y |   |                                       |          |   | * |        |
| > |   |                                       |          |   | Y |        |
|   |   |                                       |          |   | o |        |
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| f |   |                                       |          |   | * |        |
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| t |   |                                       |          |   |   |        |
| * |   |                                       |          |   |   |        |
| * |   |                                       |          |   |   |        |
+---+---+---------------------------------------+----------+---+---+--------+
| > |   |                                       | Any      |   | A |        |
|   |   |                                       | di       |   | n |        |
| W |   |                                       | fference |   | y |        |
| e |   |                                       | between  |   | d |        |
| > |   |                                       | our fee  |   | i |        |
|   |   |                                       | schedule |   | f |        |
| c |   |                                       | and the  |   | f |        |
| o |   |                                       | actual   |   | e |        |
| v |   |                                       | charges. |   | r |        |
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| i |   |                                       |          |   |   |        |
| t |   |                                       |          |   |   |        |
| h |   |                                       |          |   |   |        |
| t |   |                                       |          |   |   |        |
| h |   |                                       |          |   |   |        |
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| f |   |                                       |          |   |   |        |
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| s |   |                                       |          |   |   |        |
| l |   |                                       |          |   |   |        |
| i |   |                                       |          |   |   |        |
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| t |   |                                       |          |   |   |        |
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| d |   |                                       |          |   |   |        |
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| w |   |                                       |          |   |   |        |
| . |   |                                       |          |   |   |        |
+---+---+---------------------------------------+----------+---+---+--------+
| > |   |                                       | **High\  |   | * |        |
|   |   |                                       | Option** |   | * |        |
| * |   |                                       |          |   | S |        |
| * |   |                                       | **You    |   | t |        |
| S |   |                                       | Pay**    |   | a |        |
| e |   |                                       |          |   | n |        |
| r |   |                                       |          |   | d |        |
| v |   |                                       |          |   | a |        |
| i |   |                                       |          |   | r |        |
| c |   |                                       |          |   | d |        |
| e |   |                                       |          |   | \ |        |
| * |   |                                       |          |   | O |        |
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|   |   |                                       |          |   | t |        |
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|   |   |                                       |          |   | * |        |
|   |   |                                       |          |   | * |        |
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+---+---+---------------------------------------+----------+---+---+--------+
| E |   |                                       | Nothing  |   | N |        |
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+---+---+---------------------------------------+----------+---+---+--------+
| P |   |                                       | Nothing  |   | N |        |
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|   |   |                                       |          |   | g |        |
|   |   |                                       |          |   | p |        |
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|   |   |                                       |          |   | o |        |
|   |   |                                       |          |   | v |        |
|   |   |                                       |          |   | i |        |
|   |   |                                       |          |   | d |        |
|   |   |                                       |          |   | e |        |
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|   |   |                                       |          |   | s |        |
|   |   |                                       |          |   | . |        |
+---+---+---------------------------------------+----------+---+---+--------+

Dental benefits continued on next page.

+---------------------------------------------+-----------+-----------+
| > **Dental benefits** *(continued)*         | **High\   | **        |
|                                             | Option**  | Standard\ |
|                                             |           | Option**  |
|                                             | **You     |           |
|                                             | Pay**     | **You     |
|                                             |           | Pay**     |
+---------------------------------------------+-----------+-----------+
| > **Service**                               |           |           |
+---------------------------------------------+-----------+-----------+
| Prophylaxes (over 12 years maximum 2 per    | Nothing   | Nothing   |
| calendar year)                              | for a     | for a     |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | provider. | provider. |
|                                             |           |           |
|                                             | POS: All  | All       |
|                                             | charges   | charges   |
|                                             | in excess | for       |
|                                             | of        | non-part  |
|                                             | \$10.00   | icipating |
|                                             |           | p         |
|                                             |           | roviders. |
+---------------------------------------------+-----------+-----------+
| Emergency visits for relief of pain (1 per  | Nothing   | Nothing   |
| calendar year)                              | for a     | for a     |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | provider. | provider. |
|                                             |           |           |
|                                             | POS: All  | All       |
|                                             | charges   | charges   |
|                                             | in excess | for       |
|                                             | of        | non-part  |
|                                             | \$10.00.  | icipating |
|                                             |           | p         |
|                                             |           | roviders. |
+---------------------------------------------+-----------+-----------+
| X-rays (Full-mouth series, 1 every 3 years) | Nothing   | Nothing   |
|                                             | for a     | for a     |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | provider. | provider. |
|                                             |           |           |
|                                             | POS: All  | All       |
|                                             | charges   | charges   |
|                                             | in excess | for       |
|                                             | of        | non-part  |
|                                             | \$20.00.  | icipating |
|                                             |           | p         |
|                                             |           | roviders. |
+---------------------------------------------+-----------+-----------+
| Bitewings (4 per calendar year)             | Nothing   | Nothing   |
|                                             | for a     | for a     |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | provider. | provider. |
|                                             |           |           |
|                                             | POS: All  | All       |
|                                             | charges   | charges   |
|                                             | in excess | for       |
|                                             | of \$2.50 | non-part  |
|                                             | per each  | icipating |
|                                             | bitewing  | p         |
|                                             |           | roviders. |
+---------------------------------------------+-----------+-----------+
| Space maintainers                           | Nothing   | Nothing   |
|                                             | for a     | for a     |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | provider. | provider. |
|                                             |           |           |
|                                             | POS: All  | All       |
|                                             | charges   | charges   |
|                                             | in excess | for       |
|                                             | of        | non-part  |
|                                             | \$65.00.  | icipating |
|                                             |           | p         |
|                                             |           | roviders. |
+---------------------------------------------+-----------+-----------+
| Fluoride Treatments -- dependent children   | Nothing   | Nothing   |
| to age 22                                   | for a     | for a     |
|                                             | part      | part      |
|                                             | icipating | icipating |
|                                             | provider. | provider. |
|                                             |           |           |
|                                             | POS: All  | All       |
|                                             | charges   | charges   |
|                                             | in excess | for       |
|                                             | of \$5.00 | non-part  |
|                                             |           | icipating |
|                                             |           | p         |
|                                             |           | roviders. |
+---------------------------------------------+-----------+-----------+

  -----------------------------------------------------------------------
  **Section 5 (i). High Option Point of Service Benefits**

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

[High Option Point of Service (POS) Benefits]{.underline}

[Facts about this Plan's High Option POS benefits]{.underline}

At your option, you may choose to obtain benefits covered by this Plan
from non-participating doctors and hospitals whenever you need care,
[except]{.underline} for those benefits listed below which are available
only through plan providers. Benefits not covered under Point of Service
must be received from Plan doctors to be covered.

[What is covered]{.underline}

All services are covered under our POS except:

-   High-tech nursing and infusion therapy

-   Skilled nursing care facility confinements

-   Home health care services

-   Mental conditions and substance abuse

-   Prescription drugs

Remember, only participating providers have agreed to accept the Plan's
allowance, except for any applicable copayments, as payment in full. If
you choose to receive benefits not covered through non-participating or
out-of-network providers, you will be reimbursed at the POS level that
in most cases is 50% of the Plan's allowance.

Covered POS benefits are available whether the services are received
within or outside the GHI Health Plan's Service Area.

All non-emergency hospital admissions including inpatient admissions for
maternity care and skilled nursing facilities must be pre-certified.

There is a \$150 annual deductible for nursing services and a \$100
annual deductible for appliances, oxygen and equipment. There is also a
\$25 deductible, per referral, for ambulatory laboratory test and
diagnostic X-rays.

In most cases, the POS coinsurance is any amount in excess of 50% of the
Plan's fee schedule. The Plan's fee schedule is set at approximately 50%
of the New York State 1999 HIAA mean. Members, when receiving POS
services, will be responsible for 50% of the Plan's fee schedule plus
any difference between our fee schedule and the billed amount.

After your out-of-pocket expenses total \$10,000 per person in any
calendar year for covered services provided by a non-participating
provider, GHI will then pay catastrophic benefits at 100% of reasonable
and customary charges as determined by the Plan. Out-of-pocket expenses
are calculated based upon the reasonable and customary charge for
covered catastrophic services. Covered catastrophic services include: 1)
surgery, 2) administration of anesthesia, 3) chemotherapy and radiation
therapy, 4) covered in-hospital services and diagnostic services, and 5)
maternity. However, expenses for the following services do not count
toward your catastrophic protection out-of-pocket maximum, and you must
continue to pay coinsurance and deductibles for these services:

-   Home and office visits and related diagnostic services

-   Nursing, appliances, oxygen and equipment

-   Dental services

-   Vision services

-   Prescription drugs

If you are in a true emergency situation, POS benefits are available
within or outside the GHI's Health Plan's\
service area.

**Emergencies within the service are:**

Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider would result in
death, disability or significant jeopardy to your condition.

Plan pays Emergency fee schedule for emergency care services to the
extent the services would have been covered if received from Plan
providers.

You pay the emergency room deductible plus any charges that exceed the
emergency fee schedule. You also pay charges that exceed the Plan's
emergency fee schedule. If the emergency care is provided by private
physicians who are not hospital employees, you may receive a separate
bill for these services, which will be processed as a medical benefit.

**Emergencies outside the service area:**

**\
**Benefits are available for any medically necessary health service that
is immediately required because of injury or unforeseen illness.

Plan pays full emergency fee schedule for emergency care services to the
extent the services would have been covered if received from Plan
providers.

You pay the emergency room deductible plus any difference between our
emergency fee schedule and billed amount for a non-participating
provider. If the emergency care is provided by private physicians who
are not hospital employees, you may receive a separate bill for these
services, which will be processed as a medical benefit.

**What is covered**

-   Emergency care at a doctor's office or an urgent care center.

-   Ambulance service (see page 40).

-   Emergency care as an outpatient or inpatient at a hospital,
    including doctors' services.

If the medical/surgical care received from non-participating providers
is not due to a medical emergency as defined above, the Plan will pay
50% of its fee schedule. Follow-up care after an emergency is covered in
full only if received from participating providers.

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

####### Dental services are available at reduced fees

If you should require additional dental services, a GHI dental provider
participating in the benefit offer will provide these services at
reduced fees. All reduced fees for dental services must be paid directly
to the participating dental provider. You must verify that your provider
is still participating in the program.

Dental services available in the reduced fee program include:

+---------------------------------+------------------+----------------+
|                                 | DOWNSTATE\*      | UPSTATE\*\*    |
|                                 |                  |                |
|                                 | **You Pay**      | **You Pay**    |
+---------------------------------+------------------+----------------+
| **DIAGNOSTIC RESTORATIVE        | \$60.00          | \$49.00        |
| (Fillings)**                    |                  |                |
|                                 | \$82.00          | \$58.00        |
| Resin (anterior) 1 surface      |                  |                |
|                                 | \$99.00          | \$69.00        |
| Resin (anterior) 2 surface      |                  |                |
|                                 |                  |                |
| Resin (anterior) 3 surface      |                  |                |
+---------------------------------+------------------+----------------+
| ####### PROSTHODONTICS REMOVAL  | \$660.00         | \$441.00       |
|                                 |                  |                |
| Complete denture (upper)        | \$665.00         | \$453.00       |
|                                 |                  |                |
| Upper Partial denture, resin    | \$65.00          | \$54.00        |
| base (cast metal framework)     |                  |                |
|                                 | \$73.00          | \$59.00        |
| Add tooth to existing partial   |                  |                |
|                                 |                  |                |
| Add clasp to existing partial   |                  |                |
+---------------------------------+------------------+----------------+
| ####### PROSTHODONTICS FIXED    | \$472.00         | \$431.00       |
|                                 |                  |                |
| Bridge pontic (resin with high  | \$527.00         | \$436.00       |
| noble metal)                    |                  |                |
|                                 |                  |                |
| Abutment crown-Porcelain fused  |                  |                |
| to high noble metal             |                  |                |
+---------------------------------+------------------+----------------+
| ####### ORAL SURGERY            | \$269.00         | \$210.00       |
|                                 |                  |                |
| Removal of impacted tooth -     | \$173.00         | \$118.00       |
| completely bone                 |                  |                |
|                                 | \$118.00         | \$00.00        |
| Removal of impacted teeth -     |                  |                |
| Soft tissue                     |                  |                |
|                                 |                  |                |
| Surgical removal of erupted     |                  |                |
| tooth                           |                  |                |
+---------------------------------+------------------+----------------+
| **PERIODONTICS (Gum             | \$200.00         | \$169.00       |
| Treatment)**                    |                  |                |
|                                 | \$470.00         | \$383.00       |
| Gingivectomy (per quadrant)     |                  |                |
|                                 |                  |                |
| Osseous Surgery (per quadrant)  |                  |                |
+---------------------------------+------------------+----------------+
| **ENDODONTICS (Root Canal)**    | \$82.00          | \$50.00        |
|                                 |                  |                |
| Therapeutic pulpotomy           | \$467.00         | \$466.00       |
|                                 |                  |                |
| Root canals (3 canals)          | \$306.00         | \$314.00       |
|                                 |                  |                |
| Apicoectomy (first root)        |                  |                |
+---------------------------------+------------------+----------------+
| **ORTHODONTICS (Braces)**       | \$912.00         | \$686.00       |
|                                 |                  |                |
| Diagnostic and planning fee     | \$2,220.00       | \$1,680.00     |
|                                 |                  |                |
| Active Treatment Maximum        |                  |                |
+---------------------------------+------------------+----------------+
| ***Benefits on this page are    |                  |                |
| not part of the FEHB            |                  |                |
| contract.***                    |                  |                |
|                                 |                  |                |
| \* Downstate includes New York, |                  |                |
| Bronx, Kings, Queens, Richmond, |                  |                |
| Nassau, Suffolk, Putnam,        |                  |                |
| Orange, Rockland and            |                  |                |
| Westchester Counties\           |                  |                |
| and New Jersey                  |                  |                |
|                                 |                  |                |
| \*\* Upstate includes Eastern,  |                  |                |
| Central, and Western New York   |                  |                |
| Counties.                       |                  |                |
+---------------------------------+------------------+----------------+

+-----------------------------------------------------------------------+
| > 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 determines it is medically necessary to prevent, diagnose,
> or treat your illness, disease, injury or condition.**
>
> We do not cover the following:

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

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

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

-   Experimental or investigational procedures, treatments, drugs or
    services

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

-   Services or supplies you receive from a provider or facility barred
    from the FEHB Program.

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

-   Under the Standard Option benefit package, care by non-participating
    providers are not covered except for emergencies.

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

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

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

You will only need to file a claim when you receive services from
non-plan providers. If you need to file the claim, here is the process:

**Medical and hospital benefits** In most cases, providers and
facilities file claims for you. Physicians must file the form HCFA-1500,
Health Insurance Claim Form. Facilities will file the UB-92 form. For
claims questions and assistance, call us at (212) 501-4GHI (4444).

When you must file a claim, submit the HCFA-1500 or a claim form that
includes the information shown below. Bills and receipts should be
itemized and show:

-   Covered member's name and ID number

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

-   Dates you received the services or supplies

-   Diagnosis

-   Type of each service or supply

-   The charge for each service or supply

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

-   Receipts, if you paid for your services.

> **Submit your claims to:** Group Health Inc.\
> P.O. Box 3000\
> New York, New York 10116-3000

**Prescription drugs** For drugs obtained at a non-participating
pharmacy in an emergency call 877-534-3682 to obtain a claim form.

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

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

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

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

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

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) Write to us within 6 months from the date of our decision;   |
| * |     and                                                          |
| * |                                                                  |
|   | (b) Send your request to us at: 88 West End Avenue, New York, NY |
|   |     10023; and                                                   |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or, if applicable, arrange for the health     |
| * |     care provider to give you the care); or                      |
| * |                                                                  |
|   | (b) Write to you and maintain our denial \-- go to step 4; or    |
|   |                                                                  |
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request---go   |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us \-- if we did not       |
|   |     answer that request in some way within 30 days; or           |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at:United States Office of Personnel Management,    |
|   | Insurance Services Program, Health Insurance Group II, 1900 E    |
|   | Street, NW, Washington, D.C. 20415-3620.                         |
+---+------------------------------------------------------------------+
|   | **The Disputed Claims process,** *continued*                     |
|   |                                                                  |
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure        |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms             |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim         |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim, and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must include a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | If you do not agree with OPM's decision, your only recourse is   |
|   | to sue. If you decide to sue, you must file the suit against OPM |
|   | in Federal court by December 31 of the third year after the year |
|   | in which you received the disputed services, drugs, or supplies  |
|   | or from the year in which you were denied precertification or    |
|   | prior approval. This is the only deadline that may not be        |
|   | extended.                                                        |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support their disputed claim decision. This           |
|   | information will become part of the court record.                |
+---+------------------------------------------------------------------+
|   | You may not sue until you have completed the disputed claims     |
|   | process. Further, Federal law governs your lawsuit, benefits,    |
|   | and payment of benefits. The Federal court will base its review  |
|   | on the record that was before OPM when OPM decided to uphold or  |
|   | overturn our decision. You may recover only the amount of        |
|   | benefits in dispute.                                             |
+---+------------------------------------------------------------------+

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

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at (212) 615-4662 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 II at (202) 606-3818
> between 8 a.m. and 5 p.m. eastern time.

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

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

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

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

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

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

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

-   People 65 years of age and older.

```{=html}
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```
-   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.

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

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

Everyone is charged a premium for Medicare Part B coverage. The Social
Security Administration can provide you with premium and benefit
information. Review the information and decide if it makes sense for you
to buy the Medicare Part B coverage.

If you are eligible for Medicare, you may have choices in how you get
your health care. Medicare + Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care you have.

> **Claims process when you have The Original Medicare Plan --** You
> probably will never have to file a claim form when you have both our
> Plan and the Original Medicare Plan.

-   When we are the primary payer, we process the claim first.

-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In most cases, your claims will be coordinated
    automatically and we will then provide secondary benefits for
    covered charges. You will not need to do anything. To find out if
    you need to do something about filing your claims, call us at
    212/501-4GHI (4444), or access our web site at
    [http://www.ghi.com](http://www.ghi.com/)

> **We waive some costs if the Original Medicare Plan is your primary
> payer** -- We will waive some out-of-pocket costs, as follows:

-   Medical services and supplies provided by physicians and other
    health care professionals. If you are enrolled in Medicare Part B,
    we will waive thecopay for office visits and deductible and
    coinsurance for durable medical equipment.

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

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

We will waive some copayments, coinsurance, and deductibles as follows:

-   Medical services and supplies provided by physicians and other
    health care professionals. If you are enrolled in Medicare Part B,
    we will waive the \$15 copay for office visits and deductible and
    coinsurance for durable medical equipment.

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

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

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

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

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

> If you enroll in a Medicare + Choice plan, the following options are
> available to you: *\
> \
> ***This Plan and another plan\'s Medicare + Choice plan:** You may
> enroll in another plan's Medicare + Choice plan and also remain
> enrolled in our FEHB plan. We will still provide benefits when your
> Medicare + Choice plan is primary, even out of the managed care
> plan\'s network and/or service area (if you use our Plan providers),
> but we will not waive any of our copayments, coinsurance, or
> deductibles. If you enroll in a Medicare managed care plan, tell us.
> We will need to know whether you are in the Original Medicare Plan or
> in a Medicare + Choice plan so we can correctly coordinate benefits
> with Medicare.
>
> **Suspended FEHB coverage to enroll in a Medicare + Choice plan:** If
> you are an annuitant or former spouse, you can suspend your FEHB
> coverage to enroll in a Medicare + Choice plan, eliminating your FEHB
> premium. (OPM does not contribute to your Medicare + Choice plan
> premium.) For information on suspending your FEHB enrollment, contact
> your retirement office. If you later want to re-enroll in the FEHB
> Program, generally you may do so only at the next open season unless
> you involuntarily lose coverage or move out of the Medicare + Choice
> plan\'s service area.

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

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

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

> • you need because of a workplace-related illness or injury that the
> Office of Workers' Compensation Programs (OWCP) or a similar Federal
> or State agency determines they must provide; or
>
> • OWCP or a similar agency pays for through a third-party injury
> settlement or other similar proceeding that is based on a claim you
> filed under OWCP or similar laws.
>
> Once OWCP or a similar agency pays its maximum benefits for your
> treatment, we will cover your care. You must use our providers.

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

+-------------------------+--------------------------------------------+
| **When other Government | > We do not cover services and supplies    |
| agencies are            | > when a local, State, or Federal          |
| responsible for your    | > Government agency directly or indirectly |
| care**                  | > pays for them.                           |
+-------------------------+--------------------------------------------+
| **When others are       | > When you receive money to compensate you |
| responsible for         | > for medical or hospital care for         |
| injuries**              | > injuries or illness caused by another    |
|                         | > person, you must reimburse us for any    |
|                         | > expenses we paid. However, we will cover |
|                         | > the cost of treatment that exceeds the   |
|                         | > amount you received in the settlement.   |
|                         | >                                          |
|                         | > If you do not seek damages you must      |
|                         | > agree to let us try. This is called      |
|                         | > subrogation. If you need more            |
|                         | > information, contact us for our          |
|                         | > subrogation procedures.                  |
+-------------------------+--------------------------------------------+

+---------------------+------------------------------------------------+
| Section 10.         |                                                |
| Definitions of      |                                                |
| terms we use in     |                                                |
| this brochure       |                                                |
+---------------------+------------------------------------------------+
| **Calendar year**   | > January 1 through December 31 of the same    |
|                     | > year. For new enrollees, the calendar year   |
|                     | > begins on the effective date of their        |
|                     | > enrollment and ends on December 31 of the    |
|                     | > same year.                                   |
+---------------------+------------------------------------------------+
| **Copayment**       | > A copayment is a fixed amount of money you   |
|                     | > pay when you receive covered services. See   |
|                     | > page 12.                                     |
+---------------------+------------------------------------------------+
| **Coinsurance**     | > Coinsurance is the percentage of our         |
|                     | > allowance that you must pay for your care.   |
|                     | > See page 12.                                 |
+---------------------+------------------------------------------------+
| **Covered           | > Care we provide benefits for, as described   |
| services**          | > in this brochure.                            |
+---------------------+------------------------------------------------+
| **Deductible**      | > A deductible is a fixed amount of covered    |
|                     | > expenses you must incur for certain covered  |
|                     | > services and supplies before we start paying |
|                     | > benefits for those services. See page 12.    |
+---------------------+------------------------------------------------+
| **Medically         | > Medically necessary services are services;   |
| Necessary           | > supplies or equipment provided by a hospital |
| Services**          | > or covered provider of the health care       |
|                     | > services that the carrier determines:        |
|                     |                                                |
|                     | -   are appropriate to diagnose or treat the   |
|                     |     patient's condition, illness, or injury;   |
|                     |                                                |
|                     | -   are consistent with standards of good      |
|                     |     medical practice in the United States;     |
|                     |                                                |
|                     | -   are not primarily for the personal comfort |
|                     |     or convenience of the patient, the family, |
|                     |     or the provider;                           |
|                     |                                                |
|                     | -   are not part of or associated with         |
|                     |     scholastic education or vocational         |
|                     |     training of the patient; and               |
|                     |                                                |
|                     | -   in case of inpatient care, cannot be       |
|                     |     provided safely on an outpatient basis.    |
|                     |                                                |
|                     | > The fact that a covered provider has         |
|                     | > prescribed, recommended, or approved a       |
|                     | > service, supply or equipment does not, in    |
|                     | > itself, make it medically necessary.         |
+---------------------+------------------------------------------------+
| **Experimental or   | > Experimental treatment is a treatment that   |
| investigational     | > has not been tested in human beings; or that |
| services**          | > is being tested but has not yet been         |
|                     | > approved for general use; or that is subject |
|                     | > to review or approval by an Institutional    |
|                     | > Review Board.                                |
|                     | >                                              |
|                     | > Investigational treatment includes, but is   |
|                     | > not limited to, services or supplies which   |
|                     | > are under study or in a clinical trial to    |
|                     | > evaluate their toxicity, safety and          |
|                     | > efficiency for a particular diagnosis or set |
|                     | > of indications.                              |
|                     | >                                              |
|                     | > Clinical trials include, but are not limited |
|                     | > to, controlled experiments having a clinical |
|                     | > event as an outcome measurement involving    |
|                     | > persons having a specific disease or health  |
|                     | > condition; or involving the administration   |
|                     | > of different study treatments in a parallel  |
|                     | > treatment design done to evaluate the        |
|                     | > efficacy and safety of a test measurement.   |
|                     | > Clinical trials include Phase I, Phase II,   |
|                     | > and Phase III studies. Clinical trials also  |
|                     | > include randomized trials or studies.        |
+---------------------+------------------------------------------------+
| **Plan allowance**  | > Plan allowance is the amount we use to       |
|                     | > determine our payment and your coinsurance   |
|                     | > for covered services. Fee-for-service plans  |
|                     | > determine their allowances in different      |
|                     | > ways. We determine our allowance as follows: |
|                     | >                                              |
|                     | > The Plan allowance is the fee schedule or    |
|                     | > negotiated rate that GHI uses as payment in  |
|                     | > full for covered services rendered by        |
|                     | > participating providers.                     |
+---------------------+------------------------------------------------+
| **Us/We**           | > Us and we refer to Group Health Incorporated |
+---------------------+------------------------------------------------+
| **You**             | > You refers to the enrollee and each covered  |
|                     | > family member.                               |
+---------------------+------------------------------------------------+

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

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

**Coverage information** .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

> As long as the court/administrative order is in effect, and you have
> at least one child identified in the order who is still eligible under
> the FEHB Program, you cannot cancel your enrollment, change to Self
> Only, or change to a plan that doesn\'t serve the area in which your
> children live, unless you provide documentation that you have other
> coverage for the children. If the court/administrative order is still
> in effect when you retire, and you have at least one child still
> eligible for FEHB coverage, you must continue your FEHB coverage into
> retirement (if eligible) and cannot cancel your coverage, change to
> Self Only, or change to a plan that doesn\'t serve the area in which
> your children live as long as the court/administrative order is in
> effect. Contact you employing office for further information.
>
> The benefits in this brochure are effective on January 1. If you
> joined this Plan during Open Season, your coverage begins on the first
> day of your first pay period that starts on or after January 1. If you
> changed plans or plan options during Open Season and you receive care
> between January 1 and the effective date of coverage under your new
> plan or option, your claims will be paid according to the 2004
> benefits of your old plan or option. However, if your old plan left
> the FEHB Program at the end of the year, you are covered under the
> plan\'s 2003 benefits until the effective date of your coverage under
> your new plan. Annuitants\' coverage and premiums begin on January 1.
> If you joined at any other time during the year, your employing office
> will tell you the effective date of coverage.

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

**When you lose benefits**

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

> • Your enrollment ends, unless you cancel your enrollment, or
>
> • You are a family member no longer eligible for coverage.

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

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

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

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

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

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

-   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.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
is a Federal law that offers limited federal protections for health
coverage availability and continuity to people who lose employer group
coverage. If you leave the FEHB Program, we will give you a Certificate
of Group Health Plan Coverage that indicates how long you have been
enrolled with us. You can use this certificate when getting health
insurance or other health care coverage. Your new plan must reduce or
eliminate waiting periods, limitations, or exclusions for health related
conditions based on the information in the certificate, as long as you
enroll within 63 days of losing coverage under this Plan. If you have
been enrolled with us for less than 12 months, but were previously
enrolled in other FEHB plans, you may also request a certificate from
those plans. For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB
website ([www.opm.gov/insure/health](http://www.opm.gov/insure/health));
refer to the "TCA 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.

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

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

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

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

-   **What is an FSA?** It is a tax-favored benefit that allows you to
    set aside pre-tax money from your

> paychecks to pay for a variety of eligible expenses. *By using an
> FSA,* *you can reduce your taxes while paying for services you would
> have to pay for anyway, producing a discount that can be over 40%!!*

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

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

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

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

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

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

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

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-   **Enroll during Open Season** You **must make an election** to
    enroll in an FSA during the FEHB

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

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

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

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

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

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

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

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

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

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

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

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

> **Note:** This example is intended to demonstrate a typical tax
> savings based on 27% Federal and 7.65% FICA taxes. Actual savings will
> vary based upon in which retirement system you are enrolled (CSRS or
> FERS), as well as your individual tax situation. In this example, the
> individual received \$2,000 in services for \$1,424, a discount of
> almost 36%! You may also wish to consult a tax professional for more
> information on the tax implications of an FSA.
>
> **Tax credits and** You cannot claim expenses on your Federal income
> tax return if you
>
> **Deductions** receive reimbursement for them from your HCFSA or
> DCFSA. Below are some guidelines that may help you decide whether to
> participate in FSAFEDS.

**Health care expenses** The HCFSA is tax-free from the first dollar. In
addition, you may be reimbursed from the HCFSA at any time during the
year for expenses up to the annual amount you\'ve elected to contribute.

Only health care expenses exceeding 7.5% of your adjusted gross income
are eligible to be deducted on your Federal income tax return. Using the
example listed in the above chart, only health care expenses exceeding
\$3,750 (7.5% of \$50,000) would be eligible to be deducted on your
Federal income tax return. In addition, money set aside through a HCFSA
is also exempt from FICA taxes. This exemption is not available on your
Federal income tax return.

**Dependent care expenses** The DCFSA generally allows many families to
save more than they would with the Federal tax credit for dependent care
expenses. Note that you may only be reimbursed from the DCFSA up to your
current account balance. If you file a claim for more than your current
balance, it will be held until additional payroll allotments have been
added to your account.

> Visit [www.fsafeds.com](http://www.fsafeds.com/) and download the
> Dependent Care Tax Credit Worksheet from the Quick Links box to help
> you determine what is best for your situation. You may also wish to
> consult a tax professional for more details.

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

**to participate in FSAFEDS?** an HCFSA and 1.5% of the annual election
for a DCFSA, most agencies have elected to pay these fees out of their
share of employment tax savings. To be sure, check the FSAFEDS.com web
site or call 1-877-FSAFEDS (372-3337). Also, remember that participating
in FSAFEDS can cost you money if you don't spend your entire account
balance by the end of the plan year and wind up forfeiting your end of
year account balance, per the IRS "use-it-or-lose-it" rule.

**Contact us** To find out more or to enroll, please visit the **FSAFEDS
Web site** at

> [**www.fsafeds.com**](http://www.fsafeds.com/), or contact SHPS by
> email or by phone**.** SHPS Benefit Counselors are available from 9:00
> a.m. until 9:00 p.m. eastern time, Monday through Friday.

-   E-mail:<fsafeds@shps.net>

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

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

**The Federal Long Term Care Insurance Program**

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

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

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

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

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

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

**to request an application** (TTY 1-800-843-3557) or visit
[www.ltcfeds.com](http://www.ltcfeds.com/).

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

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

Do not rely on this page; it is for your convenience and does not
explain your benefit coverage.

**A**ccidental injury 41

Allergy tests 21

Allogeneic (donor) bone marrow transplant.............................35

Ambulance 40

Anesthesia 36

Autologous bone marrow\
transplant 35

Blood and blood plasma 38

Breast cancer screening 17

**C**asts 27

Catastrophic protection 12

Changes for 2003 8

Chemotherapy 21

Childbirth 19

Chiropractic 29

Cholesterol tests 16

Claims 58

Coinsurance 12

Colorectal cancer screening 16

Congenital anomalies 31

Contraceptive devices and drugs 20/48

Coordination of benefits 61

Covered charges 12

Covered providers 9

Crutches 27

**D**eductible 12

Definitions 66

Dental care 52

Diagnostic services 14

Disputed claims review 59

Donor expenses (transplants) 35

Durable medical equipment (DME) 27

Educational classes\
and programs 30

Effective date of enrollment 69

Emergency 41

Experimental or investigational 67

Eyeglasses 24

**F**amily planning 20

Fecal occult blood test 16

Fraud 3

**G**eneral exclusions 57

**H**earing services 23

Home health services 28

Hospice care 40

Home nursing care 28

Hospital 38

**I**mmunizations 18

Infertility 20

Inhospital physician care 15

Inpatient hospital benefits 38

Insulin 48

**L**aboratory and\
pathological services 15

**M**agnetic Resonance\
Imagings (MRIs) 15

Mail order prescription drugs 46

Mammograms 17

Maternity benefits 19

Medicaid 65

Medically necessary 66

Medicare 62

Members 67

Mental conditions/\
substance abuse benefits 44

**N**eurological testing 15

Newborn care 19

Non-FEHB Benefits 56

Nurse

> Licensed Practical Nurse 28
>
> Nurse midwife 28
>
> Nurse practitioner 28
>
> Registered nurse 28

Nursery charges 19

**O**bstetrical care 19

Occupational therapy 23

Office visits 14

Oral and maxillofacial surgery 34

Orthopedic devices 26

Ostomy and catheter supplies 26

Out-of-pocket expenses 12

Outpatient facility care 39

Oxygen 27

**P**ap test 17

Physical examination 14/15

Physical therapy 22

Physician 14

Point-of-Service (POS) 54

Pre-admission testing 31

Precertification 11

Preventive care, adult 16

Preventive care, children 18

Prescription drugs 46

Preventive services 16

Prior approval 11

Prostate cancer screening 16

Prosthetic devices 26

Psychologist 44

Psychotherapy 44

**R**adiation therapy 21

Rehabilitation therapies 22

Renal dialysis 21

Room and board 38

**S**econd surgical opinion 14

Skilled nursing facility care 37

Smoking cessation 48

Speech therapy 23

Splints 26

Subrogation 53

Substance abuse 44

Surgery 31

Anesthesia 37

Oral 34

Outpatient 39

Reconstructive 33

Syringes 38

**T**emporary continuation\
of coverage 70

Transplants 35

Treatment therapies 21

**V**ision services 24

**W**ell child care 18

Wheelchairs 27

Workers' compensation 64

**X**-rays 15

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

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

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

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

+----------------------------+---+---------------+---+---------------+--------+
| **Benefits**               | # |               | # |               | **     |
|                            | # |               | # |               | Page** |
|                            | # |               | # |               |        |
|                            | # |               | # |               |        |
|                            | # |               | # |               |        |
|                            | # |               | # |               |        |
|                            | # |               | # |               |        |
|                            |   |               |   |               |        |
|                            | H |               | S |               |        |
|                            | i |               | t |               |        |
|                            | g |               | a |               |        |
|                            | h |               | n |               |        |
|                            |   |               | d |               |        |
|                            | O |               | a |               |        |
|                            | p |               | r |               |        |
|                            | t |               | d |               |        |
|                            | i |               |   |               |        |
|                            | o |               | O |               |        |
|                            | n |               | p |               |        |
|                            |   |               | t |               |        |
|                            | # |               | i |               |        |
|                            | # |               | o |               |        |
|                            | # |               | n |               |        |
|                            | # |               |   |               |        |
|                            | # |               | # |               |        |
|                            | # |               | # |               |        |
|                            | # |               | # |               |        |
|                            |   |               | # |               |        |
|                            | Y |               | # |               |        |
|                            | o |               | # |               |        |
|                            | u |               | # |               |        |
|                            |   |               |   |               |        |
|                            | P |               | Y |               |        |
|                            | a |               | o |               |        |
|                            | y |               | u |               |        |
|                            |   |               |   |               |        |
|                            |   |               | P |               |        |
|                            |   |               | a |               |        |
|                            |   |               | y |               |        |
+----------------------------+---+---------------+---+---------------+--------+
| > Medical services         | \ |               | \ |               | > 14   |
| > provided by physicians:  | $ |               | $ |               |        |
|                            | 1 |               | 2 |               |        |
| -   Diagnostic and         | 5 |               | 5 |               |        |
|     treatment services     | p |               | p |               |        |
|     provided in the office | e |               | e |               |        |
|                            | r |               | r |               |        |
|                            | v |               | v |               |        |
|                            | i |               | i |               |        |
|                            | s |               | s |               |        |
|                            | i |               | i |               |        |
|                            | t |               | t |               |        |
|                            | f |               | f |               |        |
|                            | o |               | o |               |        |
|                            | r |               | r |               |        |
|                            | a |               | a |               |        |
|                            | P |               | P |               |        |
|                            | a |               | a |               |        |
|                            | r |               | r |               |        |
|                            | t |               | t |               |        |
|                            | i |               | i |               |        |
|                            | c |               | c |               |        |
|                            | i |               | i |               |        |
|                            | p |               | p |               |        |
|                            | a |               | a |               |        |
|                            | t |               | t |               |        |
|                            | i |               | i |               |        |
|                            | n |               | n |               |        |
|                            | g |               | g |               |        |
|                            | P |               | P |               |        |
|                            | r |               | r |               |        |
|                            | o |               | o |               |        |
|                            | v |               | v |               |        |
|                            | i |               | i |               |        |
|                            | d |               | d |               |        |
|                            | e |               | e |               |        |
|                            | r |               | r |               |        |
|                            | . |               | . |               |        |
|                            |   |               |   |               |        |
|                            | P |               | A |               |        |
|                            | O |               | l |               |        |
|                            | S |               | l |               |        |
|                            | : |               | c |               |        |
|                            | 5 |               | h |               |        |
|                            | 0 |               | a |               |        |
|                            | % |               | r |               |        |
|                            | o |               | g |               |        |
|                            | f |               | e |               |        |
|                            | t |               | s |               |        |
|                            | h |               | f |               |        |
|                            | e |               | o |               |        |
|                            | P |               | r |               |        |
|                            | l |               | n |               |        |
|                            | a |               | o |               |        |
|                            | n |               | n |               |        |
|                            | ' |               | - |               |        |
|                            | s |               | p |               |        |
|                            | f |               | a |               |        |
|                            | e |               | r |               |        |
|                            | e |               | t |               |        |
|                            | s |               | i |               |        |
|                            | c |               | c |               |        |
|                            | h |               | i |               |        |
|                            | e |               | p |               |        |
|                            | d |               | a |               |        |
|                            | u |               | t |               |        |
|                            | l |               | i |               |        |
|                            | e |               | n |               |        |
|                            | a |               | g |               |        |
|                            | n |               | p |               |        |
|                            | d |               | r |               |        |
|                            | a |               | o |               |        |
|                            | n |               | v |               |        |
|                            | y |               | i |               |        |
|                            | d |               | d |               |        |
|                            | i |               | e |               |        |
|                            | f |               | r |               |        |
|                            | f |               | s |               |        |
|                            | e |               | . |               |        |
|                            | r |               |   |               |        |
|                            | e |               |   |               |        |
|                            | n |               |   |               |        |
|                            | c |               |   |               |        |
|                            | e |               |   |               |        |
|                            | b |               |   |               |        |
|                            | e |               |   |               |        |
|                            | t |               |   |               |        |
|                            | w |               |   |               |        |
|                            | e |               |   |               |        |
|                            | e |               |   |               |        |
|                            | n |               |   |               |        |
|                            | o |               |   |               |        |
|                            | u |               |   |               |        |
|                            | r |               |   |               |        |
|                            | f |               |   |               |        |
|                            | e |               |   |               |        |
|                            | e |               |   |               |        |
|                            | s |               |   |               |        |
|                            | c |               |   |               |        |
|                            | h |               |   |               |        |
|                            | e |               |   |               |        |
|                            | d |               |   |               |        |
|                            | u |               |   |               |        |
|                            | l |               |   |               |        |
|                            | e |               |   |               |        |
|                            | a |               |   |               |        |
|                            | n |               |   |               |        |
|                            | d |               |   |               |        |
|                            | t |               |   |               |        |
|                            | h |               |   |               |        |
|                            | e |               |   |               |        |
|                            | b |               |   |               |        |
|                            | i |               |   |               |        |
|                            | l |               |   |               |        |
|                            | l |               |   |               |        |
|                            | e |               |   |               |        |
|                            | d |               |   |               |        |
|                            | a |               |   |               |        |
|                            | m |               |   |               |        |
|                            | o |               |   |               |        |
|                            | u |               |   |               |        |
|                            | n |               |   |               |        |
|                            | t |               |   |               |        |
|                            | f |               |   |               |        |
|                            | o |               |   |               |        |
|                            | r |               |   |               |        |
|                            | a |               |   |               |        |
|                            | n |               |   |               |        |
|                            | o |               |   |               |        |
|                            | n |               |   |               |        |
|                            | - |               |   |               |        |
|                            | p |               |   |               |        |
|                            | a |               |   |               |        |
|                            | r |               |   |               |        |
|                            | t |               |   |               |        |
|                            | i |               |   |               |        |
|                            | c |               |   |               |        |
|                            | i |               |   |               |        |
|                            | p |               |   |               |        |
|                            | a |               |   |               |        |
|                            | t |               |   |               |        |
|                            | i |               |   |               |        |
|                            | n |               |   |               |        |
|                            | g |               |   |               |        |
|                            | p |               |   |               |        |
|                            | r |               |   |               |        |
|                            | o |               |   |               |        |
|                            | v |               |   |               |        |
|                            | i |               |   |               |        |
|                            | d |               |   |               |        |
|                            | e |               |   |               |        |
|                            | r |               |   |               |        |
|                            | . |               |   |               |        |
+----------------------------+---+---------------+---+---------------+--------+
| > Services provided by a   | N |               | \ |               | > 38   |
| > hospital:                | o |               | $ |               | >      |
|                            | t |               | 2 |               | > 39   |
| -   Inpatient              | h |               | 5 |               |        |
|                            | i |               | 0 |               |        |
| -   Outpatient             | n |               | p |               |        |
|                            | g |               | e |               |        |
|                            |   |               | r |               |        |
|                            | > |               | d |               |        |
|                            |   |               | a |               |        |
|                            | N |               | y |               |        |
|                            | o |               | i |               |        |
|                            | t |               | n |               |        |
|                            | e |               | p |               |        |
|                            | : |               | a |               |        |
|                            | > |               | t |               |        |
|                            |   |               | i |               |        |
|                            | \ |               | e |               |        |
|                            | $ |               | n |               |        |
|                            | 2 |               | t |               |        |
|                            | 5 |               | a |               |        |
|                            | > |               | d |               |        |
|                            |   |               | m |               |        |
|                            | d |               | i |               |        |
|                            | e |               | s |               |        |
|                            | d |               | s |               |        |
|                            | u |               | i |               |        |
|                            | c |               | o |               |        |
|                            | t |               | n |               |        |
|                            | i |               | u |               |        |
|                            | b |               | p |               |        |
|                            | l |               | t |               |        |
|                            | e |               | o |               |        |
|                            | > |               | a |               |        |
|                            |   |               | m |               |        |
|                            | p |               | a |               |        |
|                            | e |               | x |               |        |
|                            | r |               | i |               |        |
|                            | > |               | m |               |        |
|                            |   |               | u |               |        |
|                            | r |               | m |               |        |
|                            | e |               | o |               |        |
|                            | f |               | f |               |        |
|                            | e |               | \ |               |        |
|                            | r |               | $ |               |        |
|                            | r |               | 7 |               |        |
|                            | a |               | 5 |               |        |
|                            | l |               | 0 |               |        |
|                            | > |               | p |               |        |
|                            |   |               | e |               |        |
|                            | f |               | r |               |        |
|                            | o |               | a |               |        |
|                            | r |               | d |               |        |
|                            | > |               | m |               |        |
|                            |   |               | i |               |        |
|                            | a |               | s |               |        |
|                            | m |               | s |               |        |
|                            | b |               | i |               |        |
|                            | u |               | o |               |        |
|                            | l |               | n |               |        |
|                            | a |               | . |               |        |
|                            | t |               | ( |               |        |
|                            | o |               | W |               |        |
|                            | r |               | a |               |        |
|                            | y |               | i |               |        |
|                            | > |               | v |               |        |
|                            |   |               | e |               |        |
|                            | l |               | d |               |        |
|                            | a |               | f |               |        |
|                            | b |               | o |               |        |
|                            | o |               | r |               |        |
|                            | r |               | m |               |        |
|                            | a |               | a |               |        |
|                            | t |               | t |               |        |
|                            | o |               | e |               |        |
|                            | r |               | r |               |        |
|                            | y |               | n |               |        |
|                            | > |               | i |               |        |
|                            |   |               | t |               |        |
|                            | t |               | y |               |        |
|                            | e |               | c |               |        |
|                            | s |               | a |               |        |
|                            | t |               | r |               |        |
|                            | > |               | e |               |        |
|                            |   |               | ) |               |        |
|                            | a |               |   |               |        |
|                            | n |               | A |               |        |
|                            | d |               | l |               |        |
|                            | > |               | l |               |        |
|                            |   |               | c |               |        |
|                            | d |               | h |               |        |
|                            | i |               | a |               |        |
|                            | a |               | r |               |        |
|                            | g |               | g |               |        |
|                            | n |               | e |               |        |
|                            | o |               | s |               |        |
|                            | s |               | f |               |        |
|                            | t |               | o |               |        |
|                            | i |               | r |               |        |
|                            | c |               | n |               |        |
|                            | > |               | o |               |        |
|                            |   |               | n |               |        |
|                            | X |               | - |               |        |
|                            | - |               | p |               |        |
|                            | r |               | a |               |        |
|                            | a |               | r |               |        |
|                            | y |               | t |               |        |
|                            | s |               | i |               |        |
|                            | > |               | c |               |        |
|                            |   |               | i |               |        |
|                            | w |               | p |               |        |
|                            | h |               | a |               |        |
|                            | e |               | t |               |        |
|                            | n |               | i |               |        |
|                            | > |               | n |               |        |
|                            |   |               | g |               |        |
|                            | r |               | p |               |        |
|                            | e |               | r |               |        |
|                            | f |               | o |               |        |
|                            | e |               | v |               |        |
|                            | r |               | i |               |        |
|                            | r |               | d |               |        |
|                            | e |               | e |               |        |
|                            | d |               | r |               |        |
|                            | > |               | s |               |        |
|                            |   |               | . |               |        |
|                            | a |               |   |               |        |
|                            | n |               |   |               |        |
|                            | d |               |   |               |        |
|                            | > |               |   |               |        |
|                            |   |               |   |               |        |
|                            | r |               |   |               |        |
|                            | e |               |   |               |        |
|                            | n |               |   |               |        |
|                            | d |               |   |               |        |
|                            | e |               |   |               |        |
|                            | r |               |   |               |        |
|                            | e |               |   |               |        |
|                            | d |               |   |               |        |
|                            | . |               |   |               |        |
+----------------------------+---+---------------+---+---------------+--------+
| > Emergency benefits:      | > |               | > |               | > 41   |
|                            |   |               |   |               | >      |
| -   In-area                | \ |               | \ |               | > 41   |
|                            | $ |               | $ |               |        |
| -   Out-of-area            | 5 |               | 7 |               |        |
|                            | 0 |               | 5 |               |        |
|                            | > |               | > |               |        |
|                            |   |               |   |               |        |
|                            | p |               | p |               |        |
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|                            | s |               | s |               |        |
|                            | . |               | . |               |        |
+----------------------------+---+---------------+---+---------------+--------+
| > Mental health and        | > |               | > |               | > 44   |
| > substance abuse          |   |               |   |               |        |
| > treatment                | R |               | R |               |        |
|                            | e |               | e |               |        |
|                            | g |               | g |               |        |
|                            | u |               | u |               |        |
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|                            | h |               | h |               |        |
|                            | a |               | a |               |        |
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|                            | i |               | i |               |        |
|                            | n |               | n |               |        |
|                            | g |               | g |               |        |
|                            | . |               | . |               |        |
+----------------------------+---+---------------+---+---------------+--------+
| Prescription drugs         | > |               | > |               | > 46   |
| prescribed by a doctor and |   |               |   |               |        |
| obtained at a              | \ |               | \ |               |        |
| participating pharmacy     | $ |               | $ |               |        |
|                            | 1 |               | 1 |               |        |
| > Mandatory Mail           | 0 |               | 0 |               |        |
|                            | > |               | > |               |        |
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+----------------------------+---+---------------+---+---------------+--------+
| > Dental Care              | > |               | > |               | > 52   |
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|                            | . |               |   |               |        |
+----------------------------+---+---------------+---+---------------+--------+
| > Vision Care              | > |               | > |               | > 24   |
|                            |   |               |   |               |        |
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|                            | > |               | > |               |        |
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|                            | t |               | t |               |        |
|                            | e |               | e |               |        |
|                            | r |               | r |               |        |
|                            | s |               | s |               |        |
|                            | . |               | . |               |        |
+----------------------------+---+---------------+---+---------------+--------+
| Special features: Large    |   |               |   |               | > 50   |
| Case Management, High Risk |   |               |   |               |        |
| Pregnancies, Centers of    |   |               |   |               |        |
| Excellence for             |   |               |   |               |        |
| Trans                      |   |               |   |               |        |
| plants/Heart/Surgery/etc., |   |               |   |               |        |
+----------------------------+---+---------------+---+---------------+--------+
| > Point-of-Service         |   | > Yes         |   | > No          | > 54   |
| > benefits \--             |   |               |   |               |        |
+----------------------------+---+---------------+---+---------------+--------+
| > Protection against       |   | Nothing after | N |               | > 12   |
| > catastrophic costs       |   | \$10,000 per  | o |               |        |
| >                          |   | person per    | b |               |        |
| > (your catastrophic       |   | year          | e |               |        |
| > protection out-of-pocket |   |               | n |               |        |
| > maximum)                 |   | Some costs do | e |               |        |
|                            |   | not count     | f |               |        |
|                            |   | toward this   | i |               |        |
|                            |   | protection    | t |               |        |
|                            |   |               | s |               |        |
+----------------------------+---+---------------+---+---------------+--------+

**2004 Rate Information for**

**GHI Health Plan**

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

**Postal rates** apply to career Postal Service employees. Most
employees should refer to the FEHB Guide for United States Postal
Service Employees, RI 70-2. Different postal rates apply and special
FEHB guides are published for Postal Service Nurses (see RI 70-2B); and
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.
Refer to the applicable FEHB Guide.

+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | **    |       |       |       | **P   |       |
|              |     | Non-P |       |       |       | ostal |       |
|              |     | ostal |       |       |       | Prem  |       |
|              |     | Prem  |       |       |       | ium** |       |
|              |     | ium** |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | **    |       | *     |       | **    |       |
|              |     | Biwee |       | *Mont |       | Biwee |       |
|              |     | kly** |       | hly** |       | kly** |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Type of**  | **  | **Go  | **Y   | **Go  | **Y   | **U   | **Y   |
|              | Cod | v't** | our** | v't** | our** | SPS** | our** |
| **           | e** |       |       |       |       |       |       |
| Enrollment** |     | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  |
|              |     | are** | are** | are** | are** | are** | are** |
+--------------+-----+-------+-------+-------+-------+-------+-------+

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | *     | **    | **    | **    | *     |
| Option**     | *80 | \$121 | *\$63 | \$263 | \$138 | \$143 | *\$41 |
|              | 1** | .40** | .77** | .03** | .17** | .32** | .85** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | **    | **    | **    | **    | **    |
| Option**     | *80 | \$277 | \$185 | \$600 | \$402 | \$327 | \$135 |
|              | 2** | .09** | .83** | .36** | .63** | .12** | .80** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | *     | **    | *     | **    | *     |
| Option**     | *80 | \$119 | *\$39 | \$258 | *\$86 | \$141 | *\$17 |
|              | 4** | .15** | .72** | .17** | .05** | .00** | .87** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | **    | **    | **    | **    | *     |
| Option**     | *80 | \$277 | \$120 | \$600 | \$260 | \$327 | *\$70 |
|              | 5** | .09** | .11** | .36** | .24** | .12** | .08** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+