Government Employees Hospital Association, Inc.

#### Benefit Plan

**[http://www.geha.com]{.underline}**![](media/image1.png){width="1.8875in"
height="0.5868055555555556in"}

**2004**

**A fee-for-service plan**

**with a preferred provider
organization**![](media/image2.png){width="1.175in"
height="1.1909722222222223in"}

# Sponsored and administered by: 

# Government Employees Hospital Association, Inc.

**Who may enroll in this Plan:** All Federal employees and annuitants
who are eligible to enroll in the Federal Employees Health Benefits
Program may become members of GEHA. You must be, or must become a member
of Government Employees Hospital Association, Inc.

**To become a member:** You join simply by signing a completed Standard
Form 2809, Health Benefits Registration Form, evidencing your enrollment
in the Plan.

**Membership dues:** There are no membership dues for the Year 2004.

**Enrollment codes for this Plan:**

#  311 Self Only -- High Option

#  312 Self and Family -- High Option

#  314 Self Only -- Standard Option

**315 Self and Family -- Standard Option**

**RI 71-006**

![](media/image7.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]{.underline}](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/image8.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

![](media/image9.png){width="1.195138888888889in"
height="1.0354166666666667in"}
![](media/image10.png){width="1.1715277777777777in"
height="0.9208333333333333in"}

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

# 

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice,
look at
[[www.opm.gov/insure]{.underline}](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.]{.underline}~~

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  Table of Contents
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Introduction 4

Plain Language 4

Stop Health Care Fraud! 5

Preventing medical mistakes 6

Section 1. Facts about this fee-for-service plan 7-8

Section 2. How we change for 2004 9-10

Section 3. How you get care 11-15

Identification cards 11

Where you get covered care 11-12

• Covered providers 11

• Covered facilities 11-12

What you must do to get covered care 12-13

How to get approval for 13-15

• Your hospital stay (precertification) 13-14

• Other services 15

Section 4. Your costs for covered services 16-21

• Copayments 16

• Deductible 16

• Coinsurance 16

• Differences between our allowance and the bill 17

Your catastrophic protection out-of-pocket maximum 17-19

When Government facilities bill us 19

If we overpay you 19

When you are age 65 or over and you do **not** have Medicare 20

When you have Medicare 21

Should I enroll in Medicare? 21

Section 5. Benefits 22-70

Overview 22

(a) Medical services and supplies provided by physicians and other
    health care professionals 23-36

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 37-45

(c) Services provided by a hospital or other facility, and ambulance
    services 46-52

(d) Emergency services/accidents 53-55

(e) Mental health and substance abuse benefits 56-60

(f) Prescription drug benefits 61-67

(g) Special features 68

-   Flexible benefits option 68

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-   Services for deaf and hearing impaired 68

-   High risk pregnancies 68

(h) Dental benefits 69-70

(i) Non-FEHB benefits available to Plan members 71-72

Section 6. General exclusions \-- things we don\'t cover 73-74

Section 7. Filing a claim for covered services 75-76

Section 8. The disputed claims process 77-78

Section 9. Coordinating benefits with other coverage 79-84

• When you have other health coverage 79

• What is Medicare 79-81

• Medicare + Choice 82

• TRICARE and CHAMPVA 82-83

• Workers\' Compensation 83

• Medicaid 83

• When other Government agencies are responsible for your care 83

• When others are responsible for injuries 83-84

Section 10. Definitions of terms we use in this brochure 85-89

Section 11. FEHB facts 90-93

Coverage information 90

• No pre-existing condition limitation 90

• Where you can get information about enrolling in the FEHB Program 90

• Types of coverage available for you and your family 90-91

• Children's Equity Act 91

• When benefits and premiums start 91

• When you retire 92

When you lose benefits 92-93

• When FEHB coverage ends 92

> • Spouse equity coverage 92
>
> • Temporary Continuation of Coverage (TCC) 92
>
> • Converting to individual coverage 92-93
>
> • Getting a Certificate of Group Health Plan Coverage 93

Two new Federal Programs complement FEHB benefits 94-98

The Federal Flexible Spending Account Program - *FSAFEDS* 94-97

The Federal Long Term Care Insurance Program 98

Index 99-100

Summary of Standard Option benefits 101

Summary of High Option benefits 102

Rates Back cover

  -----------------------------------------------------------------------
  Introduction

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

This brochure describes the benefits of **Government Employees Hospital
Association, Inc.** under our contract (CS 1063) with the United States
Office of Personnel Management, as authorized by the Federal Employees
Health Benefits law. This plan is underwritten by Government Employees
Hospital Association, Inc. The address for the Government Employees
Hospital Association, Inc. administrative offices is:

Government Employees Hospital Association, Inc.

P.O. Box 4665

Independence, Missouri 64051-4665

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

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

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and changes are summarized on
pages 9 and 10. Rates are shown at the end of this brochure.

  -----------------------------------------------------------------------
  Plain Language

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

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

-   Except for necessary technical terms, we use common words. For
    instance, \"you\" means the enrollee or family member; \"we\" means
    Government Employees Hospital Association, Inc.

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

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

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

  -----------------------------------------------------------------------
  Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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-   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 (800)
    821-6136 and explain the situation.

-   If we do not resolve the issue:

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

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

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

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

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

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

  -----------------------------------------------------------------------
  Preventing medical mistakes

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

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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.

2.  **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.

3.  **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.

4.  **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]{.underline}](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 health care providers and
    improve the quality of care you receive.

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

-   [[www.talkaboutrx.org/consumer.html]{.underline}](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]{.underline}](http://www.leapfroggroup.org/).
    The Leapfrog Group is active in promoting safe practices in hospital
    care.

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

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

  -----------------------------------------------------------------------
  **Section 1. Facts about this fee-for-service plan**

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

This Plan is a fee-for-service (FFS) plan. You can choose your own
physicians, hospitals, and other health care providers.

We reimburse you or your provider for your covered services, usually
based on a percentage of the amount we allow. The type and extent of
covered services, and the amount we allow, may be different from other
plans. Read brochures carefully.

**We also have a Preferred Provider Organization (PPO):**

Our fee-for-service plan offers services through a PPO. When you use our
PPO providers, you will receive covered services at reduced cost.
Government Employees Hospital Association, Inc. is solely responsible
for the selection of PPO providers in your area. Contact us for the
names of PPO providers and to verify their continued participation. You
can also go to our Web page, which you can reach through the FEHB Web
site, [[www.opm.gov/insure](http://www.opm.gov/insure).]{.underline}
Contact Government Employees Hospital Association, Inc. to request a PPO
directory.

We have entered into arrangements with Alliance PPO, Inc.; Arizona
Foundation for Medical Care; FCHN; Freedom Network; HealthCare
Preferred; HealthLink; MedSolutions; MultiPlan; PPO Oklahoma; PPO USA;
Private Healthcare Systems; Providence Preferred; and SouthCare, which
are Preferred Providers or networks of hospitals and/or doctors in all
states. The doctors and hospitals participating in these networks have
agreed to provide services to Plan members. You always have the right to
choose a PPO provider or a non-PPO provider for medical treatment.

PPO networks are now available in many metropolitan areas and additional
coverage areas will be added throughout the year. Enrollees residing in
a PPO network area will receive a directory of the PPO providers in
their service area. These providers are required to meet licensure and
certification standards established by State and Federal authorities,
however, inclusion in the network does not represent a guarantee of
professional performance nor does it constitute medical advice. To
locate a participating provider in your area, call (800) 296-0776 or
visit the GEHA Web site at
[[www.geha.com]{.underline}](http://www.geha.com/). When you phone for
an appointment, please remember to verify that the physician is still a
PPO provider.

The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. Provider networks may
be more extensive in some areas than others. We cannot guarantee the
availability of every specialty in all areas. If no PPO provider is
available, or you do not use a PPO provider, the standard non-PPO
benefits apply. However, if the services are rendered at a PPO hospital,
we will pay the services of radiologists, anesthesiologists and
pathologists who are not preferred providers at the preferred provider
rate. This non-standard benefit does not include the services of
emergency room physicians. In addition, providers outside the United
States will be paid at the PPO level of benefits.

How we pay providers

Fee-for-service plans reimburse you or your provider for covered
services. They do not typically provide or arrange for health care.
Fee-for-service plans let you choose your own physicians, hospitals and
other health care providers.

The FFS plan reimburses you for your health care expenses, usually on a
percentage basis. These percentages, as well as deductibles, methods for
applying deductibles to families, and the percentage of coinsurance you
must pay vary by plan.

We offer a preferred provider organization (PPO) arrangement. This
arrangement with health care providers gives you enhanced benefits or
limits your out-of-pocket expenses.

**Your Rights**

OPM requires that all FEHB Plans provide certain information to their
FEHB members. You may get information about us, our networks, providers,
and facilities. OPM's FEHB Web site
([[www.opm.gov/insure]{.underline}](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.

Government Employees Hospital Association, Inc. was founded in 1937 as
the Railway Mail Hospital Association. For more than 60 years now, GEHA
has provided health insurance benefits to federal employees and
retirees.

GEHA is incorporated as a General Not-For-Profit Corporation pursuant to
Chapter 355 of the Revised Statutes of the State of Missouri.

GEHA's Preferred Provider Organization includes more than 3,800
hospitals and more than 450,000 physician locations throughout the
United States. In circumstances where there is limited access to PPO
providers, GEHA may negotiate discounts with some providers, which will
reduce your overall out-of-pocket expenses.

[If you want more information about us, call (800) 821-6136, or write to
GEHA, P. O. Box 4665, Independence, MO 64051. You may also contact us by
fax at (816) 257-3233 or visit our Web site at
[www.geha.com](http://www.geha.com/)]{.underline}.

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

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program - *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See pages 94-98.

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

-   We added information regarding enrolling in Medicare. See page 21

-   We revised the Medicare Primary Payer Chart. See page 81

**Changes to this Plan**

• Your share of the non-Postal premium under the High Option will
increase by 13.5% for Self Only or 13.8% for Self and Family. Under the
Standard Option, your share of the premium will increase by 10% for Self
Only or 10% for Self and Family.

-   United Behavioral Health network is no longer a preferred provider
    network for mental health and substance

abuse services.

-   The separate calendar year mental health-substance abuse deductible
    has been eliminated. All mental health and substance abuse services
    by PPO providers and inpatient or outpatient professional mental
    health and substance abuse services by non-PPO providers are now
    subject to the same calendar year deductible as medical expenses.

> Inpatient hospital services by non-PPO providers and outpatient
> intensive day treatment by non-PPO providers are still subject to the
> separate \$500 calendar year deductible per person.

-   The separate PPO mental health and substance abuse catastrophic
    out-of-pocket maximum has been eliminated. All mental health and
    substance abuse services by PPO providers are subject to the same
    catastrophic out-of-pocket maximums as medical services.

> Non-PPO mental health and substance abuse services are still subject
> to the separate \$8,000 catastrophic out-of-pocket maximum

-   It is no longer necessary to obtain approval of outpatient mental
    health and substance abuse professional services to receive PPO
    benefits from PPO providers. You must still obtain approval of
    inpatient services and outpatient intensive day treatment by PPO
    providers to receive PPO benefits.

> You must also still pre-certify inpatient hospital services by non-PPO
> providers.
>
> The medical necessity of your admission to a hospital or other covered
> facility including in-network outpatient intensive day treatment for
> mental health or substance abuse must be precertified. Emergency
> admissions must be reported with two business days following the day
> of admission even if you have been discharged. Otherwise, the benefits
> will be reduced. See Section 3 for details.

-   All medically necessary sonograms during pregnancy are covered.

## Changes to High Option Only

-   The copayment for single source brand name drugs for Non-Medicare
    members is now \$25 at network retail pharmacies and \$45 at Home
    Delivery.

-   The copayment for multisource brand name drugs for Non-Medicare
    members is now \$40 at network retail pharmacies and \$60 at Home
    Delivery.

We clarified the following:

-   We have clarified that no computer programs are covered.

-   We have clarified that we do not cover bioelectric computer
    programmed prosthetic devices.

-   We have clarified that colonoscopies are covered as routine
    screenings.

-   We have clarified that bone density tests are covered for women over
    65 and women over 60 who are at high risk.

-   We have clarified that average wholesale pricing data is used to
    determine plan allowable for prescription drugs.

-   We have clarified that state law may prohibit the substitution of
    generic drugs for some brand name drugs.

-   We have clarified the subrogation language.

-   We have expanded the instructions on how to file foreign claims.

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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

> \(800\) 821-6136 or write to us at GEHA, P. O. Box 4665, Independence,
> MO 64051. You may also request replacement cards through our Web site:
> [www.geha.com]{.underline}.

**Where you get covered care** You can get care from any "covered
provider" or "covered facility." How much we pay -- and you pay --
depends on the type of covered provider or facility you use. If you use
our preferred providers, you will pay less.

**• Covered providers** We consider the following to be covered
providers when they perform services within the scope of their license
or certification:

A licensed doctor of medicine (M.D.) or a licensed doctor of osteopathy
(D.O.). Other covered providers include a chiropractor, nurse midwife,
nurse anesthetist, audiologist, dentist, optometrist, licensed clinical
social worker, licensed clinical psychologist, podiatrist, speech,
physical and occupational therapist, nurse practitioner/clinical
specialist, nursing school administered clinic and physician assistant.

The term "doctor" includes all of these providers when the services are
performed within the scope of their license or certification. The term
"primary care physician" includes family or general practitioners,
pediatricians, obstetricians/gynecologists and medical internists.

> **Medically underserved areas.** Note: We cover any licensed medical
> practitioner for any covered service performed within the scope of
> that license in states OPM determines are \"medically underserved\".
> For 2004, the states are: Alabama, Idaho, Kentucky, Louisiana, Maine,
> Mississippi, Missouri, Montana, New Mexico, North Dakota, South
> Carolina, South Dakota, Texas, Utah, West Virginia, and Wyoming.

**• Covered facilities** Covered facilities include:

-   Freestanding ambulatory facility

> A facility which is licensed by the state as an ambulatory surgery
> center or has Medicare certification as an ambulatory surgical center,
> has permanent facilities and equipment for the primary purpose of
> performing surgical and/or renal dialysis procedures on an outpatient
> basis; provides treatment by or under the supervision of doctors and
> nursing services whenever the patient is in the facility; does not
> provide inpatient accommodations; and is not, other than incidentally,
> a facility used as an office or clinic for the private practice of a
> doctor or other professional.

-   Hospice

> A facility which meets all of the following:

(1) primarily provides inpatient hospice care to terminally ill persons;

(2) is certified by Medicare as such, or is licensed or accredited as
    such by the jurisdiction it is in;

(3) is supervised by a staff of M.D.'s or D.O.'s, at least one of whom
    must be on call at all times;

(4) provides 24 hour a day nursing services under the direction of an
    R.N. and has a full-time administrator; and

(5) provides an ongoing quality assurance program.

-   Hospital

(1) An institution which is accredited as a hospital under the Hospital
    Accreditation Program of the Joint Commission on Accreditation of
    Healthcare Organizations (JCAHO); or

(2) A medical institution which is operated pursuant to law, under the
    supervision of a staff of doctors, and with 24 hour a day nursing
    service, and which is primarily engaged in providing general
    inpatient care and treatment of sick and injured persons through
    medical, diagnostic, and major surgical facilities, all of which
    facilities must be provided on its premises or have such
    arrangements by contract or agreement: or

(3) An institution which is operated pursuant to law, under the
    supervision of a staff of doctors and with 24 hour a day nursing
    service and which provides services on the premises for the
    diagnosis, treatment, and care of persons with mental/substance
    abuse disorders and has for each patient a written treatment plan
    which must include diagnostic assessment of the patient and a
    description of the treatment to be rendered and provides for
    follow-up assessments by or under the direction of the supervising
    doctor.

> The term hospital does not include a convalescent home or skilled
> nursing facility, or any institution or part thereof which: a) is used
> principally as a convalescent facility, nursing facility, or facility
> for the aged; b) furnishes primarily domiciliary or custodial care,
> including training in the routines of daily living; or c) is operating
> as a school or residential treatment facility.

**What you must do to** It depends on the kind of care you want to
receive. You can go to any

**get covered care** provider you want, but we must approve some care in
advance.

**Transitional care: Specialty care:** If you have a chronic or
disabling condition and

-   lose access to your PPO specialist because we drop out of the
    Federal Employees Health Benefits (FEHB) Program and you enroll in
    another FEHB Plan, or

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-   lose access to your PPO specialist because we terminate our contract
    with your specialist for other than cause,

you may be able to continue seeing your specialist and receiving any PPO
benefits 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 PPO specialist based on the above circumstances, you can
continue to see your specialist and any PPO benefits continue until the
end of your postpartum care, even if it is beyond the 90 days.

**Hospital care:** We pay for covered services from the effective date
of your enrollment. However, if you are in the hospital when your
enrollment in our Plan begins, call our customer service department
immediately at

\(800\) 821-6136.

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

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

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

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

happens first.

> These provisions apply only to the benefits of the hospitalized
> person. If your plan terminates participation in the FEHB 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.

### How to Get Approval for...

### 

**• Your hospital stay Precertification** is the process by which --
prior to your inpatient hospital admission -- we evaluate the medical
necessity of your proposed stay and the number of days required to treat
your condition. Unless we are misled by the information given to us, we
won't change our decision on medical necessity.

In most cases, your physician or hospital will take care of
precertification. Because you are still responsible for ensuring that we
are asked to precertify your care, you should always ask your physician
or hospital whether they have contacted us.

**Warning:** We will reduce our benefits for the inpatient hospital stay
by \$500 if no one contacts us for precertification. If the stay is not
medically necessary, we will not pay any benefits.

> **How to precertify an admission:**

-   For medical and surgical services, you, your representative, your
    doctor, or your hospital must call Encompass before admission. The
    toll-free number is (888) 372-3190. (See page 60 for mental
    health/substance abuse precertification.)

-   If you have an emergency admission due to a condition that you
    reasonably believe puts your life in danger or could cause serious
    damage to bodily function, you, your representative, the doctor, or
    the hospital must telephone us within two business days following
    the day of the emergency admission, even if you have been discharged
    from the hospital.

-   Provide the following information:

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-   Enrollee\'s name and Plan identification number;

-   Patient\'s name, birth date, and phone number;

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-   Reason for hospitalization, proposed treatment, or surgery;

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-   Name and phone number of admitting doctor;

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-   Name of hospital or facility; and

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-   Number of planned days of confinement.

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-   We will then tell the doctor and/or hospital the number of approved
    inpatient days and we will send written confirmation of our decision
    to you, your doctor, and the hospital.

Maternity care You do not need to precertify a maternity admission for a
routine delivery. However, if your medical condition requires you to
stay more than 48 hours after a vaginal delivery or 96 hours after a
cesarean section, then your physician or the hospital must contact us
for precertification of additional days. Further, if your baby stays
after you are discharged, then your physician or the hospital must
contact us for precertification of additional days for your baby.

**If your hospital stay** If your hospital stay \-- including for
maternity care \-- needs to be

**needs to be extended:** extended, you, your representative, your
doctor or the hospital must ask us to approve the additional days.

> What happens when you If no one contacted us, we will decide whether
> the hospital stay was
>
> do not follow the medically necessary.
>
> precertification rules

-   If we determine that the stay was medically necessary, we will pay
    the inpatient charges, less the \$500 penalty.

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-   If we determine that it was not medically necessary for you to be an
    inpatient, we will not pay inpatient hospital benefits. We will only
    pay for any covered medical supplies and services that are otherwise
    payable on an outpatient basis.

> If we denied the precertification request, we will not pay inpatient
> hospital benefits. We will only pay for any covered medical supplies
> and services that are otherwise payable on an outpatient basis.
>
> When we precertified the admission but you remained in the hospital
> beyond the number of days we approved and did not get the additional
> days precertified, then:

-   for the part of the admission that was medically necessary, we will
    pay inpatient benefits, but

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-   for the part of the admission that was not medically necessary, we
    will pay only medical services and supplies otherwise payable on an
    outpatient basis and will not pay inpatient benefits.

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

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-   You are admitted to a hospital outside the United States and

    Puerto Rico.

-   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.

**• Radiology/Imaging Procedures** Radiology precertification is the
process by which prior to scheduling

> **Precertification** specific imaging procedures we evaluate the
> medical necessity of your
>
> proposed procedure to ensure the appropriate procedure is being
> requested for your condition. In most cases your physician will take
> care of precertification. Because you are still responsible for
> ensuring that we are asked to precertify your procedure, you should
> ask your doctor to contact us.

The following outpatient radiology services need to be precertified:

CT - Computerized Axial Tomography

MRI - Magnetic Resonance Imaging

MRA - Magnetic Resonance Angiography

NC - Nuclear Cardiology

PET - Positron Emission Tomography

How to precertify a radiology/ For outpatient CT, MRI, MRA, NC and PET
studies, you, your

Imaging procedure: representative or your doctor must call MedSolutions
before scheduling the procedure. The toll free number is (866) 879-8317.
Provide the following information: patient\'s name, plan identification
number, and birth date, requested procedure and clinical support for
request, name and telephone number of ordering provider, and name of
requested imaging facility.

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

• You have another health insurance policy that is primary payer

including Medicare Part A & B or Part B only;

• The procedure is performed outside the United States and

Puerto Rico;

• You are an inpatient in a hospital;

• The procedure is performed as an emergency.

> **Warning:** We will reduce our benefits for these procedures by \$100
> if no one contacts us for precertification. If the procedure is not
> medically necessary, we will not pay any benefits.

**• Other services** Some services require a referral, precertification,
or prior authorization. You need to call us at (800) 821-6136 before
receiving treatment care such as:

Physical therapy

Growth hormone therapy (GHT)

Surgical treatment of morbid obesity

Certain prescription drugs

Organ and tissue transplant procedures

Surgical correction of congenital anomalies

> In-network and out of network inpatient Mental Health and Substance
> Abuse Benefits and in- network outpatient Intensive Day Treatment (See
> pages 56-58)

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

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

This is what you will pay out-of-pocket for your covered care:

> **• Copayments** A copayment is a fixed amount of money you pay to the
> provider, facility, pharmacy, etc., when you receive services.
>
> Example: When you see your PPO physician, under the High Option, you
> pay a copayment of \$20 per office visit.

**• 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 them. Copayments do not count toward any deductible.

-   The calendar year deductible is \$350 per person under High Option
    and \$450 per person under Standard Option. After the deductible
    amount is satisfied for an individual, covered services are payable
    for that individual. Under a family enrollment, all family member\'s
    individual deductibles are considered to be satisfied when the
    family member\'s deductibles are combined and reach \$700 under High
    Option and \$900 under Standard Option.

-   We also have a separate deductible for:

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-   A High Option per admission (including in-network mental health)
    deductible of \$100 per person (PPO) and (excluding mental health)
    \$300 per person (non-PPO) for inpatient hospital services up to a
    maximum of two per person, per calendar year.

-   Mental health and substance abuse treatment of \$500, per person,
    per calendar year, for out-of-network hospital inpatient and
    hospital outpatient/intensive day treatment

> 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** Coinsurance is the percentage of our allowance that
you must pay for your care. Coinsurance doesn't begin until you meet
your deductible. We will base this percentage on either the billed
charge or the Plan Allowance, whichever is less.

Example: Under the High Option, you pay 25% of our allowance for non-PPO
office visits.

Note: If your provider routinely waives (does not require you to pay)
your copayments, deductibles, or coinsurance, the provider is misstating
the fee and may be violating the law. In this case, when we calculate
our share, we will reduce the provider's fee by the amount waived.

For example, if your physician ordinarily charges \$100 for a service
but routinely waives your 25% coinsurance, the actual charge is \$75. We
will pay \$56.25 (75% of the actual charge of \$75).

**• Differences between** Our \"Plan allowance\" is the amount we use to
calculate our payment

**our allowance and** for covered services. Fee-for-service plans arrive
at their allowances in

**the bill** different ways, so their allowances vary. For more
information about how

we determine our Plan allowance, see the definition of Plan allowance in
Section 10.

Often, the provider\'s bill is more than a fee-for-service plan\'s
allowance. Whether or not you have to pay the difference between our
allowance and the bill will depend on the provider you use.

-   **PPO providers** agree to limit what they will bill you. Because of
    that, when you use a preferred provider, your share of covered
    charges consists only of your deductible and coinsurance or
    copayment. Here is an example about coinsurance: You see a PPO
    physician who charges \$150, but our allowance is \$100. If you have
    met your deductible, you are only responsible for your coinsurance.
    That is, with High Option you pay just 10% of our \$100 allowance
    (\$10). Because of the agreement, your PPO physician will not bill
    you for the \$50 difference between our allowance and his bill.

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-   **Non-PPO providers**, on the other hand, have no agreement to limit
    what they will bill you. When you use a non-PPO provider, you will
    pay your deductible and coinsurance \-- **plus** any difference
    between our allowance and charges on the bill. Here is an example:
    You see a non-PPO physician who charges \$150 and our allowance is
    again \$100. Because you\'ve met your deductible, you are
    responsible for your coinsurance, so with High Option you pay 25% of
    our \$100 allowance (\$25). Plus, because there is no agreement
    between the non-PPO physician and us, he can bill you for the \$50
    difference between our allowance and his bill.

The following table illustrates the examples of how much you have to pay
out-of-pocket, under the High Option, for services from a PPO physician
vs. a non-PPO physician. The table uses our example of a service for
which the physician charges \$150 and our allowance is \$100. The table
shows the amount you pay if you have met your calendar year deductible.

+-----------------+-----------------------+---------------------------+
| **EXAMPLE**     | **PPO physician**     | **Non-PPO physician**     |
+-----------------+-----------------------+---------------------------+
| Physician\'s    | \$150                 | \$150                     |
| charge          |                       |                           |
+-----------------+-----------------------+---------------------------+
| Our allowance   | We set it at: 100     | We set it at: 100         |
+-----------------+-----------------------+---------------------------+
| We pay          | 90% of our allowance: | 75% of our allowance: 75  |
|                 | 90                    |                           |
+-----------------+-----------------------+---------------------------+
| You owe:        | 10% of our allowance: | 25% of our allowance: 25  |
|                 | 10                    |                           |
| Coinsurance     |                       |                           |
+-----------------+-----------------------+---------------------------+
| +Difference up  | No: 0                 | Yes: 50                   |
| to              |                       |                           |
|                 |                       |                           |
| charge?         |                       |                           |
+-----------------+-----------------------+---------------------------+
| **TOTAL YOU     | \$10                  | \$75                      |
| PAY**           |                       |                           |
+-----------------+-----------------------+---------------------------+

**Your catastrophic protection** For those medical and surgical services
with coinsurance, we pay 100%

**out-of-pocket maximum for** of our allowable amount for the remainder
of the calendar year after

**deductibles, coinsurance,** **and** out-of-pocket expenses for
coinsurance exceed:

**copayments**

> **PPO •** \$3,500 for Self and Family (High Option) or \$4,500
> (Standard Option) and \$3,000 for Self Only (High Option) or \$4,000
> (Standard Option) if you use PPO Providers. Out-of-pocket expenses
> from both PPO and non-PPO providers count toward this limit. If you
> reach this limit, expenses from non-PPO providers must reach the
> non-PPO out-of-pocket limit before they are paid at 100% of our
> allowable amount.
>
> **Non-PPO •** \$4,500 for Self and Family (High Option) or \$5,500
> (Standard Option) and \$4,000 for Self Only (High Option) or \$5,000
> (Standard Option) if you use non-PPO providers. Any of the above
> expenses for PPO providers also count toward this limit. Your eligible
> out-of-pocket expenses will not exceed this amount whether or not you
> use PPO providers.
>
> Out-of-pocket expenses for this benefit are:

-   The 10% (High Option) or 15% (Standard Option) you pay for PPO
    charges under medical services and supplies, surgical and anesthesia
    services and hospital, facility, ambulance services and mental
    health and substance abuse services.

-   The 25% (High Option) or 35% (Standard Option) you pay for

> non-PPO charges under medical services and supplies, surgical and
> anesthesia services and hospital, facility and ambulance services.
> (This does not include Out-of-Network mental health and substance
> abuse services).
>
> The following cannot be counted toward catastrophic protection out-of-
>
> pocket expenses and you must continue to pay them even after your
> expenses exceed the limits described above:

-   The \$350 (High Option) or \$450 (Standard Option) calendar year
    deductible;

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```
-   The (High Option) \$100 (PPO) or \$300 (non-PPO) per in-hospital
    admission deductible;

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```
-   The \$20 copayment for doctor's office visits (High Option); or the
    \$10 copayment for primary care physician/\$25 specialist office
    visits (Standard Option);

-   Expenses in excess of our allowable amount or maximum benefit
    limitations;

-   Expenses for well child care and immunizations;

-   Expenses for dental and chiropractic care;

-   Any amounts you pay because benefits have been reduced for
    non-compliance with our cost containment requirements (see pages
    13-14);

-   Expenses for prescription drugs purchased through retail or Home
    Delivery Pharmacy service.

**Non-PPO mental** The Plan pays **100%** of reasonable and customary
charges for the

**conditions and** remainder of the calendar year up to the calendar
year day or visit

**substance abuse benefits** maximum after the \$500 deductible is met,
if out-of-pocket expenses for inpatient or outpatient mental conditions
and outpatient substance abuse treatment total \$8,000 for all family
members combined in that calendar year.

> Out-of-pocket expenses for purposes of this benefit are:

-   \$500 deductible for Inpatient Hospital and Intensive Day Treatment
    under the Mental Conditions/Substance Abuse Benefit;

-   The **50%** you pay for inpatient hospital and intensive day
    treatment expenses;

-   The **50%** you pay for inpatient visits;

-   The **50%** you pay for outpatient care.

> The following cannot be included in the accumulation of out-of-pocket
> expenses:

-   Expenses in excess of plan allowance or maximum benefit limitations;

-   Expenses for outpatient psychotherapy sessions in excess of 30
    sessions per year;

-   Expenses for inpatient care in excess of 100 days per year;

-   Expenses for inpatient provider visits in excess of 100 visits per
    year;

-   Expenses for intensive day treatment in excess of 60 days per year;

-   Any amounts you pay because benefits have been reduced for
    non-compliance with this Plan's cost containment requirements (see
    pages 13-14);

-   Expenses for prescription drugs purchased through retail or Mail
    Order Drug Program;

-   Expenses in excess of the **50%** of plan allowance for inpatient
    substance abuse charges.

**Carryover** If you changed to this Plan during open season from a plan
with a catastrophic protection benefit and the effective date of the
change was after January 1, any expenses that would have applied to that
plan's catastrophic protection benefit during the prior year will be
covered by your old plan if they are for care you got in January
**before** the effective date of your coverage in this Plan. If you
already met the covered out-of -pocket maximum expense level in full,
your old plan's catastrophic protection benefit will continue to apply
until the effective date. If you have not met this expense level in
full, your old plan will first apply your covered out-of-pocket expenses
until the prior year's catastrophic level is reached and then apply the
catastrophic protection benefit to covered out-of-pocket expenses
incurred from that point until the effective date. The old plan will pay
these covered expenses according to this year's benefits; benefit
changes are effective on January 1.

**When Government facilities** Facilities of the Department of Veterans
Affairs, the Department of

**bill us** Defense, and the Indian Health Service are entitled to seek

reimbursement from us for certain services and supplies they provide to
you or a family member. They may not seek more than their governing laws
allow.

**If we overpay you** We will make diligent efforts to recover benefit
payments we made in

error but in good faith. We may reduce subsequent benefit payments to
offset overpayments.

**When you are age 65 or over and you do not have Medicare**

Under the FEHB law, we must limit our payments for **inpatient hospital
care** and **physician care** to those benefits you would be entitled to
if you had Medicare. And, your physician and hospital must follow
Medicare rules and cannot bill you for more than they could bill you if
you had Medicare. You and the FEHB benefit from these payment limits.
Outpatient hospital care is not covered by this law; regular Plan
benefits apply. The following chart has more information about the
limits.

+-----------------------------------------------------------------------+
| **If you...**                                                         |
|                                                                       |
| -   are age 65 or over, and                                           |
|                                                                       |
| -   do not have Medicare Part A, Part B, or both; and                 |
|                                                                       |
| -   have this Plan as an annuitant or as a former spouse, **or** as a |
|     family member of an annuitant or former spouse; and               |
|                                                                       |
| -   are not employed in a position that gives FEHB coverage. (Your    |
|     employing office can tell you if this applies.)                   |
+-----------------------------------------------------------------------+
| **Then, for your inpatient hospital care,**                           |
|                                                                       |
| -   the law requires us to base our payment on an amount \-- the      |
|     \"equivalent Medicare amount\" \-- set by Medicare's rules for    |
|     what Medicare would pay, not on the actual charge;                |
|                                                                       |
| -   you are responsible for your applicable deductibles, coinsurance, |
|     or copayments you owe under this Plan;                            |
|                                                                       |
| -   you are not responsible for any charges greater than the          |
|     equivalent Medicare amount; we will show that amount on the       |
|     explanation of benefits (EOB) form that we send you; and          |
|                                                                       |
| -   the law prohibits a hospital from collecting more than the        |
|     Medicare equivalent amount.                                       |
|                                                                       |
| > When inpatient claims are paid according to a Diagnostic Related    |
| > Group (DRG) limit (for instance, for admissions of certain retirees |
| > who do not have Medicare), we will pay 30% of the total covered     |
| > amount as room and board charges and 70% as other charges and will  |
| > apply your coinsurance accordingly.                                 |
+-----------------------------------------------------------------------+
| **And, for your physician care,** the law requires us to base our     |
| payment and your coinsurance on...                                    |
|                                                                       |
| -   an amount set by Medicare and called the \"Medicare approved      |
|     amount,\" or                                                      |
|                                                                       |
| -   the actual charge if it is lower than the Medicare approved       |
|     amount.                                                           |
+-----------------------------------------------------------------------+

+-------+-------------------------+----------------------------+-------+
|       | ###                     | **Then you are responsible |       |
|       | ## If your physician... | for...**                   |       |
+-------+-------------------------+----------------------------+-------+
|       | Participates with       | your deductibles,          |       |
|       | Medicare or accepts     | coinsurance, and           |       |
|       | Medicare assignment for | copayments;                |       |
|       | the claim and is a      |                            |       |
|       | member of our PPO       |                            |       |
|       | network,                |                            |       |
+-------+-------------------------+----------------------------+-------+
|       | Participates with       | your deductibles,          |       |
|       | Medicare and is **not** | coinsurance, copayments,   |       |
|       | in our PPO network,     | and any balance up to the  |       |
|       |                         | Medicare approved amount;  |       |
+-------+-------------------------+----------------------------+-------+
|       | Does not participate    | your deductibles,          |       |
|       | with Medicare,          | coinsurance, copayments,   |       |
|       |                         | and any balance up to 115% |       |
|       |                         | of the Medicare approved   |       |
|       |                         | amount                     |       |
+-------+-------------------------+----------------------------+-------+

+-----------------------------------------------------------------------+
| It is generally to your financial advantage to use a physician who    |
| participates with Medicare. Such physicians are permitted to collect  |
| only up to the Medicare approved amount.                              |
|                                                                       |
| Our explanation of benefits (EOB) form will tell you how much the     |
| physician or hospital can collect from you. If your physician or      |
| hospital tries to collect more than allowed by law, ask the physician |
| or hospital to reduce the charges. If you have paid more than         |
| allowed, ask for a refund. If you need further assistance, call us.   |
+-----------------------------------------------------------------------+

**When you have the** We limit our payment to an amount that supplements
the benefits that

**Original Medicare Plan** Medicare would pay under Medicare Part A
(Hospital insurance) and **(Part A, Part B, or both)** Medicare Part B
(Medical insurance), regardless of whether Medicare

pays. Note: We pay our regular benefits for emergency services to an
institutional provider, such as a hospital, that does not participate
with Medicare and is not reimbursed by Medicare.

> If you are covered by Medicare Part B and it is primary, your
> out-of-pocket costs for services that both Medicare Part B and we
> cover depend on whether your physician accepts Medicare assignment for
> the claim.

-   If your physician **accepts** Medicare assignment, then we waive
    some of your deductibles, copayment and coinsurance for covered
    charges.

-   If your physician **does not accept** Medicare assignment, then you
    pay the difference between the "limiting charge" or the physician's
    charge (whichever is less) and our payment combined with Medicare's
    payment.

> It's important to know that a physician who does not accept Medicare
> assignment may not bill you for more than 115% of the amount Medicare
> bases its payment on, called the "limiting charge." The Medicare
> Summary Notice (MSN) that Medicare will send you will have more
> information about the limiting charge. If your physician tries to
> collect more than allowed by law, ask the physician to reduce the
> charges. If the physician does not, report the physician to your
> Medicare carrier who sent you the MSN form. Call us if you need
> further assistance.

**Should I enroll in** The decision to enroll in Medicare is yours. We
encourage you to apply for

**Medicare?** 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**. Medicare Part A covers hospital
> stays, skilled nursing facility care and other expenses. 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.
>
> Medicare Part B covers doctors' services and outpatient hospital care.
> 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.

**Please see Section 9, Coordinating benefits with other coverage, for
more information about how we coordinate benefits with Medicare**.

+-----------------------------------------------------------------------+
| ####### Section 5. Benefits -- OVERVIEW                               |
|                                                                       |
| ***(See pages 9 and 10 for how our benefits changed this year and     |
| pages 101 and 102 for a benefits summary.)***                         |
+-----------------------------------------------------------------------+

**Note**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
(800) 821-6136 or at our Web site at [[www.geha.com]{.underline}]()

(a) Medical services and supplies provided by physicians and other
    health care professionals 23-36

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 37-45

+-----------------------+----------------------+----------------------+
| -   Surgical          | -   Oral and         | -   Anesthesia       |
|     procedures        |     maxillofacial    |                      |
|                       |     surgery          |                      |
| ```{=html}            |                      |                      |
| <!-- -->              | ```{=html}           |                      |
| ```                   | <!-- -->             |                      |
| -   Reconstructive    | ```                  |                      |
|     surgery           | -   Organ/tissue     |                      |
|                       |     transplants      |                      |
+-----------------------+----------------------+----------------------+

(c) Services provided by a hospital or other facility, and ambulance
    services 46-52

+-----------------------+----------------------+----------------------+
| -   Inpatient         | -   Extended care    | -   Hospice care     |
|     hospital          |     benefits/Skilled |                      |
|                       |     nursing care     | -   Ambulance        |
| ```{=html}            |     facility         |                      |
| <!-- -->              |     benefits         |                      |
| ```                   |                      |                      |
| -   Outpatient        |                      |                      |
|     hospital or       |                      |                      |
|     ambulatory        |                      |                      |
|     surgical center   |                      |                      |
+-----------------------+----------------------+----------------------+

(d) Emergency services/Accidents 53-55

+-----------------------+----------------------+----------------------+
| -   Accidental injury | -   Medical          | -   Ambulance        |
|                       |     emergency        |                      |
+-----------------------+----------------------+----------------------+

(e) Mental health and substance abuse benefits 56-60

(f) Prescription drug benefits 61-67

(g) Special features 68

-   Flexible benefits option • Services for deaf and hearing impaired •
    High risk pregnancies

(h) Dental benefits 69-70

(i) Non-FEHB benefits available to Plan members 71-72

*SUMMARY OF BENEFITS 101-102*

+---+---+-----------------------------------+---+--------------+--------+---+---+
| # |   |                                   |   |              |        |   |   |
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| t |   |                                   |   |              |        |   |   |
| h |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
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| a |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
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|   |   |                                   |   |              |        |   |   |
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| r |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| f |   |                                   |   |              |        |   |   |
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| s |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
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| s |   |                                   |   |              |        |   |   |
+---+---+-----------------------------------+---+--------------+--------+---+---+
|   | # | **Here are some important things  |   |              |        | # |   |
|   | # | you should keep in mind about     |   |              |        | # |   |
|   | # | these benefits:**                 |   |              |        | # |   |
|   | # |                                   |   |              |        | # |   |
|   | # | -   Please remember that all      |   |              |        | # |   |
|   | # |     benefits are subject to the   |   |              |        | # |   |
|   |   |     definitions, limitations, and |   |              |        |   |   |
|   | I |     exclusions in this brochure   |   |              |        | I |   |
|   |   |     and are payable only when we  |   |              |        |   |   |
|   | * |     determine they are medically  |   |              |        | * |   |
|   | * |     necessary.                    |   |              |        | * |   |
|   | M |                                   |   |              |        | M |   |
|   | * | ```{=html}                        |   |              |        | * |   |
|   | * | <!-- -->                          |   |              |        | * |   |
|   |   | ```                               |   |              |        |   |   |
|   | * | -   The calendar year deductible  |   |              |        | * |   |
|   | * |     is \$350 per person (\$700    |   |              |        | * |   |
|   | P |     per family) under the High    |   |              |        | P |   |
|   | * |     Option and \$450 per person   |   |              |        | * |   |
|   | * |     (\$900 per family) under the  |   |              |        | * |   |
|   |   |     Standard Option. The calendar |   |              |        |   |   |
|   | * |     year deductible applies to    |   |              |        | * |   |
|   | * |     almost all benefits in this   |   |              |        | * |   |
|   | O |     Section. We added "(No        |   |              |        | O |   |
|   | * |     deductible)" to show when the |   |              |        | * |   |
|   | * |     calendar year deductible does |   |              |        | * |   |
|   |   |     not apply.                    |   |              |        |   |   |
|   | * |                                   |   |              |        | * |   |
|   | * | ```{=html}                        |   |              |        | * |   |
|   | R | <!-- -->                          |   |              |        | R |   |
|   | * | ```                               |   |              |        | * |   |
|   | * | -   The non-PPO benefits are the  |   |              |        | * |   |
|   |   |     standard benefits of this     |   |              |        |   |   |
|   | * |     Plan. PPO benefits apply only |   |              |        | * |   |
|   | * |     when you use a PPO provider.  |   |              |        | * |   |
|   | T |     When no PPO provider is       |   |              |        | T |   |
|   | * |     available, non-PPO benefits   |   |              |        | * |   |
|   | * |     apply.                        |   |              |        | * |   |
|   |   |                                   |   |              |        |   |   |
|   | * | -   Be sure to read Section 4,    |   |              |        | * |   |
|   | * |     *Your costs for covered       |   |              |        | * |   |
|   | A |     services,* for valuable       |   |              |        | A |   |
|   | * |     information about how cost    |   |              |        | * |   |
|   | * |     sharing works, with special   |   |              |        | * |   |
|   |   |     sections for members who are  |   |              |        |   |   |
|   | * |     age 65 or over. Also read     |   |              |        | * |   |
|   | * |     Section 9 about coordinating  |   |              |        | * |   |
|   | N |     benefits with other coverage, |   |              |        | N |   |
|   | * |     including with Medicare.      |   |              |        | * |   |
|   | * |                                   |   |              |        | * |   |
|   |   | -   When you use a PPO hospital   |   |              |        |   |   |
|   | * |     the professionals who provide |   |              |        | * |   |
|   | * |     services to you in a hospital |   |              |        | * |   |
|   | T |     may not all be preferred      |   |              |        | T |   |
|   | * |     providers. If they are not,   |   |              |        | * |   |
|   | * |     they will be paid by this     |   |              |        | * |   |
|   |   |     plan as non-PPO providers.    |   |              |        |   |   |
|   |   |     However, if the services are  |   |              |        |   |   |
|   |   |     rendered at a PPO hospital,   |   |              |        |   |   |
|   |   |     we will pay the services of   |   |              |        |   |   |
|   |   |     radiologists,                 |   |              |        |   |   |
|   |   |     anesthesiologists and         |   |              |        |   |   |
|   |   |     pathologists who are not      |   |              |        |   |   |
|   |   |     preferred providers at the    |   |              |        |   |   |
|   |   |     preferred provider rate. This |   |              |        |   |   |
|   |   |     non-standard benefit does not |   |              |        |   |   |
|   |   |     include the services of       |   |              |        |   |   |
|   |   |     emergency room physicians.    |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   | -   **YOU MUST GET                |   |              |        |   |   |
|   |   |     PRECERTIFICATION OF CERTAIN   |   |              |        |   |   |
|   |   |     OUTPATIENT IMAGING            |   |              |        |   |   |
|   |   |     PROCEDURES. FAILURE TO DO SO  |   |              |        |   |   |
|   |   |     WILL RESULT IN A MINIMUM OF   |   |              |        |   |   |
|   |   |     \$100 PENALTY.** Please refer |   |              |        |   |   |
|   |   |     to precertification           |   |              |        |   |   |
|   |   |     information in Section 3 to   |   |              |        |   |   |
|   |   |     be sure which procedures      |   |              |        |   |   |
|   |   |     require precertification.     |   |              |        |   |   |
+---+---+-----------------------------------+---+--------------+--------+---+---+
| * |   |                                   | # |              |        |   |   |
| * |   |                                   | # |              |        |   |   |
| B |   |                                   | # |              |        |   |   |
| e |   |                                   | # |              |        |   |   |
| n |   |                                   | # |              |        |   |   |
| e |   |                                   | # |              |        |   |   |
| f |   |                                   | # |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
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| D |   |                                   | o |              |        |   |   |
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|   |   |                                   | . |              |        |   |   |
|   |   |                                   | . |              |        |   |   |
|   |   |                                   | . |              |        |   |   |
+---+---+-----------------------------------+---+--------------+--------+---+---+
| # |   |                                   |   |              |        |   |   |
| # |   |                                   |   |              |        |   |   |
| # |   |                                   |   |              |        |   |   |
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| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| b |   |                                   |   |              |        |   |   |
| y |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| h |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| p |   |                                   |   |              |        |   |   |
| h |   |                                   |   |              |        |   |   |
| y |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| . |   |                                   |   |              |        |   |   |
+---+---+-----------------------------------+---+--------------+--------+---+---+
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| * |   |                                   |   |              |        |   |   |
| D |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| g |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| d |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| m |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| v |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| - |   |                                   |   |              |        |   |   |
| - |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| u |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| d |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| x |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| p |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| g |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| * |   |                                   |   |              |        |   |   |
+---+---+-----------------------------------+---+--------------+--------+---+---+
|   |   |                                   |   |              |        |   |   |
+---+---+-----------------------------------+---+--------------+--------+---+---+
| # |   |                                   |   | > **You      |        |   |   |
| # |   |                                   |   | > pay**      |        |   |   |
| # |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| D |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| g |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| d |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| m |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| v |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| * |   |                                   |   |              |        |   |   |
| ( |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| u |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| d |   |                                   |   |              |        |   |   |
| ) |   |                                   |   |              |        |   |   |
| * |   |                                   |   |              |        |   |   |
+---+---+-----------------------------------+---+--------------+--------+---+---+
|   |   |                                   |   | > **Standard | >      |   |   |
|   |   |                                   |   | > Option**   | **High |   |   |
|   |   |                                   |   |              | > Op   |   |   |
|   |   |                                   |   |              | tion** |   |   |
+---+---+-----------------------------------+---+--------------+--------+---+---+
| > |   |                                   |   | PPO: 15% of  | PPO:   |   |   |
|   |   |                                   |   | the Plan     | 10% of |   |   |
| P |   |                                   |   | allowance    | the    |   |   |
| r |   |                                   |   |              | Plan   |   |   |
| o |   |                                   |   | Non-PPO: 35% | all    |   |   |
| f |   |                                   |   | of the Plan  | owance |   |   |
| e |   |                                   |   | allowance    |        |   |   |
| s |   |                                   |   | and any      | No     |   |   |
| s |   |                                   |   | difference   | n-PPO: |   |   |
| i |   |                                   |   | between our  | 25% of |   |   |
| o |   |                                   |   | allowance    | the    |   |   |
| n |   |                                   |   | and the      | Plan   |   |   |
| a |   |                                   |   | billed       | all    |   |   |
| l |   |                                   |   | amount       | owance |   |   |
| > |   |                                   |   |              | and    |   |   |
|   |   |                                   |   |              | any    |   |   |
| s |   |                                   |   |              | diff   |   |   |
| e |   |                                   |   |              | erence |   |   |
| r |   |                                   |   |              | b      |   |   |
| v |   |                                   |   |              | etween |   |   |
| i |   |                                   |   |              | our    |   |   |
| c |   |                                   |   |              | all    |   |   |
| e |   |                                   |   |              | owance |   |   |
| s |   |                                   |   |              | and    |   |   |
| > |   |                                   |   |              | the    |   |   |
|   |   |                                   |   |              | billed |   |   |
| o |   |                                   |   |              | amount |   |   |
| f |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| p |   |                                   |   |              |        |   |   |
| h |   |                                   |   |              |        |   |   |
| y |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| - |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| E |   |                                   |   |              |        |   |   |
| m |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| g |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| y |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| m |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| p |   |                                   |   |              |        |   |   |
| h |   |                                   |   |              |        |   |   |
| y |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| ( |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| - |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| d |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| l |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| j |   |                                   |   |              |        |   |   |
| u |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| y |   |                                   |   |              |        |   |   |
| ) |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| ` |   |                                   |   |              |        |   |   |
| ` |   |                                   |   |              |        |   |   |
| ` |   |                                   |   |              |        |   |   |
| { |   |                                   |   |              |        |   |   |
| = |   |                                   |   |              |        |   |   |
| h |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| m |   |                                   |   |              |        |   |   |
| l |   |                                   |   |              |        |   |   |
| } |   |                                   |   |              |        |   |   |
| < |   |                                   |   |              |        |   |   |
| ! |   |                                   |   |              |        |   |   |
| - |   |                                   |   |              |        |   |   |
| - |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
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| - |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
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| r |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
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| g |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
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|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| h |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| p |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| l |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| y |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| - |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| A |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| h |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| m |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
+---+---+-----------------------------------+---+--------------+--------+---+---+
| > |   |                                   |   | *All         | *All   |   |   |
|   |   |                                   |   | charges*     | ch     |   |   |
| * |   |                                   |   |              | arges* |   |   |
| N |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| > |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| v |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| d |   |                                   |   |              |        |   |   |
| : |   |                                   |   |              |        |   |   |
| * |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| - |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| * |   |                                   |   |              |        |   |   |
| U |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| g |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| f |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| l |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| x |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| p |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| f |   |                                   |   |              |        |   |   |
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+---+---+-----------------------------------+---+--------------+--------+---+---+
| # |   |                                   |   | ###          | ###    |   |   |
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| # |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
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| - |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| y |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
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| d |   |                                   |   |              |        |   |   |
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| t |   |                                   |   |              |        |   |   |
| h |   |                                   |   |              |        |   |   |
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|   |   |                                   |   |              |        |   |   |
| d |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
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| n |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| s |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
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| s |   |                                   |   |              |        |   |   |
+---+---+-----------------------------------+---+--------------+--------+---+---+
| > |   |                                   |   | PPO: 15% of  | PPO:   |   |   |
|   |   |                                   |   | the Plan     | 10% of |   |   |
| T |   |                                   |   | allowance    | the    |   |   |
| e |   |                                   |   |              | Plan   |   |   |
| s |   |                                   |   | Non-PPO: 35% | all    |   |   |
| t |   |                                   |   | of the Plan  | owance |   |   |
| s |   |                                   |   | allowance    |        |   |   |
| , |   |                                   |   | and any      | No     |   |   |
| > |   |                                   |   | difference   | n-PPO: |   |   |
|   |   |                                   |   | between our  | 25% of |   |   |
| s |   |                                   |   | allowance    | the    |   |   |
| u |   |                                   |   | and the      | Plan   |   |   |
| c |   |                                   |   | billed       | all    |   |   |
| h |   |                                   |   | amount       | owance |   |   |
| > |   |                                   |   |              | and    |   |   |
|   |   |                                   |   | Note: If     | any    |   |   |
| a |   |                                   |   | your PPO     | diff   |   |   |
| s |   |                                   |   | provider     | erence |   |   |
| : |   |                                   |   | uses a       | b      |   |   |
|   |   |                                   |   | non-PPO lab  | etween |   |   |
| - |   |                                   |   | or           | our    |   |   |
|   |   |                                   |   | radiologist, | all    |   |   |
|   |   |                                   |   | we will pay  | owance |   |   |
|   |   |                                   |   | non-PPO      | and    |   |   |
| B |   |                                   |   | benefits for | the    |   |   |
| l |   |                                   |   | any lab and  | billed |   |   |
| o |   |                                   |   | X-ray        | amount |   |   |
| o |   |                                   |   | charges.     |        |   |   |
| d |   |                                   |   |              | Note:  |   |   |
|   |   |                                   |   |              | If     |   |   |
|   |   |                                   |   |              | your   |   |   |
|   |   |                                   |   |              | PPO    |   |   |
|   |   |                                   |   |              | pr     |   |   |
| t |   |                                   |   |              | ovider |   |   |
| e |   |                                   |   |              | uses a |   |   |
| s |   |                                   |   |              | n      |   |   |
| t |   |                                   |   |              | on-PPO |   |   |
| s |   |                                   |   |              | lab or |   |   |
|   |   |                                   |   |              | radiol |   |   |
| - |   |                                   |   |              | ogist, |   |   |
|   |   |                                   |   |              | we     |   |   |
|   |   |                                   |   |              | will   |   |   |
|   |   |                                   |   |              | pay    |   |   |
| U |   |                                   |   |              | n      |   |   |
| r |   |                                   |   |              | on-PPO |   |   |
| i |   |                                   |   |              | be     |   |   |
| n |   |                                   |   |              | nefits |   |   |
| a |   |                                   |   |              | for    |   |   |
| l |   |                                   |   |              | any    |   |   |
| y |   |                                   |   |              | lab    |   |   |
| s |   |                                   |   |              | and    |   |   |
| i |   |                                   |   |              | X-ray  |   |   |
| s |   |                                   |   |              | ch     |   |   |
|   |   |                                   |   |              | arges. |   |   |
| - |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| N |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| - |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| u |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
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|   |   |                                   |   |              |        |   |   |
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| u |   |                                   |   |              |        |   |   |
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| d |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| - |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| E |   |                                   |   |              |        |   |   |
| l |   |                                   |   |              |        |   |   |
| e |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| t |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| c |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| d |   |                                   |   |              |        |   |   |
| i |   |                                   |   |              |        |   |   |
| o |   |                                   |   |              |        |   |   |
| g |   |                                   |   |              |        |   |   |
| r |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| m |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| a |   |                                   |   |              |        |   |   |
| n |   |                                   |   |              |        |   |   |
| d |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
|   |   |                                   |   |              |        |   |   |
| E |   |                                   |   |              |        |   |   |
| E |   |                                   |   |              |        |   |   |
| G |   |                                   |   |              |        |   |   |
+---+---+-----------------------------------+---+--------------+--------+---+---+

+----------------------------------------+--------------+-------------+
| ### Preventive care, adult             | > **You      |             |
|                                        | > Pay**      |             |
+----------------------------------------+--------------+-------------+
|                                        | > **Standard | > **High    |
|                                        | > Option**   | > Option**  |
+----------------------------------------+--------------+-------------+
| > Routine screenings, limited to:      | PPO: 15% of  | PPO: 10% of |
|                                        | the Plan     | the Plan    |
| -   Total Blood Cholesterol screenings | allowance    | allowance   |
|                                        |              |             |
| -   Chlamydial infection               | Non-PPO: 35% | Non-PPO:    |
|                                        | of the Plan  | 25% of the  |
| -   Colorectal cancer screening,       | allowance    | Plan        |
|     including                          | and any      | allowance   |
|                                        | difference   | and any     |
| ```{=html}                             | between our  | difference  |
| <!-- -->                               | allowance    | between our |
| ```                                    | and the      | allowance   |
| -   Annual coverage of one fecal       | billed       | and the     |
|     occult blood test for members age  | amount       | billed      |
|     40 and older                       |              | amount      |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Sigmoidoscopy                      |              |             |
|                                        |              |             |
| -   Colonoscopy                        |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Prostate cancer screening          |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Annual coverage of one PSA         |              |             |
|     (Prostate Specific Antigen) test   |              |             |
|     for men age 40 and older           |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Routine pap test                   |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Annual coverage of one pap smear   |              |             |
|     for women age 18 and older         |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Routine mammogram                  |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Mammograms for diagnostic and/or   |              |             |
|     routine screening                  |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Routine immunizations              |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Tetanus-diphtheria (Td) booster    |              |             |
|                                        |              |             |
| -   Influenza/Pneumococcal vaccines    |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Osteoporosis screening             |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Bone density tests for routine     |              |             |
|     screening for women 65 or older or |              |             |
|     women 60 or older who are at       |              |             |
|     increased risk                     |              |             |
+----------------------------------------+--------------+-------------+
| ### Preventive care, children          | ###          | ###         |
+----------------------------------------+--------------+-------------+
| > For dependent children under age 22: | PPO: Nothing | PPO:        |
|                                        | (No          | Nothing (No |
| -   Childhood immunizations            | deductible)  | deductible) |
|     recommended by the American        |              |             |
|     Academy of Pediatrics              | Non-PPO:     | Non-PPO:    |
|                                        | Nothing,     | Nothing,    |
| -   For well-child care charges for    | except any   | except any  |
|     routine examinations,              | difference   | difference  |
|     immunizations and care             | between our  | between our |
|                                        | Plan         | Plan        |
| -   Initial examination of a newborn   | allowance    | allowance   |
|     child covered under a family       | and the      | and the     |
|     enrollment                         | billed       | billed      |
|                                        | amount. (No  | amount. (No |
|                                        | deductible)  | deductible) |
+----------------------------------------+--------------+-------------+
| *Preventive care, children --          |              |             |
| continued next page*                   |              |             |
+----------------------------------------+--------------+-------------+

+----------------------------------------+--------------+-------------+
| ### P                                  | **You Pay**  |             |
| reventive care, children *(continued)* |              |             |
+----------------------------------------+--------------+-------------+
|                                        | ### Sta      | ###         |
|                                        | ndard Option | High Option |
+----------------------------------------+--------------+-------------+
| -   Vision examinations, limited to:   | PPO: \$10    | PPO: \$20   |
|                                        | copayment    | copayment   |
| ```{=html}                             | for office   | (No         |
| <!-- -->                               | visits to    | deductible) |
| ```                                    | primary care |             |
| -   Examinations for amblyopia and     | physicians;  | Non-PPO:    |
|     strabismus                         | \$25         | 25% of the  |
|                                        | copayment    | Plan        |
|                                        | for office   | allowance   |
|                                        | visits to    | and any     |
|                                        | specialists  | difference  |
|                                        | (No          | between our |
|                                        | deductible)  | allowance   |
|                                        |              | and the     |
|                                        | Non-PPO: 35% | billed      |
|                                        | of the Plan  | amount      |
|                                        | allowance    |             |
|                                        | and any      |             |
|                                        | difference   |             |
|                                        | between our  |             |
|                                        | allowance    |             |
|                                        | and the      |             |
|                                        | billed       |             |
|                                        | amount       |             |
+----------------------------------------+--------------+-------------+
| > **Maternity Care**                   |              |             |
+----------------------------------------+--------------+-------------+
| > Complete maternity (obstetrical)     | PPO: Nothing | PPO:        |
| > care, such as:                       | (No          | Nothing (No |
|                                        | deductible)  | deductible) |
| -   Prenatal care                      |              |             |
|                                        | Non-PPO: 35% | Non-PPO:    |
| -   Delivery                           | of the Plan  | 25% of the  |
|                                        | allowance    | Plan        |
| -   Postnatal care                     | and any      | allowance   |
|                                        | difference   | and any     |
| -   Physician care such as sonograms   | between our  | difference  |
|                                        | allowance    | between our |
| > Note: Here are some things to keep   | and the      | allowance   |
| > in mind:                             | billed       | and the     |
|                                        | amount       | billed      |
| -   You do not need to precertify your |              | amount      |
|     normal delivery, see page 14 for   |              |             |
|     other circumstances, such as       |              |             |
|     extended stays for you or your     |              |             |
|     baby.                              |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   You may remain in the hospital up  |              |             |
|     to 48 hours after a regular        |              |             |
|     delivery and 96 hours after a      |              |             |
|     cesarean delivery. We will cover   |              |             |
|     an extended stay if medically      |              |             |
|     necessary, but you, your           |              |             |
|     representative, your doctor, or    |              |             |
|     your hospital must precertify.     |              |             |
|                                        |              |             |
| -   We cover routine nursery care of   |              |             |
|     the newborn child during the       |              |             |
|     covered portion of the mother\'s   |              |             |
|     maternity stay.                    |              |             |
|                                        |              |             |
| -   We will cover other care of an     |              |             |
|     infant who requires non-routine    |              |             |
|     treatment if we cover the infant   |              |             |
|     under a Self and Family            |              |             |
|     enrollment. See Hospital benefits  |              |             |
|     (Section 5 (c)) and Surgery        |              |             |
|     benefits (Section 5 (b))           |              |             |
|                                        |              |             |
| -   Circumcision is covered under      |              |             |
|     Surgery benefits. (Section 5 (b))  |              |             |
+----------------------------------------+--------------+-------------+
| *Maternity Care - continued next page* |              |             |
+----------------------------------------+--------------+-------------+
|                                        |              |             |
+----------------------------------------+--------------+-------------+

+----------------------------------------+--------------+-------------+
|                                        |              |             |
+----------------------------------------+--------------+-------------+
| > **Maternity Care** *(continued)*     | > **You      |             |
|                                        | > Pay**      |             |
+----------------------------------------+--------------+-------------+
|                                        | > **Standard | > **High    |
|                                        | > Option**   | > Option**  |
+----------------------------------------+--------------+-------------+
| > Approved fetal monitors are covered  | PPO: 15% of  | PPO: 10% of |
| > the same as other medical benefits   | the Plan     | the Plan    |
| > for diagnostic and treatment         | allowance    | allowance   |
| > services                             |              |             |
|                                        | Non-PPO: 35% | Non-PPO:    |
|                                        | of the Plan  | 25% of the  |
|                                        | allowance    | Plan        |
|                                        | and any      | allowance   |
|                                        | difference   | and any     |
|                                        | between our  | difference  |
|                                        | allowance    | between our |
|                                        | and the      | allowance   |
|                                        | billed       | and the     |
|                                        | amount       | billed      |
|                                        |              | amount      |
+----------------------------------------+--------------+-------------+
| > *Not covered:*                       | *All         | *All        |
|                                        | charges*     | charges*    |
| -   *Home uterine monitoring devices,  |              |             |
|     unless preauthorized by our        |              |             |
|     Medical Director.*                 |              |             |
|                                        |              |             |
| -   *Charges 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 rape or |              |             |
|     incest.*                           |              |             |
|                                        |              |             |
| -   *Charges for services and supplies |              |             |
|     incurred after termination of      |              |             |
|     coverage.*                         |              |             |
+----------------------------------------+--------------+-------------+
| > **Family planning**                  |              |             |
+----------------------------------------+--------------+-------------+
| > A range of voluntary family planning | PPO: 15% of  | PPO: 10% of |
| > services, limited to:                | the Plan     | the Plan    |
|                                        | allowance    | allowance   |
| -   Voluntary sterilization (See       |              |             |
|     Surgical procedures Section 5 (b)) | Non-PPO: 35% | Non-PPO:    |
|                                        | of the Plan  | 25% of the  |
| -   Surgically implanted               | allowance    | Plan        |
|     contraceptives                     | and any      | allowance   |
|                                        | difference   | and any     |
| -   Injectable contraceptive drugs     | between our  | difference  |
|     (such as Depo provera)             | allowance    | between our |
|                                        | and the      | allowance   |
| -   Intrauterine devices (IUDs)        | billed       | and the     |
|                                        | amount       | billed      |
| -   Diaphragms                         |              | amount      |
|                                        |              |             |
| > Note: We cover oral contraceptives   |              |             |
| > under the prescription drug benefit. |              |             |
+----------------------------------------+--------------+-------------+
| > *Not covered:*                       | *All         | *All        |
|                                        | charges*     | charges*    |
| -   *Reversal of voluntary surgical    |              |             |
|     sterilization*                     |              |             |
|                                        |              |             |
| -   *Genetic counseling*               |              |             |
+----------------------------------------+--------------+-------------+

+----------------------------------------+--------------+---+---+------------+---+
| > **Infertility services**             | **You Pay**  |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
|                                        | **Standard   | * |   |            |   |
|                                        | Option**     | * |   |            |   |
|                                        |              | H |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | g |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | O |   |            |   |
|                                        |              | p |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | * |   |            |   |
|                                        |              | * |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > Diagnosis and treatment of           | PPO: 15% of  | P |   |            |   |
| > infertility, except as shown in *Not | the Plan     | P |   |            |   |
| > covered*.                            | allowance    | O |   |            |   |
| >                                      |              | : |   |            |   |
| > Note: Benefits are limited to a      | > Non-PPO:   | 1 |   |            |   |
| > maximum of \$3,000 per calendar year | > 35% of the | 0 |   |            |   |
| > per person.                          | > Plan       | % |   |            |   |
|                                        | > allowance  | o |   |            |   |
|                                        | > and any    | f |   |            |   |
|                                        | > difference | t |   |            |   |
|                                        | > between    | h |   |            |   |
|                                        | > our        | e |   |            |   |
|                                        | > allowance  | P |   |            |   |
|                                        | > and the    | l |   |            |   |
|                                        | > billed     | a |   |            |   |
|                                        | > amount     | n |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              |   |   |            |   |
|                                        |              | N |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | - |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | O |   |            |   |
|                                        |              | : |   |            |   |
|                                        |              | 2 |   |            |   |
|                                        |              | 5 |   |            |   |
|                                        |              | % |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | y |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | m |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | t |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > *Not covered:*                       | *All         | * |   |            |   |
|                                        | charges*     | A |   |            |   |
| -   *Infertility services after        |              | l |   |            |   |
|     voluntary sterilization*           |              | l |   |            |   |
|                                        |              | c |   |            |   |
| -   *Fertility drugs*                  |              | h |   |            |   |
|                                        |              | a |   |            |   |
| ```{=html}                             |              | r |   |            |   |
| <!-- -->                               |              | g |   |            |   |
| ```                                    |              | e |   |            |   |
| -   *Assisted reproductive technology  |              | s |   |            |   |
|     (ART) procedures, such as:*        |              | * |   |            |   |
|                                        |              |   |   |            |   |
| ```{=html}                             |              |   |   |            |   |
| <!-- -->                               |              |   |   |            |   |
| ```                                    |              |   |   |            |   |
| -   *Artificial insemination*          |              |   |   |            |   |
|                                        |              |   |   |            |   |
| -   *In vitro fertilization*           |              |   |   |            |   |
|                                        |              |   |   |            |   |
| -   *Embryo transfer and gamete        |              |   |   |            |   |
|     intrafallopian transfer (GIFT)*    |              |   |   |            |   |
|                                        |              |   |   |            |   |
| -   *Intravaginal insemination (IVI)*  |              |   |   |            |   |
|                                        |              |   |   |            |   |
| -   *Intracervical insemination (ICI)* |              |   |   |            |   |
|                                        |              |   |   |            |   |
| -   *Intrauterine insemination (IUI)*  |              |   |   |            |   |
|                                        |              |   |   |            |   |
| ```{=html}                             |              |   |   |            |   |
| <!-- -->                               |              |   |   |            |   |
| ```                                    |              |   |   |            |   |
| -   *Services and supplies related to  |              |   |   |            |   |
|     ART procedures*                    |              |   |   |            |   |
|                                        |              |   |   |            |   |
| -   *Cost of donor sperm*              |              |   |   |            |   |
|                                        |              |   |   |            |   |
| -   *Cost of donor egg*                |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > **Allergy care**                     |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > Testing and treatment, including     | PPO: 15% of  | P |   |            |   |
| > materials (such as allergy serum)    | the Plan     | P |   |            |   |
| >                                      | allowance    | O |   |            |   |
| > Allergy testing is limited to \$500  |              | : |   |            |   |
| > per person per calendar year         | Non-PPO: 35% | 1 |   |            |   |
| >                                      | of the Plan  | 0 |   |            |   |
| > Allergy injections                   | allowance    | % |   |            |   |
|                                        | and any      | o |   |            |   |
|                                        | difference   | f |   |            |   |
|                                        | between our  | t |   |            |   |
|                                        | allowance    | h |   |            |   |
|                                        | and the      | e |   |            |   |
|                                        | billed       | P |   |            |   |
|                                        | amount       | l |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              |   |   |            |   |
|                                        |              | N |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | - |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | O |   |            |   |
|                                        |              | : |   |            |   |
|                                        |              | 2 |   |            |   |
|                                        |              | 5 |   |            |   |
|                                        |              | % |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | y |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | m |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | t |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > *Not covered:*                       | *All         | * |   |            |   |
|                                        | charges*     | A |   |            |   |
| -   *Clinical ecology and              |              | l |   |            |   |
|     environmental medicine*            |              | l |   |            |   |
|                                        |              | c |   |            |   |
| -   *Provocative food testing and      |              | h |   |            |   |
|     sublingual allergy                 |              | a |   |            |   |
|     desensitization*                   |              | r |   |            |   |
|                                        |              | g |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | s |   |            |   |
|                                        |              | * |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| ### Treatment therapies                | ### You Pay  |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
|                                        | ### Sta      | # |   |            |   |
|                                        | ndard Option | # |   |            |   |
|                                        |              | # |   |            |   |
|                                        |              |   |   |            |   |
|                                        |              | H |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | g |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              |   |   |            |   |
|                                        |              | O |   |            |   |
|                                        |              | p |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | n |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| -   Antibiotic therapy                 | PPO: 15% of  | P |   |            |   |
|                                        | the Plan     | P |   |            |   |
| -   Outpatient cardiac rehabilitation  | allowance    | O |   |            |   |
|                                        |              | : |   |            |   |
| -   Chemotherapy and radiation therapy | Non-PPO: 35% | 1 |   |            |   |
|                                        | of the Plan  | 0 |   |            |   |
| > Note: High-dose chemotherapy in      | allowance    | % |   |            |   |
| > association with autologous bone     | and any      | o |   |            |   |
| > marrow transplants is limited to     | difference   | f |   |            |   |
| > those transplants listed on page 42. | between our  | t |   |            |   |
|                                        | allowance    | h |   |            |   |
| -   Dialysis -- hemodialysis and       | and the      | e |   |            |   |
|     peritoneal dialysis                | billed       | P |   |            |   |
|                                        | amount       | l |   |            |   |
| ```{=html}                             |              | a |   |            |   |
| <!-- -->                               |              | n |   |            |   |
| ```                                    |              | a |   |            |   |
| -   Intravenous (IV)/Infusion Therapy  |              | l |   |            |   |
|                                        |              | l |   |            |   |
| -   Growth hormone therapy (GHT)       |              | o |   |            |   |
|                                        |              | w |   |            |   |
| > Note: GHT is covered under the       |              | a |   |            |   |
| > prescription drug benefit. We only   |              | n |   |            |   |
| > cover GHT when we preauthorize the   |              | c |   |            |   |
| > treatment. Call (800) 821-6136 for   |              | e |   |            |   |
| > preauthorization. We will ask you to |              |   |   |            |   |
| > submit information that establishes  |              | N |   |            |   |
| > that the GHT is medically necessary. |              | o |   |            |   |
| > Ask us to authorize GHT before you   |              | n |   |            |   |
| > begin treatment; otherwise, we will  |              | - |   |            |   |
| > only cover GHT services from the     |              | P |   |            |   |
| > date you submit the information. If  |              | P |   |            |   |
| > you do not ask or if we determine    |              | O |   |            |   |
| > GHT is not medically necessary, we   |              | : |   |            |   |
| > will not cover the GHT or related    |              | 2 |   |            |   |
| > services and supplies. See *Other*   |              | 5 |   |            |   |
| > *services* under *How to get         |              | % |   |            |   |
| > approval for...* in Section 3.       |              | o |   |            |   |
|                                        |              | f |   |            |   |
| -   Respiratory and inhalation         |              | t |   |            |   |
|     therapies                          |              | h |   |            |   |
|                                        |              | e |   |            |   |
| > Note: -- Some medications required   |              | P |   |            |   |
| > for treatment therapies may be       |              | l |   |            |   |
| > available through the Home Delivery  |              | a |   |            |   |
| > Pharmacy service or a Medco          |              | n |   |            |   |
| > Participating Pharmacy. Medications  |              | a |   |            |   |
| > obtained from these sources are      |              | l |   |            |   |
| > covered under the Prescription Drug  |              | l |   |            |   |
| > Benefits in Section 5 (f).           |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | y |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | m |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | t |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > *Not covered:*                       | ### *        | # |   |            |   |
|                                        | All charges* | # |   |            |   |
| -   *Chelating therapy except for      |              | # |   |            |   |
|     acute arsenic, gold or lead        |              |   |   |            |   |
|     poisoning*                         |              | * |   |            |   |
|                                        |              | A |   |            |   |
| -   *Maintenance cardiac               |              | l |   |            |   |
|     rehabilitation*                    |              | l |   |            |   |
|                                        |              |   |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | g |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | s |   |            |   |
|                                        |              | * |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| ###                                    | **You Pay**  |   |   |            |   |
| ## Physical and occupational therapies |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
|                                        | **Standard   | * |   |            |   |
|                                        | Option**     | * |   |            |   |
|                                        |              | H |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | g |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | O |   |            |   |
|                                        |              | p |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | * |   |            |   |
|                                        |              | * |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| -   60 visits per calendar year for    | PPO: 15% of  | P |   |            |   |
|     the combined services of the       | the Plan     | P |   |            |   |
|     following:                         | allowance    | O |   |            |   |
|                                        |              | : |   |            |   |
| ```{=html}                             | Non-PPO: 35% | 1 |   |            |   |
| <!-- -->                               | of the Plan  | 0 |   |            |   |
| ```                                    | allowance    | % |   |            |   |
| -   qualified physical therapists and  | and any      | o |   |            |   |
|                                        | difference   | f |   |            |   |
| -   qualified occupational therapists  | between our  | t |   |            |   |
|                                        | allowance    | h |   |            |   |
| > Prior to beginning physical therapy  | and the      | e |   |            |   |
| > treatments, you should contact our   | billed       | P |   |            |   |
| > Medical Management Department, (800) | amount       | l |   |            |   |
| > 821-6136, to preauthorize benefits.  |              | a |   |            |   |
| > Continuing physical therapy claims   |              | n |   |            |   |
| > will be subject to concurrent review |              | a |   |            |   |
| > for medical necessity. Physical      |              | l |   |            |   |
| > therapy claims will be denied if we  |              | l |   |            |   |
| > determine the therapy is not         |              | o |   |            |   |
| > medically necessary. Please          |              | w |   |            |   |
| > preauthorize.                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              |   |   |            |   |
|                                        |              | N |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | - |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | O |   |            |   |
|                                        |              | : |   |            |   |
|                                        |              | 2 |   |            |   |
|                                        |              | 5 |   |            |   |
|                                        |              | % |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | y |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | m |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | t |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > Note: We only cover therapy to       | ###          | # |   |            |   |
| > restore bodily function when there   |              | # |   |            |   |
| > has been a total or partial loss of  |              | # |   |            |   |
| > bodily function due to illness or    |              |   |   |            |   |
| > injury and when a physician:         |              |   |   |            |   |
|                                        |              |   |   |            |   |
| 1)  orders the care;                   |              |   |   |            |   |
|                                        |              |   |   |            |   |
| 2)  identifies the specific            |              |   |   |            |   |
|     professional skills the patient    |              |   |   |            |   |
|     requires and the medical necessity |              |   |   |            |   |
|     for skilled services; and          |              |   |   |            |   |
|                                        |              |   |   |            |   |
| 3)  indicates the length of time the   |              |   |   |            |   |
|     services are needed.               |              |   |   |            |   |
|                                        |              |   |   |            |   |
| > Note: When you receive medically     |              |   |   |            |   |
| > necessary physical or occupational   |              |   |   |            |   |
| > therapy on an outpatient basis from  |              |   |   |            |   |
| > a qualified professional therapist   |              |   |   |            |   |
| > at a skilled nursing facility, your  |              |   |   |            |   |
| > therapy is covered up to plan        |              |   |   |            |   |
| > limits.                              |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > *Not covered:*                       | *All         | * |   |            |   |
|                                        | charges*     | A |   |            |   |
| -   *Exercise programs*                |              | l |   |            |   |
|                                        |              | l |   |            |   |
| ```{=html}                             |              | c |   |            |   |
| <!-- -->                               |              | h |   |            |   |
| ```                                    |              | a |   |            |   |
| -   *Long-term rehabilitative therapy* |              | r |   |            |   |
|                                        |              | g |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | s |   |            |   |
|                                        |              | * |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| ##### Speech therapy                   | **You Pay**  |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
|                                        | ### Stan     | # |   |            |   |
|                                        | dard Option  | # |   |            |   |
|                                        |              | # |   |            |   |
|                                        |              |   |   |            |   |
|                                        |              | H |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | g |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              |   |   |            |   |
|                                        |              | O |   |            |   |
|                                        |              | p |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | n |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > 30 visits per calendar year for the  | PPO: 15% of  | P |   |            |   |
| > services of a qualified speech       | the Plan     | P |   |            |   |
| > therapist.                           | allowance    | O |   |            |   |
| >                                      |              | : |   |            |   |
| > Note: We only cover speech therapy   | Non-PPO: 35% | 1 |   |            |   |
| > when a physician:                    | of the Plan  | 0 |   |            |   |
|                                        | allowance    | % |   |            |   |
| 1)  Orders the care;                   | and any      | o |   |            |   |
|                                        | difference   | f |   |            |   |
| 2)  Identifies the specific            | between our  | t |   |            |   |
|     professional skills the patient    | allowance    | h |   |            |   |
|     requires and the medical necessity | and the      | e |   |            |   |
|     for skilled services; and          | billed       | P |   |            |   |
|                                        | amount       | l |   |            |   |
| 3)  Indicates the length of time the   |              | a |   |            |   |
|     services are needed.               |              | n |   |            |   |
|                                        |              | a |   |            |   |
| > Note: When you receive medically     |              | l |   |            |   |
| > necessary speech therapy on an       |              | l |   |            |   |
| > outpatient basis from a qualified    |              | o |   |            |   |
| > speech therapist at a skilled        |              | w |   |            |   |
| > nursing facility, your therapy is    |              | a |   |            |   |
| > covered up to plan limits.           |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              |   |   |            |   |
|                                        |              | N |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | - |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | O |   |            |   |
|                                        |              | : |   |            |   |
|                                        |              | 2 |   |            |   |
|                                        |              | 5 |   |            |   |
|                                        |              | % |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | y |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | m |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | t |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > *Not covered:*                       | > *All       | > |   |            |   |
|                                        | > charges*   |   |   |            |   |
| -   *Computer devices to assist with   |              | * |   |            |   |
|     communications*                    |              | A |   |            |   |
|                                        |              | l |   |            |   |
| ```{=html}                             |              | l |   |            |   |
| <!-- -->                               |              | > |   |            |   |
| ```                                    |              |   |   |            |   |
| -   *Computer programs of any type,    |              | c |   |            |   |
|     including but not limited to those |              | h |   |            |   |
|     to assist with speech therapy*     |              | a |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | g |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | s |   |            |   |
|                                        |              | * |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > **Hearing services (testing,         | ###          | # |   |            |   |
| > treatment, and supplies)**           |              | # |   |            |   |
|                                        |              | # |   |            |   |
|                                        |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > Diagnostic hearing tests performed   | PPO: 15% of  | P |   |            |   |
| > by a M.D., D.O. or audiologist.      | the Plan     | P |   |            |   |
|                                        | allowance    | O |   |            |   |
|                                        |              | : |   |            |   |
|                                        | Non-PPO: 35% | 1 |   |            |   |
|                                        | of the Plan  | 0 |   |            |   |
|                                        | allowance    | % |   |            |   |
|                                        | and any      | o |   |            |   |
|                                        | difference   | f |   |            |   |
|                                        | between our  | t |   |            |   |
|                                        | allowance    | h |   |            |   |
|                                        | and the      | e |   |            |   |
|                                        | billed       | P |   |            |   |
|                                        | amount       | l |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              |   |   |            |   |
|                                        |              | N |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | - |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | O |   |            |   |
|                                        |              | : |   |            |   |
|                                        |              | 2 |   |            |   |
|                                        |              | 5 |   |            |   |
|                                        |              | % |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | P |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              |   |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | y |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | f |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | w |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | t |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | b |   |            |   |
|                                        |              | i |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | l |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | d |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | m |   |            |   |
|                                        |              | o |   |            |   |
|                                        |              | u |   |            |   |
|                                        |              | n |   |            |   |
|                                        |              | t |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > *Not covered:*                       | *All         | * |   |            |   |
|                                        | charges*     | A |   |            |   |
| -   *Hearing aids, testing and         |              | l |   |            |   |
|     examinations for them*             |              | l |   |            |   |
|                                        |              | c |   |            |   |
|                                        |              | h |   |            |   |
|                                        |              | a |   |            |   |
|                                        |              | r |   |            |   |
|                                        |              | g |   |            |   |
|                                        |              | e |   |            |   |
|                                        |              | s |   |            |   |
|                                        |              | * |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
|                                        |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > **Vision services (testing,          | ### You Pay  |   |   |            |   |
| > treatment, and supplies)**           |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
|                                        | ### Stan     |   |   | ### H      |   |
|                                        | dard Option  |   |   | igh Option |   |
+----------------------------------------+--------------+---+---+------------+---+
| -   First pair of contact lenses or    | PPO: 15% of  |   |   | PPO: 10%   |   |
|     ocular implant lenses if required  | the Plan     |   |   | of the     |   |
|     to correct an impairment existing  | allowance    |   |   | Plan       |   |
|     after intraocular surgery or       |              |   |   | allowance  |   |
|     accidental injury.                 | Non-PPO: 35% |   |   |            |   |
|                                        | of the Plan  |   |   | Non-PPO:   |   |
| ```{=html}                             | allowance    |   |   | 25% of the |   |
| <!-- -->                               | and any      |   |   | Plan       |   |
| ```                                    | difference   |   |   | allowance  |   |
| -   30 outpatient vision therapy       | between our  |   |   | and any    |   |
|     visits by an ophthalmologist or    | allowance    |   |   | difference |   |
|     optometrist per person per         | and the      |   |   | between    |   |
|     lifetime                           | billed       |   |   | our        |   |
|                                        | amount       |   |   | allowance  |   |
|                                        |              |   |   | and the    |   |
|                                        |              |   |   | billed     |   |
|                                        |              |   |   | amount     |   |
+----------------------------------------+--------------+---+---+------------+---+
| > *Not covered:*                       | *All         |   |   | *All       |   |
|                                        | charges*     |   |   | charges*   |   |
| -   *Computer programs of any type,    |              |   |   |            |   |
|     including but not limited to those |              |   |   |            |   |
|     to assist with vision therapy.*    |              |   |   |            |   |
|                                        |              |   |   |            |   |
| -   *Eyeglasses*                       |              |   |   |            |   |
|                                        |              |   |   |            |   |
| -   *Radial keratotomy and other       |              |   |   |            |   |
|     refractive surgeries*              |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| ##### Foot care                        | ###          |   |   | ###        |   |
+----------------------------------------+--------------+---+---+------------+---+
| > Routine foot care only when you are  | PPO: \$10    |   |   | PPO: \$20  |   |
| > under active treatment for a         | copayment    |   |   | copayment  |   |
| > metabolic or peripheral vascular     | for office   |   |   | for the    |   |
| > disease, such as diabetes.           | visits to    |   |   | office     |   |
|                                        | primary care |   |   | visit (No  |   |
|                                        | physicians;  |   |   | d          |   |
|                                        | \$25         |   |   | eductible) |   |
|                                        | copayment    |   |   | plus 10%   |   |
|                                        | for office   |   |   | of the     |   |
|                                        | visits to    |   |   | Plan       |   |
|                                        | specialists  |   |   | allowance  |   |
|                                        | (No          |   |   | for other  |   |
|                                        | deductible)  |   |   | services   |   |
|                                        | plus 15% of  |   |   | performed  |   |
|                                        | the Plan     |   |   | during the |   |
|                                        | allowance    |   |   | visit      |   |
|                                        | for other    |   |   |            |   |
|                                        | services     |   |   | Non-PPO:   |   |
|                                        | performed    |   |   | 25% of the |   |
|                                        | during the   |   |   | Plan       |   |
|                                        | visit        |   |   | allowance  |   |
|                                        |              |   |   | and any    |   |
|                                        | Non-PPO: 35% |   |   | difference |   |
|                                        | of the Plan  |   |   | between    |   |
|                                        | allowance    |   |   | our        |   |
|                                        | and any      |   |   | allowance  |   |
|                                        | difference   |   |   | and the    |   |
|                                        | between our  |   |   | billed     |   |
|                                        | allowance    |   |   | amount     |   |
|                                        | and the      |   |   |            |   |
|                                        | billed       |   |   |            |   |
|                                        | amount       |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > *Not covered:*                       | *All         |   |   | *All       |   |
|                                        | charges*     |   |   | charges*   |   |
| -   *Cutting or trimming of toenails   |              |   |   |            |   |
|     or removal of corns, calluses, or  |              |   |   |            |   |
|     similar routine treatment of       |              |   |   |            |   |
|     conditions of the foot, except as  |              |   |   |            |   |
|     stated above.*                     |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > **Orthopedic and prosthetic          | ### You Pay  |   |   |            |   |
| > devices**                            |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
|                                        | ### Stan     |   | # |            |   |
|                                        | dard Option  |   | # |            |   |
|                                        |              |   | # |            |   |
|                                        |              |   |   |            |   |
|                                        |              |   | H |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | g |            |   |
|                                        |              |   | h |            |   |
|                                        |              |   |   |            |   |
|                                        |              |   | O |            |   |
|                                        |              |   | p |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | n |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| -   Artificial limbs and eyes; stump   | PPO: 15% of  |   | P |            |   |
|     hose                               | the Plan     |   | P |            |   |
|                                        | allowance    |   | O |            |   |
| -   Externally worn breast prostheses  |              |   | : |            |   |
|     and surgical bras, including       | Non-PPO: 35% |   | 1 |            |   |
|     necessary replacements following a | of the Plan  |   | 0 |            |   |
|     mastectomy                         | allowance    |   | % |            |   |
|                                        | and any      |   | o |            |   |
| ```{=html}                             | difference   |   | f |            |   |
| <!-- -->                               | between our  |   | t |            |   |
| ```                                    | allowance    |   | h |            |   |
| -   Internal prosthetic devices, such  | and the      |   | e |            |   |
|     as artificial joints, pacemakers,  | billed       |   | P |            |   |
|     cochlear implants, and surgically  | amount       |   | l |            |   |
|     implanted breast implant following |              |   | a |            |   |
|     mastectomy. Note: See Section      |              |   | n |            |   |
|     5 (b) for coverage of the surgery  |              |   | a |            |   |
|     to insert the device.              |              |   | l |            |   |
|                                        |              |   | l |            |   |
| > Note: We will pay only for the cost  |              |   | o |            |   |
| > of the standard item. Coverage for   |              |   | w |            |   |
| > specialty items such as bionics is   |              |   | a |            |   |
| > limited to the cost of the standard  |              |   | n |            |   |
| > item.                                |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   |   |            |   |
|                                        |              |   | N |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | - |            |   |
|                                        |              |   | P |            |   |
|                                        |              |   | P |            |   |
|                                        |              |   | O |            |   |
|                                        |              |   | : |            |   |
|                                        |              |   | 2 |            |   |
|                                        |              |   | 5 |            |   |
|                                        |              |   | % |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | h |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | P |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | y |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | r |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | b |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | u |            |   |
|                                        |              |   | r |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | h |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | b |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | m |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | u |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | t |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > *Not covered:*                       | *All         |   | * |            |   |
|                                        | charges*     |   | A |            |   |
| -   *Orthopedic and corrective shoes*  |              |   | l |            |   |
|                                        |              |   | l |            |   |
| -   *Arch supports*                    |              |   | c |            |   |
|                                        |              |   | h |            |   |
| -   *Foot orthotics*                   |              |   | a |            |   |
|                                        |              |   | r |            |   |
| -   *Heel pads and heel cups*          |              |   | g |            |   |
|                                        |              |   | e |            |   |
| -   *Diabetic shoes*                   |              |   | s |            |   |
|                                        |              |   | * |            |   |
| -   *Bioelectric, computer programmed  |              |   |   |            |   |
|     prosthetic devices*                |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| ##### Durable medical equipment (DME)  | #####        |   | # |            |   |
|                                        |              |   | # |            |   |
|                                        |              |   | # |            |   |
|                                        |              |   | # |            |   |
|                                        |              |   | # |            |   |
|                                        |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > Durable medical equipment (DME) is   | PPO: 15% of  |   | P |            |   |
| > equipment and supplies that:         | the Plan     |   | P |            |   |
|                                        | allowance    |   | O |            |   |
| 1.  Are prescribed by your attending   |              |   | : |            |   |
|     physician (i.e., the physician who | Non-PPO: 35% |   | 1 |            |   |
|     is treating your illness or        | of the Plan  |   | 0 |            |   |
|     injury);                           | allowance    |   | % |            |   |
|                                        | and any      |   | o |            |   |
| 2.  Are medically necessary;           | difference   |   | f |            |   |
|                                        | between our  |   | t |            |   |
| 3.  Are primarily and customarily used | allowance    |   | h |            |   |
|     only for a medical purpose;        | and the      |   | e |            |   |
|                                        | billed       |   | P |            |   |
| 4.  Are generally useful only to a     | amount       |   | l |            |   |
|     person with an illness or injury;  |              |   | a |            |   |
|                                        |              |   | n |            |   |
| 5.  Are designed for prolonged use;    |              |   | a |            |   |
|     and                                |              |   | l |            |   |
|                                        |              |   | l |            |   |
| 6.  Serve a specific therapeutic       |              |   | o |            |   |
|     purpose in the treatment of an     |              |   | w |            |   |
|     illness or injury.                 |              |   | a |            |   |
|                                        |              |   | n |            |   |
| > We cover rental or purchase, at our  |              |   | c |            |   |
| > option, including repair and         |              |   | e |            |   |
| > adjustment, of durable medical       |              |   |   |            |   |
| > equipment, such as oxygen and        |              |   | N |            |   |
| > dialysis equipment. Under this       |              |   | o |            |   |
| > benefit, we also cover:              |              |   | n |            |   |
|                                        |              |   | - |            |   |
| -   Hospital beds;                     |              |   | P |            |   |
|                                        |              |   | P |            |   |
| -   Wheelchairs;                       |              |   | O |            |   |
|                                        |              |   | : |            |   |
| -   Crutches; and                      |              |   | 2 |            |   |
|                                        |              |   | 5 |            |   |
| -   Walkers.                           |              |   | % |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | h |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | P |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | y |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | r |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | b |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | u |            |   |
|                                        |              |   | r |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | h |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | b |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | m |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | u |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | t |            |   |
+----------------------------------------+--------------+---+---+------------+---+
|                                        |              |   | * |            |   |
|                                        |              |   | D |            |   |
|                                        |              |   | M |            |   |
|                                        |              |   | E |            |   |
|                                        |              |   |   |            |   |
|                                        |              |   | - |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | u |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | x |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | p |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | g |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | * |            |   |
+----------------------------------------+--------------+---+---+------------+---+
|                                        |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| ##### Durable                          | ### You Pay  |   |   |            |   |
| medical equipment (DME) -*(continued)* |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
|                                        | ### Sta      |   | # |            |   |
|                                        | ndard Option |   | # |            |   |
|                                        |              |   | # |            |   |
|                                        |              |   |   |            |   |
|                                        |              |   | H |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | g |            |   |
|                                        |              |   | h |            |   |
|                                        |              |   |   |            |   |
|                                        |              |   | O |            |   |
|                                        |              |   | p |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | n |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > Note: Call us at (800) 821-6136 as   | PPO: 15% of  |   | P |            |   |
| > soon as your physician prescribes    | the Plan     |   | P |            |   |
| > this equipment. We will arrange with | allowance    |   | O |            |   |
| > a health care provider to rent or    |              |   | : |            |   |
| > sell you durable medical equipment   | Non-PPO: 35% |   | 1 |            |   |
| > at discounted rates and will tell    | of the Plan  |   | 0 |            |   |
| > you more about this service when you | allowance    |   | % |            |   |
| > call.                                | and any      |   | o |            |   |
| >                                      | difference   |   | f |            |   |
| > Note: Benefits for durable medical   | between our  |   | t |            |   |
| > equipment are limited to \$10,000    | allowance    |   | h |            |   |
| > per person, lifetime maximum.        | and the      |   | e |            |   |
| >                                      | billed       |   | P |            |   |
| > Note: We will pay only for the cost  | amount       |   | l |            |   |
| > of the standard item. Coverage for   |              |   | a |            |   |
| > specialty equipment such as          |              |   | n |            |   |
| > all-terrain wheelchairs is limited   |              |   | a |            |   |
| > to the cost of the standard          |              |   | l |            |   |
| > equipment.                           |              |   | l |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   |   |            |   |
|                                        |              |   | N |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | - |            |   |
|                                        |              |   | P |            |   |
|                                        |              |   | P |            |   |
|                                        |              |   | O |            |   |
|                                        |              |   | : |            |   |
|                                        |              |   | 2 |            |   |
|                                        |              |   | 5 |            |   |
|                                        |              |   | % |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | h |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | P |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | y |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | r |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | b |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | u |            |   |
|                                        |              |   | r |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | h |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | b |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | m |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | u |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | t |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| *Not covered:*                         | *All         |   | * |            |   |
|                                        | charges*     |   | A |            |   |
| -   *Computer devices to assist with   |              |   | l |            |   |
|     communications*                    |              |   | l |            |   |
|                                        |              |   | c |            |   |
| -   *Computer programs of any type*    |              |   | h |            |   |
|                                        |              |   | a |            |   |
| -   *Air purifiers, air conditioners,  |              |   | r |            |   |
|     heating pads, cold therapy units,  |              |   | g |            |   |
|     whirlpool bathing equipment, sun   |              |   | e |            |   |
|     and heat lamps, exercise devices   |              |   | s |            |   |
|     (even if ordered by a doctor), and |              |   | * |            |   |
|     other equipment that does not meet |              |   |   |            |   |
|     the definition of durable medical  |              |   |   |            |   |
|     equipment (page 86)*               |              |   |   |            |   |
|                                        |              |   |   |            |   |
| -   *Lifts, such as seat, chair or van |              |   |   |            |   |
|     lifts*                             |              |   |   |            |   |
|                                        |              |   |   |            |   |
| -   *Wigs*                             |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| ##### Home health services             | ###          |   | # |            |   |
|                                        |              |   | # |            |   |
|                                        |              |   | # |            |   |
|                                        |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > 25 in-home visits per calendar year, | PPO: 15% of  |   | P |            |   |
| > not to exceed one visit up to two    | the Plan     |   | P |            |   |
| > hours per day when:                  | allowance    |   | O |            |   |
|                                        |              |   | : |            |   |
| -   A registered nurse (R.N.),         | Non-PPO: 35% |   | 1 |            |   |
|     licensed practical nurse (L.P.N.)  | of the Plan  |   | 0 |            |   |
|     provides the services;             | allowance    |   | % |            |   |
|                                        | and any      |   | o |            |   |
| ```{=html}                             | difference   |   | f |            |   |
| <!-- -->                               | between our  |   | t |            |   |
| ```                                    | allowance    |   | h |            |   |
| -   The attending physician orders the | and the      |   | e |            |   |
|     care;                              | billed       |   | P |            |   |
|                                        | amount       |   | l |            |   |
| -   The physician identifies the       |              |   | a |            |   |
|     specific professional skills       |              |   | n |            |   |
|     required by the patient and the    |              |   | a |            |   |
|     medical necessity for skilled      |              |   | l |            |   |
|     services; and                      |              |   | l |            |   |
|                                        |              |   | o |            |   |
| -   The physician indicates the length |              |   | w |            |   |
|     of time the services are needed.   |              |   | a |            |   |
|                                        |              |   | n |            |   |
| > Note: Covered services are based on  |              |   | c |            |   |
| > our review for medical necessity.    |              |   | e |            |   |
|                                        |              |   |   |            |   |
|                                        |              |   | N |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | - |            |   |
|                                        |              |   | P |            |   |
|                                        |              |   | P |            |   |
|                                        |              |   | O |            |   |
|                                        |              |   | : |            |   |
|                                        |              |   | 2 |            |   |
|                                        |              |   | 5 |            |   |
|                                        |              |   | % |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | h |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | P |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | y |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | f |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | r |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | b |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | u |            |   |
|                                        |              |   | r |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | w |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | c |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | t |            |   |
|                                        |              |   | h |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | b |            |   |
|                                        |              |   | i |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | l |            |   |
|                                        |              |   | e |            |   |
|                                        |              |   | d |            |   |
|                                        |              |   | a |            |   |
|                                        |              |   | m |            |   |
|                                        |              |   | o |            |   |
|                                        |              |   | u |            |   |
|                                        |              |   | n |            |   |
|                                        |              |   | t |            |   |
+----------------------------------------+--------------+---+---+------------+---+
| > *Home health services - continue on  |              |   |   |            |   |
| > next page*                           |              |   |   |            |   |
+----------------------------------------+--------------+---+---+------------+---+

+----------------------------------------+--------------+--------------+
| ###                                    | ### You Pay  |              |
| ## Home health services -*(continued)* |              |              |
+----------------------------------------+--------------+--------------+
|                                        | ### Sta      | ###          |
|                                        | ndard Option |  High Option |
+----------------------------------------+--------------+--------------+
| > Not covered:                         | > All        | > All        |
|                                        | > charges    | > charges    |
| -   Nursing care requested by, or for  |              |              |
|     the convenience of, the patient or |              |              |
|     the patient's family;              |              |              |
|                                        |              |              |
| -   Services primarily for hygiene,    |              |              |
|     feeding, exercising, moving the    |              |              |
|     patient, homemaking, companionship |              |              |
|     or giving oral medication;         |              |              |
|                                        |              |              |
| -   Home care primarily for personal   |              |              |
|     assistance that does not include a |              |              |
|     medical component and is not       |              |              |
|     diagnostic, therapeutic, or        |              |              |
|     rehabilitative;                    |              |              |
|                                        |              |              |
| -   Custodial Care;                    |              |              |
|                                        |              |              |
| -   Services or supplies furnished by  |              |              |
|     immediate relatives or household   |              |              |
|     members, such as spouse, parents,  |              |              |
|     children, brothers or sisters by   |              |              |
|     blood, marriage or adoption;       |              |              |
|                                        |              |              |
| -   Inpatient private duty nursing.    |              |              |
+----------------------------------------+--------------+--------------+
| ##### Chiropractic                     | ###          | ###          |
+----------------------------------------+--------------+--------------+
| ## *Chiropractic services limited to:* | > PPO and    | > PPO and    |
|                                        | > Non-PPO:   | > Non-PPO:   |
| ## *30 visits per calend               | >            | >            |
| ar year for manipulation of the spine* | > All        | > All        |
|                                        | > charges in | > charges in |
| ## *X-rays, used to detect and         | > excess of  | > excess of  |
|  determine nerve interferences due to  | > \$9 per    | > \$9 per    |
| spinal subluxations or misalignments.* | > visit      | > visit      |
|                                        | >            | >            |
| ## *Note: No other benef               | > All        | > All        |
| its for the services of a chiropractor | > charges in | > charges in |
|  are covered under any other provision | > excess of  | > excess of  |
|  of this Plan. In medically underserve | > \$25 for   | > \$25 for   |
| d areas, services of a chiropractor th | > X-rays of  | > X-rays of  |
| at are listed above are subject to the | > the spine  | > the spine  |
|  stated limitations. In medically unde | >            | >            |
| rserved areas, services of a chiroprac | > Note:      | > Note:      |
| tor that are within the scope of his/h | > Visits and | > Visits and |
| er license and are not listed above ar | > charges    | > charges    |
| e eligible for regular Plan benefits.* | > exceeding  | > exceeding  |
|                                        | > these      | > these      |
|                                        | > amounts    | > amounts    |
|                                        | > are not    | > are not    |
|                                        | > applied    | > applied    |
|                                        | > toward the | > toward the |
|                                        | > calendar   | > calendar   |
|                                        | > year       | > year       |
|                                        | >            | >            |
|                                        |  deductible. |  deductible. |
+----------------------------------------+--------------+--------------+
| > Not covered:                         | > All        | > All        |
|                                        | > Charges    | > Charges    |
| -   Any treatment not specifically     |              |              |
|     listed as covered;                 |              |              |
|                                        |              |              |
| -   Adjunctive procedures such as      |              |              |
|     ultrasound, electrical muscle      |              |              |
|     stimulation, vibratory therapy,    |              |              |
|     and cold pack application.         |              |              |
+----------------------------------------+--------------+--------------+

+----------------------------------------+--------------+--------------+
| ##### Alternative treatments           | > *You Pay*  |              |
+----------------------------------------+--------------+--------------+
|                                        | ### Stan     | ###          |
|                                        | dard Option  |  High Option |
+----------------------------------------+--------------+--------------+
| ## *Acupuncture*                       | PPO: 15% of  | PPO: 10% of  |
|                                        | the Plan     | the Plan     |
| ## *Benefits are limited to            | allowance    | allowance    |
|  20 procedures per calendar year for m |              |              |
| edically necessary acupuncture treatme | Non-PPO: 35% | Non-PPO: 25% |
| nts if performed by a Medical Doctor ( | of the Plan  | of the Plan  |
| M.D.) or Doctor of Osteopathy (D.O.).* | allowance    | allowance    |
|                                        | and any      | and any      |
|                                        | difference   | difference   |
|                                        | between our  | between our  |
|                                        | allowance    | allowance    |
|                                        | and the      | and the      |
|                                        | billed       | billed       |
|                                        | amount       | amount       |
+----------------------------------------+--------------+--------------+
| ## Not covered:                        | > *All       | > *All       |
|                                        | > charges*   | > charges*   |
| -   All other alternative treatments,  |              |              |
|     > including clinical ecology and   |              |              |
|     > environmental medicine           |              |              |
|                                        |              |              |
| -   Any treatment not specifically     |              |              |
|     > listed as covered                |              |              |
|                                        |              |              |
| -   Naturopathic services              |              |              |
|                                        |              |              |
| > (Note: benefits of certain           |              |              |
| > alternative treatment providers may  |              |              |
| > be covered in medically underserved  |              |              |
| > areas; see page 11.)                 |              |              |
+----------------------------------------+--------------+--------------+
| ### Educational classes and programs   | ###          | ###          |
+----------------------------------------+--------------+--------------+
| > *Coverage is limited to:*            | > PPO: all   | PPO: all     |
|                                        | > charges in | charges in   |
| -   Smoking Cessation -- Up to \$100   | > excess of  | excess of    |
|     to aid in smoking cessation-per    | > \$100      | \$100        |
|     person per lifetime, including     | >            |              |
|     related expenses such as drugs.    | > Non-PPO:   | > Non-PPO:   |
|                                        | > all        | > all        |
|                                        | > charges in | > charges in |
|                                        | > excess of  | > excess of  |
|                                        | > \$100      | > \$100      |
+----------------------------------------+--------------+--------------+

+---+---+-----------------------------------------------------------+---+---+
| * |   |                                                           |   |   |
| * |   |                                                           |   |   |
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| s |   |                                                           |   |   |
| s |   |                                                           |   |   |
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| a |   |                                                           |   |   |
| l |   |                                                           |   |   |
| s |   |                                                           |   |   |
| * |   |                                                           |   |   |
| * |   |                                                           |   |   |
+---+---+-----------------------------------------------------------+---+---+
|   | # | **Here are some important things you should keep in mind  | # |   |
|   | # | about these benefits:**                                   | # |   |
|   | # |                                                           | # |   |
|   | # | -   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.                              |   |   |
|   | I |                                                           | I |   |
|   |   | -   The calendar year deductible is \$350 per person      |   |   |
|   | * |     (\$700 per family) under the High Option and \$450    | * |   |
|   | * |     per person (\$900 per family) under the Standard      | * |   |
|   | M |     Option. The calendar year deductible applies to       | M |   |
|   | * |     almost all benefits in this Section. We added "(No    | * |   |
|   | * |     deductible)" to show when the calendar year           | * |   |
|   |   |     deductible does not apply.                            |   |   |
|   | * |                                                           | * |   |
|   | * | -   The non-PPO benefits are the standard benefits of     | * |   |
|   | P |     this Plan. PPO benefits apply only when you use a PPO | P |   |
|   | * |     provider. When no PPO provider is available, non-PPO  | * |   |
|   | * |     benefits apply.                                       | * |   |
|   |   |                                                           |   |   |
|   | * | -   Be sure to read Section 4, *Your costs for covered    | * |   |
|   | * |     services,* for valuable information about how cost    | * |   |
|   | O |     sharing works, with special sections for members who  | O |   |
|   | * |     are age 65 or over. Also read Section 9 about         | * |   |
|   | * |     coordinating benefits with other coverage, including  | * |   |
|   |   |     with Medicare.                                        |   |   |
|   | * |                                                           | * |   |
|   | * | -   The amounts listed below are for the charges billed   | * |   |
|   | R |     by a physician or other health care professional for  | R |   |
|   | * |     your surgical care. Look in Section 5 (c) for charges | * |   |
|   | * |     associated with the facility (i.e. hospital, surgical | * |   |
|   |   |     center, etc.).                                        |   |   |
|   | * |                                                           | * |   |
|   | * | ```{=html}                                                | * |   |
|   | T | <!-- -->                                                  | T |   |
|   | * | ```                                                       | * |   |
|   | * | -   **YOU MUST GET PRECERTIFICATION OF SOME SURGICAL      | * |   |
|   |   |     PROCEDURES. Please refer to the precertification      |   |   |
|   | * |     information shown in Section 3 to be sure which       | * |   |
|   | * |     services require precertification.**                  | * |   |
|   | A |                                                           | A |   |
|   | * | ```{=html}                                                | * |   |
|   | * | <!-- -->                                                  | * |   |
|   |   | ```                                                       |   |   |
|   | * | -   When you use a PPO hospital the professionals who     | * |   |
|   | * |     provide services to you in a hospital may not all be  | * |   |
|   | N |     preferred providers. If they are not, they will be    | N |   |
|   | * |     paid by this plan as non-PPO providers. However, if   | * |   |
|   | * |     the services are rendered at a PPO hospital, we will  | * |   |
|   |   |     pay the services of radiologists, anesthesiologists   |   |   |
|   | * |     and pathologists who are not preferred providers at   | * |   |
|   | * |     the preferred provider rate. This non-standard        | * |   |
|   | T |     benefit does not include the services of emergency    | T |   |
|   | * |     room physicians.                                      | * |   |
|   | * |                                                           | * |   |
+---+---+-----------------------------------------------------------+---+---+

+----------------------------------------+--------------+--------------+
| **Benefit Description**                | **You pay**  |              |
|                                        |              |              |
|                                        | **After the  |              |
|                                        | calendar     |              |
|                                        | year         |              |
|                                        | ded          |              |
|                                        | uctible...** |              |
+----------------------------------------+--------------+--------------+
| ### Note: The calenda                  |              |              |
| r year deductible applies to almost al |              |              |
| l benefits in this Section. We say "(N |              |              |
| o deductible)" when it does not apply. |              |              |
+----------------------------------------+--------------+--------------+
| ### Surgical procedures                | **Standard   | **High       |
|                                        | Option**     | Option**     |
+----------------------------------------+--------------+--------------+
| > A comprehensive range of services,   | PPO: 15% of  | PPO: 10% of  |
| > such as:                             | the Plan     | the Plan     |
|                                        | allowance    | allowance    |
| -   Operative procedures               |              |              |
|                                        | Non-PPO: 35% | Non-PPO: 25% |
| -   Treatment of fractures, including  | of the Plan  | of the Plan  |
|     casting                            | allowance    | allowance    |
|                                        | and any      | and any      |
| -   Normal pre- and post-operative     | difference   | difference   |
|     care by the surgeon                | between our  | between our  |
|                                        | allowance    | allowance    |
| -   Correction of amblyopia and        | and the      | and the      |
|     strabismus                         | billed       | billed       |
|                                        | amount       | amount       |
| -   Endoscopy procedures               |              |              |
|                                        |              |              |
| -   Biopsy procedures                  |              |              |
|                                        |              |              |
| -   Electroconvulsive therapy          |              |              |
|                                        |              |              |
| -   Removal of tumors and cysts        |              |              |
|                                        |              |              |
| -   Correction of congenital           |              |              |
|     anomalies - limited to children    |              |              |
|     under the age of 18 unless there   |              |              |
|     is a functional deficit. (See      |              |              |
|     Reconstructive surgery)            |              |              |
|                                        |              |              |
| -   Surgical treatment of morbid       |              |              |
|     obesity -- eligible members must   |              |              |
|     be age 18 or over. Criteria        |              |              |
|     regarding complications of obesity |              |              |
|     and body mass index must be met.   |              |              |
|     Treatment must be precertified.    |              |              |
|                                        |              |              |
| -   Insertion of internal prostethic   |              |              |
|     devices. See Section 5 (a) --      |              |              |
|     Orthopedic and prosthetic devices  |              |              |
|     for device coverage information    |              |              |
|                                        |              |              |
| -   Voluntary sterilization (e.g.,     |              |              |
|     Tubal ligation, Vasectomy)         |              |              |
|                                        |              |              |
| -   Surgically implanted               |              |              |
|     contraceptives                     |              |              |
|                                        |              |              |
| -   Intrauterine devices (IUDs)        |              |              |
|                                        |              |              |
| -   Treatment of burns                 |              |              |
|                                        |              |              |
| -   Assistant surgeons are covered up  |              |              |
|     to 20% of our allowance for the    |              |              |
|     surgeon\'s charge for procedures   |              |              |
|     when it is medically necessary to  |              |              |
|     have an assistant surgeon.         |              |              |
|                                        |              |              |
| > Note: Post operative care is         |              |              |
| > considered to be included in the fee |              |              |
| > charged for a surgical procedure by  |              |              |
| > a doctor. Any additional fees        |              |              |
| > charged by a doctor are not covered  |              |              |
| > unless such charge is for an         |              |              |
| > unrelated condition.                 |              |              |
+----------------------------------------+--------------+--------------+
| > *Surgical procedures -- continued on |              |              |
| > next page*                           |              |              |
+----------------------------------------+--------------+--------------+

+----------------------------------------+--------------+--------------+
|                                        |              |              |
+----------------------------------------+--------------+--------------+
| #                                      | ### You Pay  |              |
| #### Surgical procedures *(continued)* |              |              |
+----------------------------------------+--------------+--------------+
|                                        | ### Stan     | ###          |
|                                        | dard Option  |  High Option |
+----------------------------------------+--------------+--------------+
| > When multiple or bilateral surgical  | PPO: 15% of  | > PPO: 10%   |
| > procedures performed during the same | the Plan     | > of the     |
| > operative session add time or        | allowance    | > Plan       |
| > complexity to patient care, our      |              | > allowance  |
| > benefits are:                        | Non-PPO: 35% | >            |
|                                        | of the Plan  | > Non-PPO:   |
| -   For the primary procedure based    | allowance    | > 25% of the |
|     on:                                | and any      | > Plan       |
|                                        | difference   | > allowance  |
| ```{=html}                             | between our  | > and any    |
| <!-- -->                               | allowance    | > difference |
| ```                                    | and the      | > between    |
| -   Full Plan allowance                | billed       | > our        |
|                                        | amount       | > allowance  |
| ```{=html}                             |              | > and the    |
| <!-- -->                               |              | > billed     |
| ```                                    |              | > amount     |
| -   For the secondary procedure(s)     |              |              |
|     based on:                          |              |              |
|                                        |              |              |
| ```{=html}                             |              |              |
| <!-- -->                               |              |              |
| ```                                    |              |              |
| -   One-half of the Plan allowance     |              |              |
|                                        |              |              |
| > • For the subsequent procedure(s)    |              |              |
| > based on:                            |              |              |
|                                        |              |              |
| -   25% of the Plan allowance          |              |              |
|                                        |              |              |
| > Note: Multiple or bilateral surgical |              |              |
| > procedures performed through the     |              |              |
| > same incision are "incidental" to    |              |              |
| > the primary surgery. That is, the    |              |              |
| > procedure would not add time or      |              |              |
| > complexity to patient care. We do    |              |              |
| > not pay extra for incidental         |              |              |
| > procedures.                          |              |              |
+----------------------------------------+--------------+--------------+
| > *Not covered:*                       | > *All       | > *All       |
|                                        | > charges*   | > charges*   |
| -   *Reversal of voluntary             |              |              |
|     sterilization*                     |              |              |
|                                        |              |              |
| -   *Services of a standby physician   |              |              |
|     or surgeon*                        |              |              |
|                                        |              |              |
| > • *Routine treatment of conditions   |              |              |
| > of the foot; see Foot care*          |              |              |
+----------------------------------------+--------------+--------------+

+----------------------------------------+---+--------------+---+-------------+---+
| ##### Reconstructive surgery           | # |              |   |             |   |
|                                        | # |              |   |             |   |
|                                        | # |              |   |             |   |
|                                        |   |              |   |             |   |
|                                        | Y |              |   |             |   |
|                                        | o |              |   |             |   |
|                                        | u |              |   |             |   |
|                                        |   |              |   |             |   |
|                                        | P |              |   |             |   |
|                                        | a |              |   |             |   |
|                                        | y |              |   |             |   |
+----------------------------------------+---+--------------+---+-------------+---+
|                                        | # |              |   | ###         |   |
|                                        | # |              |   | High Option |   |
|                                        | # |              |   |             |   |
|                                        |   |              |   |             |   |
|                                        | S |              |   |             |   |
|                                        | t |              |   |             |   |
|                                        | a |              |   |             |   |
|                                        | n |              |   |             |   |
|                                        | d |              |   |             |   |
|                                        | a |              |   |             |   |
|                                        | r |              |   |             |   |
|                                        | d |              |   |             |   |
|                                        |   |              |   |             |   |
|                                        | O |              |   |             |   |
|                                        | p |              |   |             |   |
|                                        | t |              |   |             |   |
|                                        | i |              |   |             |   |
|                                        | o |              |   |             |   |
|                                        | n |              |   |             |   |
|                                        |   |              |   |             |   |
+----------------------------------------+---+--------------+---+-------------+---+
| -   Surgery to correct a functional    | P |              |   | PPO: 10% of |   |
|     defect                             | P |              |   | the Plan    |   |
|                                        | O |              |   | allowance   |   |
| -   Surgery to correct a condition     | : |              |   |             |   |
|     caused by injury or illness if:    | 1 |              |   | Non-PPO:    |   |
|                                        | 5 |              |   | 25% of the  |   |
| ```{=html}                             | % |              |   | Plan        |   |
| <!-- -->                               | o |              |   | allowance   |   |
| ```                                    | f |              |   | and any     |   |
| -   the condition produced a major     | t |              |   | difference  |   |
|     effect on the member's appearance  | h |              |   | between our |   |
|     and                                | e |              |   | allowance   |   |
|                                        | P |              |   | and the     |   |
| -   the condition can reasonably be    | l |              |   | billed      |   |
|     expected to be corrected by such   | a |              |   | amount      |   |
|     surgery                            | n |              |   |             |   |
|                                        | a |              |   |             |   |
| ```{=html}                             | l |              |   |             |   |
| <!-- -->                               | l |              |   |             |   |
| ```                                    | o |              |   |             |   |
| -   Surgery to correct a condition     | w |              |   |             |   |
|     that existed at or from birth and  | a |              |   |             |   |
|     is a significant deviation from    | n |              |   |             |   |
|     the common form or norm -- limited | c |              |   |             |   |
|     to children under the age of 18    | e |              |   |             |   |
|     unless there is a functional       |   |              |   |             |   |
|     deficit. Examples of congenital    | N |              |   |             |   |
|     anomalies are: cleft lip; cleft    | o |              |   |             |   |
|     palate; birth marks; and webbed    | n |              |   |             |   |
|     fingers and toes.                  | - |              |   |             |   |
|                                        | P |              |   |             |   |
| -   All stages of breast               | P |              |   |             |   |
|     reconstruction surgery following a | O |              |   |             |   |
|     mastectomy, such as:               | : |              |   |             |   |
|                                        | 3 |              |   |             |   |
| ```{=html}                             | 5 |              |   |             |   |
| <!-- -->                               | % |              |   |             |   |
| ```                                    | o |              |   |             |   |
| -   Surgery to produce a symmetrical   | f |              |   |             |   |
|     appearance of breasts;             | t |              |   |             |   |
|                                        | h |              |   |             |   |
| -   Treatment of any physical          | e |              |   |             |   |
|     complications, such as lymphedemas | P |              |   |             |   |
|                                        | l |              |   |             |   |
| -   Breast prostheses; and surgical    | a |              |   |             |   |
|     bras and replacements (see         | n |              |   |             |   |
|     Prosthetic devices for coverage)   | a |              |   |             |   |
|                                        | l |              |   |             |   |
| > Note: We pay for internal breast     | l |              |   |             |   |
| > prostheses as hospital benefits if   | o |              |   |             |   |
| > billed by a hospital. If included    | w |              |   |             |   |
| > with the surgeon's bill, surgery     | a |              |   |             |   |
| > benefits will apply.                 | n |              |   |             |   |
| >                                      | c |              |   |             |   |
| > Note: If you need a mastectomy, you  | e |              |   |             |   |
| > may choose to have the procedure     | a |              |   |             |   |
| > performed on an inpatient basis and  | n |              |   |             |   |
| > remain in the hospital up to 48      | d |              |   |             |   |
| > hours after the procedure.           | a |              |   |             |   |
|                                        | n |              |   |             |   |
|                                        | y |              |   |             |   |
|                                        | d |              |   |             |   |
|                                        | i |              |   |             |   |
|                                        | f |              |   |             |   |
|                                        | f |              |   |             |   |
|                                        | e |              |   |             |   |
|                                        | r |              |   |             |   |
|                                        | e |              |   |             |   |
|                                        | n |              |   |             |   |
|                                        | c |              |   |             |   |
|                                        | e |              |   |             |   |
|                                        | b |              |   |             |   |
|                                        | e |              |   |             |   |
|                                        | t |              |   |             |   |
|                                        | w |              |   |             |   |
|                                        | e |              |   |             |   |
|                                        | e |              |   |             |   |
|                                        | n |              |   |             |   |
|                                        | o |              |   |             |   |
|                                        | u |              |   |             |   |
|                                        | r |              |   |             |   |
|                                        | a |              |   |             |   |
|                                        | l |              |   |             |   |
|                                        | l |              |   |             |   |
|                                        | o |              |   |             |   |
|                                        | w |              |   |             |   |
|                                        | a |              |   |             |   |
|                                        | n |              |   |             |   |
|                                        | c |              |   |             |   |
|                                        | e |              |   |             |   |
|                                        | a |              |   |             |   |
|                                        | n |              |   |             |   |
|                                        | d |              |   |             |   |
|                                        | t |              |   |             |   |
|                                        | h |              |   |             |   |
|                                        | e |              |   |             |   |
|                                        | b |              |   |             |   |
|                                        | i |              |   |             |   |
|                                        | l |              |   |             |   |
|                                        | l |              |   |             |   |
|                                        | e |              |   |             |   |
|                                        | d |              |   |             |   |
|                                        | a |              |   |             |   |
|                                        | m |              |   |             |   |
|                                        | o |              |   |             |   |
|                                        | u |              |   |             |   |
|                                        | n |              |   |             |   |
|                                        | t |              |   |             |   |
+----------------------------------------+---+--------------+---+-------------+---+
| > *Not covered:*                       | > |              |   | > *All      |   |
|                                        |   |              |   | > charges*  |   |
| -   *Cosmetic surgery -- any surgical  | * |              |   |             |   |
|     procedure (or any portion of a     | A |              |   |             |   |
|     procedure) performed primarily to  | l |              |   |             |   |
|     improve physical appearance        | l |              |   |             |   |
|     through change in bodily form,     | > |              |   |             |   |
|     except repair of accidental injury |   |              |   |             |   |
|     if repair is initiated promptly or | c |              |   |             |   |
|     as soon as the member's medical    | h |              |   |             |   |
|     condition permits.*                | a |              |   |             |   |
|                                        | r |              |   |             |   |
| ```{=html}                             | g |              |   |             |   |
| <!-- -->                               | e |              |   |             |   |
| ```                                    | s |              |   |             |   |
| -   *Surgeries related to sex          | * |              |   |             |   |
|     transformation or sexual           |   |              |   |             |   |
|     dysfunction*                       |   |              |   |             |   |
|                                        |   |              |   |             |   |
| -   *Surgeries to correct congenital   |   |              |   |             |   |
|     anomalies for individuals age 18   |   |              |   |             |   |
|     and older unless there is a        |   |              |   |             |   |
|     functional deficit.*               |   |              |   |             |   |
+----------------------------------------+---+--------------+---+-------------+---+
| ##### Oral and maxillofacial surgery   |   | ### You Pay  |   |             |   |
+----------------------------------------+---+--------------+---+-------------+---+
|                                        |   | ### Stan     | # |             |   |
|                                        |   | dard Option  | # |             |   |
|                                        |   |              | # |             |   |
|                                        |   |              |   |             |   |
|                                        |   |              | H |             |   |
|                                        |   |              | i |             |   |
|                                        |   |              | g |             |   |
|                                        |   |              | h |             |   |
|                                        |   |              |   |             |   |
|                                        |   |              | O |             |   |
|                                        |   |              | p |             |   |
|                                        |   |              | t |             |   |
|                                        |   |              | i |             |   |
|                                        |   |              | o |             |   |
|                                        |   |              | n |             |   |
+----------------------------------------+---+--------------+---+-------------+---+
| > Oral surgical procedures, limited    |   | PPO: 15% of  | P |             |   |
| > to:                                  |   | the Plan     | P |             |   |
|                                        |   | allowance    | O |             |   |
| -   Reduction of fractures of the jaws |   |              | : |             |   |
|     or facial bones;                   |   | Non-PPO: 35% | 1 |             |   |
|                                        |   | of the Plan  | 0 |             |   |
| -   Surgical correction of cleft lip,  |   | allowance    | % |             |   |
|     cleft palate;                      |   | and any      | o |             |   |
|                                        |   | difference   | f |             |   |
| -   Excision of cysts and incision of  |   | between our  | t |             |   |
|     abscesses unrelated to tooth       |   | allowance    | h |             |   |
|     structure;                         |   | and the      | e |             |   |
|                                        |   | billed       | P |             |   |
| -   Extraction of impacted (unerupted  |   | amount       | l |             |   |
|     or partially erupted) teeth;       |   |              | a |             |   |
|                                        |   |              | n |             |   |
| -   Alveoloplasty, partial or radical  |   |              | a |             |   |
|     removal of the lower jaw with bone |   |              | l |             |   |
|     graft;                             |   |              | l |             |   |
|                                        |   |              | o |             |   |
| -   Excision of tori, tumors,          |   |              | w |             |   |
|     leukoplakia, premalignant and      |   |              | a |             |   |
|     malignant lesions, and biopsy of   |   |              | n |             |   |
|     hard and soft oral tissues;        |   |              | c |             |   |
|                                        |   |              | e |             |   |
| -   Open reduction of dislocations and |   |              |   |             |   |
|     excision, manipulation, aspiration |   |              | N |             |   |
|     or injection of temporomandibular  |   |              | o |             |   |
|     joints;                            |   |              | n |             |   |
|                                        |   |              | - |             |   |
| -   Removal of foreign body, skin,     |   |              | P |             |   |
|     subcutaneous areolar tissue,       |   |              | P |             |   |
|     reaction-producing foreign bodies  |   |              | O |             |   |
|     in the musculoskeletal system and  |   |              | : |             |   |
|     salivary stones and                |   |              | 2 |             |   |
|     incision/excision of salivary      |   |              | 5 |             |   |
|     glands and ducts;                  |   |              | % |             |   |
|                                        |   |              | o |             |   |
| -   Repair of traumatic wounds;        |   |              | f |             |   |
|                                        |   |              | t |             |   |
| -   Incision of the sinus and repair   |   |              | h |             |   |
|     of oral fistulas;                  |   |              | e |             |   |
|                                        |   |              | P |             |   |
| -   Surgical treatment of trigeminal   |   |              | l |             |   |
|     neuralgia;                         |   |              | a |             |   |
|                                        |   |              | n |             |   |
| -   Repair of accidental injury to     |   |              | a |             |   |
|     sound natural teeth such as:       |   |              | l |             |   |
|     expenses for X-rays, drugs,        |   |              | l |             |   |
|     crowns, bridgework, inlays and     |   |              | o |             |   |
|     dentures. Masticating (biting or   |   |              | w |             |   |
|     chewing) incidents are not         |   |              | a |             |   |
|     considered to be accidental        |   |              | n |             |   |
|     injuries. Accidental dental injury |   |              | c |             |   |
|     is covered at **100%** for charges |   |              | e |             |   |
|     incurred within 72 hours of an     |   |              | a |             |   |
|     accident (see page 53).            |   |              | n |             |   |
|                                        |   |              | d |             |   |
| -   Orthognathic surgery but only for  |   |              | a |             |   |
|     treatment of severe sleep apnea    |   |              | n |             |   |
|     and only after conservative        |   |              | y |             |   |
|     treatment of sleep apnea has       |   |              | d |             |   |
|     failed. Orthognathic surgery for   |   |              | i |             |   |
|     any other condition is not         |   |              | f |             |   |
|     covered.                           |   |              | f |             |   |
|                                        |   |              | e |             |   |
| > • Other oral surgery procedures that |   |              | r |             |   |
| > do not involve the teeth or their    |   |              | e |             |   |
| > supporting structures.               |   |              | n |             |   |
|                                        |   |              | c |             |   |
|                                        |   |              | e |             |   |
|                                        |   |              | b |             |   |
|                                        |   |              | e |             |   |
|                                        |   |              | t |             |   |
|                                        |   |              | w |             |   |
|                                        |   |              | e |             |   |
|                                        |   |              | e |             |   |
|                                        |   |              | n |             |   |
|                                        |   |              | o |             |   |
|                                        |   |              | u |             |   |
|                                        |   |              | r |             |   |
|                                        |   |              | a |             |   |
|                                        |   |              | l |             |   |
|                                        |   |              | l |             |   |
|                                        |   |              | o |             |   |
|                                        |   |              | w |             |   |
|                                        |   |              | a |             |   |
|                                        |   |              | n |             |   |
|                                        |   |              | c |             |   |
|                                        |   |              | e |             |   |
|                                        |   |              | a |             |   |
|                                        |   |              | n |             |   |
|                                        |   |              | d |             |   |
|                                        |   |              | t |             |   |
|                                        |   |              | h |             |   |
|                                        |   |              | e |             |   |
|                                        |   |              | b |             |   |
|                                        |   |              | i |             |   |
|                                        |   |              | l |             |   |
|                                        |   |              | l |             |   |
|                                        |   |              | e |             |   |
|                                        |   |              | d |             |   |
|                                        |   |              | a |             |   |
|                                        |   |              | m |             |   |
|                                        |   |              | o |             |   |
|                                        |   |              | u |             |   |
|                                        |   |              | n |             |   |
|                                        |   |              | t |             |   |
+----------------------------------------+---+--------------+---+-------------+---+
| > *Not covered:*                       |   | > *All       | > |             |   |
|                                        |   | > charges*   |   |             |   |
| -   *Oral implants and transplants*    |   |              | * |             |   |
|                                        |   |              | A |             |   |
| -   *Procedures that involve the teeth |   |              | l |             |   |
|     or their supporting structures     |   |              | l |             |   |
|     (such as the periodontal membrane, |   |              | > |             |   |
|     gingiva, and alveolar bone)*       |   |              |   |             |   |
|                                        |   |              | c |             |   |
| -   *Orthodontic treatment*            |   |              | h |             |   |
|                                        |   |              | a |             |   |
| -   *Any oral or maxillofacial surgery |   |              | r |             |   |
|     not specifically listed as         |   |              | g |             |   |
|     covered*                           |   |              | e |             |   |
|                                        |   |              | s |             |   |
| ```{=html}                             |   |              | * |             |   |
| <!-- -->                               |   |              |   |             |   |
| ```                                    |   |              |   |             |   |
| -   *Orthognathic surgery (except as   |   |              |   |             |   |
|     outlined above for severe sleep    |   |              |   |             |   |
|     apnea), even if necessary because  |   |              |   |             |   |
|     of TMJ dysfunction or disorder.*   |   |              |   |             |   |
+----------------------------------------+---+--------------+---+-------------+---+

+-----------------------------------------+--------------+-------------+
| ##### Organ/tissue transplants          | ### You Pay  |             |
+-----------------------------------------+--------------+-------------+
|                                         | ### Stan     | ###         |
|                                         | dard Option  | High Option |
+-----------------------------------------+--------------+-------------+
| > Limited to:                           | PPO: 15% of  | #           |
|                                         | the Plan     | ## PPO: 10% |
| -   Cornea                              | allowance    |  of the Pla |
|                                         |              | n allowance |
| -   Heart                               | Non-PPO: 35% |             |
|                                         | of the Plan  | Non-PPO:    |
| -   Heart/lung                          | allowance    | 25% of the  |
|                                         | and any      | Plan        |
| -   Kidney                              | difference   | allowance   |
|                                         | between our  | and any     |
| -   Kidney/Pancreas                     | allowance    | difference  |
|                                         | and the      | between our |
| -   Liver                               | billed       | allowance   |
|                                         | amount       | and the     |
| ```{=html}                              |              | billed      |
| <!-- -->                                |              | amount      |
| ```                                     |              |             |
| -   Lung: Single or double lung         |              |             |
|     transplants, limited to patients    |              |             |
|     for the following end-stage         |              |             |
|     pulmonary diseases: (1) Pulmonary   |              |             |
|     fibrosis, (2) Primary pulmonary     |              |             |
|     hypertension, (3) Emphysema, or (4) |              |             |
|     cystic fibrosis                     |              |             |
|                                         |              |             |
| ```{=html}                              |              |             |
| <!-- -->                                |              |             |
| ```                                     |              |             |
| -   Pancreas (limited to patients whose |              |             |
|     condition is not treatable by       |              |             |
|     insulin therapy)                    |              |             |
|                                         |              |             |
| -   Allogeneic bone marrow transplants  |              |             |
|     -- only for patients with acute     |              |             |
|     leukemia, advanced Hodgkin's        |              |             |
|     lymphoma, Advanced non-Hodgkin's    |              |             |
|     lymphoma, Advanced neuroblastoma    |              |             |
|     (limited to children over age one), |              |             |
|     Aplastic anemia, Chronic            |              |             |
|     myelogenous leukemia, Infantile     |              |             |
|     malignant osteopetrosis, Severe     |              |             |
|     combined immunodeficiency,          |              |             |
|     Thalassemia major, or               |              |             |
|     Wiskott-Aldrich syndrome            |              |             |
|                                         |              |             |
| ```{=html}                              |              |             |
| <!-- -->                                |              |             |
| ```                                     |              |             |
| -   Intestinal transplants (small       |              |             |
|     intestine), small intestine with    |              |             |
|     the liver, small intestine with     |              |             |
|     multiple organs such as the liver,  |              |             |
|     stomach, and pancreas               |              |             |
|                                         |              |             |
| -   Autologous bone marrow transplants  |              |             |
|     (autologous stem cell support) and  |              |             |
|     autologous peripheral stem cell     |              |             |
|     support - limited to patients with  |              |             |
|     Acute lymphocytic, or               |              |             |
|     non-lymphocytic leukemia, Advanced  |              |             |
|     Hodgkin's lymphoma, Advanced        |              |             |
|     non-Hodgkin's lymphoma, Advanced    |              |             |
|     neuroblastoma (limited to children  |              |             |
|     over age one), Breast cancer or     |              |             |
|     Testicular, Mediastinal,            |              |             |
|     Retroperitoneal and Ovarian germ    |              |             |
|     cell tumors, Multiple myeloma or    |              |             |
|     Epithelial ovarian cancer.          |              |             |
|                                         |              |             |
| > Note: We cover related medical and    |              |             |
| > hospital expenses of the donor when   |              |             |
| > we cover the recipient.               |              |             |
+-----------------------------------------+--------------+-------------+
| > *Organ/tissue transplants --          |              |             |
| > continued on next page*               |              |             |
+-----------------------------------------+--------------+-------------+

+-----------------------------------------+--------------+-------------+
|                                         |              |             |
+-----------------------------------------+--------------+-------------+
| ####                                    | ### You Pay  |             |
| # Organ/tissue transplants*(continued)* |              |             |
+-----------------------------------------+--------------+-------------+
|                                         | ### Stan     | ###         |
|                                         | dard Option  | High Option |
+-----------------------------------------+--------------+-------------+
| > Note: All allowable charges incurred  | PPO: 15% of  | #           |
| > for a surgical transplant, whether    | the Plan     | ## PPO: 10% |
| > incurred by the recipient or donor    | allowance    |  of the Pla |
| > will be considered expenses of the    |              | n allowance |
| > recipient and will be covered the     | ### N        |             |
| > same as for any other illness or      | on-PPO: 35%  | Non-PPO:    |
| > injury subject to the limits stated   | of the Plan  | 25% of the  |
| > below. This benefit applies only if   | allowance an | Plan        |
| > the recipient is covered by us and if | d any differ | allowance   |
| > the donor's expenses are not          | ence between | and any     |
| > otherwise covered.                    |  our allowan | difference  |
| >                                       | ce and the b | between our |
| > Transportation Benefit                | illed amount | allowance   |
|                                         |              | and the     |
| -   We will also provide up to \$10,000 |              | billed      |
|     per covered transplant for          |              | amount      |
|     transportation (mileage or airfare) |              |             |
|     to a plan designated facility and   |              | ###         |
|     reasonable temporary living         |              |             |
|     expenses (i.e. lodging and meals)   |              |             |
|     for the recipient and one other     |              |             |
|     individual (or in the case of a     |              |             |
|     minor, two other individuals), if   |              |             |
|     the recipient lives more than 100   |              |             |
|     miles from the designated           |              |             |
|     transplant facility. Transportation |              |             |
|     benefits are payable for follow-up  |              |             |
|     care up to one year following the   |              |             |
|     transplant. The transportation      |              |             |
|     benefit is not available for cornea |              |             |
|     or kidney transplants. You must     |              |             |
|     contact Customer Service for what   |              |             |
|     are considered reasonable temporary |              |             |
|     living expenses.                    |              |             |
+-----------------------------------------+--------------+-------------+
| > Limited Benefits                      | ###          | ###         |
|                                         |              |             |
| -   The process for preauthorizing      |              |             |
|     organ transplants is more extensive |              |             |
|     that the normal precertification    |              |             |
|     process. Before your initial        |              |             |
|     evaluation as a potential candidate |              |             |
|     for a transplant procedure, you or  |              |             |
|     your doctor must contact our        |              |             |
|     Medical Director so we can arrange  |              |             |
|     to review the clinical results of   |              |             |
|     the evaluation and determine if the |              |             |
|     proposed procedure meets our        |              |             |
|     definition of "medically necessary" |              |             |
|     and is on the list of covered       |              |             |
|     transplants. Coverage for the       |              |             |
|     transplant must be authorized in    |              |             |
|     advance, in writing by our Medical  |              |             |
|     Director. (Cornea and kidney        |              |             |
|     transplants do not require          |              |             |
|     preauthorization by GEHA\'s Medical |              |             |
|     Director.)                          |              |             |
+-----------------------------------------+--------------+-------------+
| *Organ/tissue transplants - continued   |              |             |
| on next page*                           |              |             |
+-----------------------------------------+--------------+-------------+

+-----------------------------------------+--------------+-------------+
| ####                                    | ### You Pay  |             |
| # Organ/tissue transplants*(continued)* |              |             |
+-----------------------------------------+--------------+-------------+
|                                         | ### Stan     | ###         |
|                                         | dard Option  | High Option |
+-----------------------------------------+--------------+-------------+
| -   We will pay for a second transplant | PPO: \$10    | PPO: \$20   |
|     evaluation recommended by a         | copayment    | copayment   |
|     physician qualified to perform the  | for office   | (no         |
|     transplant, if: the transplant      | visits to    | deductible) |
|     diagnosis is covered and the        | primary care |             |
|     physician is not associated or in   | physicians;  | Non-PPO:    |
|     practice with the physician who     | \$25         | 25% of the  |
|     recommended and will perform the    | copayment    | Plan        |
|     organ transplant. A third           | for office   | allowance   |
|     transplant evaluation is covered    | visits to    | and any     |
|     only if the second evaluation does  | specialists  | difference  |
|     not confirm the initial evaluation. | (no          | between our |
|                                         | deductible)  | allowance   |
| ```{=html}                              |              | and the     |
| <!-- -->                                | Non-PPO: 35% | billed      |
| ```                                     | of the Plan  | amount      |
| -   The transplant must be performed at | allowance    |             |
|     a Plan-designated organ transplant  | and any      | If prior    |
|     facility to receive maximum         | difference   | approval is |
|     benefits.                           | between our  | not         |
|                                         | allowance    | obtained or |
| -   If benefits are limited to          | and the      | a           |
|     \$100,000 per transplant, included  | billed       | Plan        |
|     in the maximum are all charges for  | amount       | -designated |
|     hospital, medical and surgical care |              | organ       |
|     incurred while the patient is       | > If prior   | transplant  |
|     hospitalized for a covered          | > approval   | facility is |
|     transplant surgery and subsequent   | > is not     | not used,   |
|     complications related to the        | > obtained   | the         |
|     transplant. Outpatient expenses for | > or a       | benefits    |
|     chemotherapy and any process of     | > Pla        | will be     |
|     obtaining stem cells or bone marrow | n-designated | limited to  |
|     associated with bone marrow         | > organ      | 10% for PPO |
|     transplant (stem cell support) are  | > transplant | hospital    |
|     included in benefits limit of       | > facility   | expenses,   |
|     \$100,000 per transplant. Tandem    | > is not     | 10% for PPO |
|     bone marrow transplants approved as | > used, the  | physician   |
|     one treatment protocol are limited  | > benefits   | expenses or |
|     to \$100,000 when not performed at  | > will be    | 25% of our  |
|     a Plan designated facility.         | > limited to | allowance   |
|     Expenses for aftercare such as      | > 15% for    | for non-PPO |
|     outpatient prescription drugs are   | > PPO        | hospital    |
|     not a part of the \$100,000 limit.  | > hospital   | and surgery |
|                                         | > expenses,  | expenses up |
|                                         | > 15% for    | to a        |
|                                         | > PPO        | maximum of  |
|                                         | > physician  | \$100,000   |
|                                         | > expenses   | per         |
|                                         | > or 35% of  | transplant. |
|                                         | > our        | If we       |
|                                         | > allowance  | cannot      |
|                                         | > for        | refer a     |
|                                         | > non-PPO    | member in   |
|                                         | > hospital   | need of a   |
|                                         | > and        | transplant  |
|                                         | > surgery    | to a        |
|                                         | > expenses   | designated  |
|                                         | > up to a    | facility,   |
|                                         | > maximum of | the         |
|                                         | > \$100,000  | \$100,000   |
|                                         | > per        | maximum     |
|                                         | >            | will not    |
|                                         |  transplant. | apply.      |
|                                         | > If we      |             |
|                                         | > cannot     |             |
|                                         | > refer a    |             |
|                                         | > member in  |             |
|                                         | > need of a  |             |
|                                         | > transplant |             |
|                                         | > to a       |             |
|                                         | > designated |             |
|                                         | > facility,  |             |
|                                         | > the        |             |
|                                         | > \$100,000  |             |
|                                         | > maximum    |             |
|                                         | > will not   |             |
|                                         | > apply.     |             |
+-----------------------------------------+--------------+-------------+
| *Organ/tissue transplants - continued   |              |             |
| on next page*                           |              |             |
+-----------------------------------------+--------------+-------------+

+----------------------------------------+--------------+-------------+
| #####                                  | ### You Pay  |             |
|  Organ/tissue transplants*(continued)* |              |             |
+----------------------------------------+--------------+-------------+
|                                        | ### Stan     | ###         |
|                                        | dard Option  | High Option |
+----------------------------------------+--------------+-------------+
| -   Chemotherapy and procedures        | PPO: 15% of  | PPO: 10% of |
|     related to bone marrow             | the Plan     | the Plan    |
|     transplantation must be performed  | allowance    | allowance   |
|     only at a Plan-designated organ    |              |             |
|     transplant facility to receive     | Non-PPO: 35% | Non-PPO:    |
|     maximum benefits.                  | of the Plan  | 25% of the  |
|                                        | allowance    | Plan        |
| ```{=html}                             | and any      | allowance   |
| <!-- -->                               | difference   | and any     |
| ```                                    | between our  | difference  |
| -   Simultaneous transplants such as   | allowance    | between our |
|     kidney/pancreas, heart/lung,       | and the      | allowance   |
|     heart/liver are considered as one  | billed       | and the     |
|     transplant procedure and are       | amount       | billed      |
|     limited to \$100,000 when not      |              | amount      |
|     performed at a Plan-designated     |              |             |
|     organ transplant facility.         |              |             |
+----------------------------------------+--------------+-------------+
| > *Not covered:*                       | > *All       | > *All      |
|                                        | > charges*   | > charges*  |
| -   *Services or supplies for or       |              |             |
|     related to surgical transplant     |              |             |
|     procedures (including              |              |             |
|     administration of high-dose        |              |             |
|     chemotherapy) for artificial or    |              |             |
|     human organ/tissue transplants not |              |             |
|     listed as specifically covered.*   |              |             |
|                                        |              |             |
| -   *Donor screening tests and donor   |              |             |
|     search expenses, except those      |              |             |
|     performed for the actual donor.*   |              |             |
|                                        |              |             |
| -   *Donor search expense for bone     |              |             |
|     marrow transplants.*               |              |             |
+----------------------------------------+--------------+-------------+
| > **Anesthesia**                       |              |             |
+----------------------------------------+--------------+-------------+
| > Professional fees for the            | PPO: 15% of  | PPO: 10% of |
| > administration of anesthesia in −    | the Plan     | the Plan    |
|                                        | allowance    | allowance   |
| -   Hospital (inpatient)               |              |             |
|                                        | Non-PPO: 35% | Non-PPO:    |
| -   Hospital outpatient department     | of the Plan  | 25% of the  |
|                                        | allowance    | Plan        |
| -   Ambulatory surgical center         | and any      | allowance   |
|                                        | difference   | and any     |
| ```{=html}                             | between our  | difference  |
| <!-- -->                               | allowance    | between our |
| ```                                    | and the      | allowance   |
| -   Office                             | billed       | and the     |
|                                        | amount       | billed      |
|                                        |              | amount      |
+----------------------------------------+--------------+-------------+

+---+---+-----------------------------------------------------------+---+---+
| * |   |                                                           |   |   |
| * |   |                                                           |   |   |
| S |   |                                                           |   |   |
| e |   |                                                           |   |   |
| c |   |                                                           |   |   |
| t |   |                                                           |   |   |
| i |   |                                                           |   |   |
| o |   |                                                           |   |   |
| n |   |                                                           |   |   |
| 5 |   |                                                           |   |   |
| ( |   |                                                           |   |   |
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+---+---+-----------------------------------------------------------+---+---+
|   | # | > **Here are some important things you should keep in     | # |   |
|   | # | > mind about these benefits:**                            | # |   |
|   | # |                                                           | # |   |
|   | # | -   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.                              |   |   |
|   | I |                                                           | I |   |
|   |   | -   In this Section, unlike Sections 5 (a) and 5 (b), the |   |   |
|   | * |     calendar year deductible applies to only a few        | * |   |
|   | * |     benefits. In that case, we added "(calendar year      | * |   |
|   | M |     deductible applies)". The calendar year deductible is | M |   |
|   | * |     \$350 per person (\$700 per family) under the High    | * |   |
|   | * |     Option and \$450 per person (\$900 per family) under  | * |   |
|   |   |     the Standard Option.                                  |   |   |
|   | * |                                                           | * |   |
|   | * | ```{=html}                                                | * |   |
|   | P | <!-- -->                                                  | P |   |
|   | * | ```                                                       | * |   |
|   | * | -   A High Option per admission deductible applies of     | * |   |
|   |   |     \$100 (PPO) and \$300 (non-PPO) for inpatient         |   |   |
|   | * |     hospital services up to a maximum of two per person,  | * |   |
|   | * |     per calendar year.                                    | * |   |
|   | O |                                                           | O |   |
|   | * | ```{=html}                                                | * |   |
|   | * | <!-- -->                                                  | * |   |
|   |   | ```                                                       |   |   |
|   | * | -   The non-PPO benefits are the standard benefits of     | * |   |
|   | * |     this Plan. PPO benefits apply only when you use a PPO | * |   |
|   | R |     provider. When no PPO provider is available, non-PPO  | R |   |
|   | * |     benefits apply.                                       | * |   |
|   | * |                                                           | * |   |
|   |   | ```{=html}                                                |   |   |
|   | * | <!-- -->                                                  | * |   |
|   | * | ```                                                       | * |   |
|   | T | -   Be sure to read Section 4, *Your costs for covered    | T |   |
|   | * |     services,* 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.                                        | * |   |
|   | A |                                                           | A |   |
|   | * | ```{=html}                                                | * |   |
|   | * | <!-- -->                                                  | * |   |
|   |   | ```                                                       |   |   |
|   | * | -   The amounts listed below are for the charges billed   | * |   |
|   | * |     by the facility (i.e. hospital or surgical center) or | * |   |
|   | N |     ambulance service for your surgery or care. Any costs | N |   |
|   | * |     associated with the professional charge (i.e.         | * |   |
|   | * |     physicians, etc.) are in Sections 5 (a) or (b).       | * |   |
|   |   |                                                           |   |   |
|   | * | ```{=html}                                                | * |   |
|   | * | <!-- -->                                                  | * |   |
|   | T | ```                                                       | T |   |
|   | * | -   When you use a PPO hospital the professionals who     | * |   |
|   | * |     provide services to you in a hospital may not all be  | * |   |
|   |   |     preferred providers. If they are not, they will be    |   |   |
|   |   |     paid by this plan as non-PPO providers. However, if   |   |   |
|   |   |     the services are rendered at a PPO hospital, we will  |   |   |
|   |   |     pay the services of radiologists, anesthesiologists   |   |   |
|   |   |     and pathologists who are not preferred providers at   |   |   |
|   |   |     the preferred provider rate. This non-standard        |   |   |
|   |   |     benefit does not include the services of emergency    |   |   |
|   |   |     room physicians.                                      |   |   |
|   |   |                                                           |   |   |
|   |   | ```{=html}                                                |   |   |
|   |   | <!-- -->                                                  |   |   |
|   |   | ```                                                       |   |   |
|   |   | -   **YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS;    |   |   |
|   |   |     FAILURE TO DO SO WILL RESULT IN A MINIMUM \$500       |   |   |
|   |   |     PENALTY.** Please refer to the precertification       |   |   |
|   |   |     information shown in Section 3 to be sure which       |   |   |
|   |   |     services require precertification.                    |   |   |
+---+---+-----------------------------------------------------------+---+---+

+----------------------------------------+---+---+--------------+---+-------------+
| **Benefit Description**                |   | * |              |   |             |
|                                        |   | * |              |   |             |
|                                        |   | Y |              |   |             |
|                                        |   | o |              |   |             |
|                                        |   | u |              |   |             |
|                                        |   | p |              |   |             |
|                                        |   | a |              |   |             |
|                                        |   | y |              |   |             |
|                                        |   | * |              |   |             |
|                                        |   | * |              |   |             |
+----------------------------------------+---+---+--------------+---+-------------+
| ### Note: The calendar year dedu       |   |   |              |   |             |
| ctible applies ONLY when we say below: |   |   |              |   |             |
|  "(calendar year deductible applies)". |   |   |              |   |             |
+----------------------------------------+---+---+--------------+---+-------------+
| ##### Inpatient Hospital               |   |   | ### Stan     |   | ###         |
|                                        |   |   | dard Option  |   | High Option |
+----------------------------------------+---+---+--------------+---+-------------+
| > Room and board, such as:             |   |   | PPO: 15% of  |   | PPO:        |
|                                        |   |   | the Plan     |   | Nothing     |
| -   Ward, semiprivate, or intensive    |   |   | allowance    |   |             |
|     care accommodations;               |   |   | (calendar    |   | Non-PPO:    |
|                                        |   |   | year         |   | Nothing     |
| -   General nursing care; and          |   |   | deductible   |   |             |
|                                        |   |   | applies)     |   |             |
| -   Meals and special diets.           |   |   |              |   |             |
|                                        |   |   | > Non-PPO:   |   |             |
| > Note: We only cover a private room   |   |   | > 35% of the |   |             |
| > if we determine it to be medically   |   |   | > Plan       |   |             |
| > necessary. Otherwise, we will pay    |   |   | > allowance  |   |             |
| > the hospital\'s average charge for   |   |   | > (calendar  |   |             |
| > semiprivate accommodations. The      |   |   | > year       |   |             |
| > remaining balance is not a covered   |   |   | > deductible |   |             |
| > expense. If the hospital only has    |   |   | > applies)   |   |             |
| > private rooms, we will cover the     |   |   |              |   |             |
| > private room rate.                   |   |   |              |   |             |
| >                                      |   |   |              |   |             |
| > Note: When the hospital bills a flat |   |   |              |   |             |
| > rate, we prorate the charges to      |   |   |              |   |             |
| > determine how to pay them, as        |   |   |              |   |             |
| > follows: 30% room and board and 70%  |   |   |              |   |             |
| > other charges.                       |   |   |              |   |             |
+----------------------------------------+---+---+--------------+---+-------------+
| #### Other ho                          |   |   | > PPO: 15%   |   | > PPO: 10%  |
| spital services and supplies, such as: |   |   | > of the     |   | > of the    |
|                                        |   |   | > Plan       |   | > Plan      |
| -   Operating, recovery and other      |   |   | > allowance  |   | > allowance |
|     treatment rooms                    |   |   | > (calendar  |   | > (\$100    |
|                                        |   |   | > year       |   | > per       |
| -   Prescribed drugs and medicines     |   |   | > deductible |   | > admission |
|                                        |   |   | > applies)   |   | >           |
| -   Diagnostic laboratory tests and    |   |   | >            |   |  deductible |
|     X-rays                             |   |   | > Non-PPO:   |   | > up to a   |
|                                        |   |   | > 35% of the |   | > maximum   |
| -   Blood or blood plasma, if not      |   |   | > Plan       |   | > of 2 per  |
|     donated or replaced                |   |   | > allowance  |   | > person    |
|                                        |   |   | > (calendar  |   | > per       |
| -   Dressings, splints, casts, and     |   |   | > year       |   | > calendar  |
|     sterile tray services              |   |   | > deductible |   | > year      |
|                                        |   |   | > applies)   |   | > applies)  |
| -   Medical supplies and equipment,    |   |   |              |   | >           |
|     including oxygen                   |   |   |              |   | > Non-PPO:  |
|                                        |   |   |              |   | > 25% of    |
| -   Anesthetics, including nurse       |   |   |              |   | > the Plan  |
|     anesthetist services               |   |   |              |   | > allowance |
|                                        |   |   |              |   | > (\$300    |
| -   Take-home items                    |   |   |              |   | > per       |
|                                        |   |   |              |   | > admission |
| -   Medical supplies, appliances,      |   |   |              |   | >           |
|     medical equipment, and any covered |   |   |              |   |  deductible |
|     items billed by a hospital for use |   |   |              |   | > up to a   |
|     at home (Note: calendar year       |   |   |              |   | > maximum   |
|     deductible applies.)               |   |   |              |   | > of 2 per  |
|                                        |   |   |              |   | > person    |
| > Note: We base payment on whether the |   |   |              |   | > per       |
| > facility or a health care            |   |   |              |   | > calendar  |
| > professional bills for the services  |   |   |              |   | > year      |
| > or supplies. For example, when the   |   |   |              |   | > applies)  |
| > hospital bills for its nurse         |   |   |              |   |             |
| > anesthetists' services, we pay       |   |   |              |   |             |
| > Hospital benefits and when the       |   |   |              |   |             |
| > anesthesiologist bills, we pay       |   |   |              |   |             |
| > Surgery benefits.                    |   |   |              |   |             |
+----------------------------------------+---+---+--------------+---+-------------+
| > *Inpatient hospital -- continued on  |   |   |              |   |             |
| > next page*                           |   |   |              |   |             |
+----------------------------------------+---+---+--------------+---+-------------+
|                                        |   |   |              |   |             |
+----------------------------------------+---+---+--------------+---+-------------+
| ##### Inpatient hospital *(continued)* | # |   |              |   |             |
|                                        | # |   |              |   |             |
|                                        | # |   |              |   |             |
|                                        |   |   |              |   |             |
|                                        | Y |   |              |   |             |
|                                        | o |   |              |   |             |
|                                        | u |   |              |   |             |
|                                        |   |   |              |   |             |
|                                        | P |   |              |   |             |
|                                        | a |   |              |   |             |
|                                        | y |   |              |   |             |
+----------------------------------------+---+---+--------------+---+-------------+
| #####                                  | # |   |              | # |             |
|                                        | # |   |              | # |             |
|                                        | # |   |              | # |             |
|                                        |   |   |              |   |             |
|                                        | S |   |              | H |             |
|                                        | t |   |              | i |             |
|                                        | a |   |              | g |             |
|                                        | n |   |              | h |             |
|                                        | d |   |              |   |             |
|                                        | a |   |              | O |             |
|                                        | r |   |              | p |             |
|                                        | d |   |              | t |             |
|                                        |   |   |              | i |             |
|                                        | O |   |              | o |             |
|                                        | p |   |              | n |             |
|                                        | t |   |              |   |             |
|                                        | i |   |              |   |             |
|                                        | o |   |              |   |             |
|                                        | n |   |              |   |             |
|                                        |   |   |              |   |             |
+----------------------------------------+---+---+--------------+---+-------------+
| > Maternity Care -- Inpatient Hospital | > |   |              | > |             |
| >                                      |   |   |              |   |             |
| > Room and board, such as:             | P |   |              | P |             |
|                                        | P |   |              | P |             |
| -   Ward, semiprivate, or intensive    | O |   |              | O |             |
|     care accommodations                | : |   |              | : |             |
|                                        | > |   |              | > |             |
| -   General nursing care; and          |   |   |              |   |             |
|                                        | N |   |              | N |             |
| -   Meals and special diets            | o |   |              | o |             |
|                                        | t |   |              | t |             |
| > Note: Here are some things to keep   | h |   |              | h |             |
| > in mind:                             | i |   |              | i |             |
|                                        | n |   |              | n |             |
| -   You do not need to precertify your | g |   |              | g |             |
|     normal delivery; see page14 for    | > |   |              | > |             |
|     other circumstances, such as       | > |   |              | > |             |
|     extended stays for you or your     |   |   |              |   |             |
|     baby.                              | N |   |              | N |             |
|                                        | o |   |              | o |             |
| ```{=html}                             | n |   |              | n |             |
| <!-- -->                               | - |   |              | - |             |
| ```                                    | P |   |              | P |             |
| -   You may remain in the hospital up  | P |   |              | P |             |
|     to 48 hours after a regular        | O |   |              | O |             |
|     delivery and 96 hours after a      | : |   |              | : |             |
|     cesarean delivery. We will cover   | > |   |              | > |             |
|     an extended stay, if medically     |   |   |              |   |             |
|     necessary, but you must            | 3 |   |              | N |             |
|     precertify.                        | 5 |   |              | o |             |
|                                        | % |   |              | t |             |
| > Other hospital services and          | > |   |              | h |             |
| > supplies, such as:                   |   |   |              | i |             |
|                                        | o |   |              | n |             |
| -   Delivery room, recovery, and other | f |   |              | g |             |
|     treatment rooms                    | > |   |              | > |             |
|                                        |   |   |              |   |             |
| -   Prescribed drugs and medicines     | t |   |              | f |             |
|                                        | h |   |              | o |             |
| -   Diagnostic laboratory tests and    | e |   |              | r |             |
|     X-rays                             | > |   |              | > |             |
|                                        |   |   |              |   |             |
| -   Blood or blood plasma, if not      | P |   |              | r |             |
|     donated or replaced                | l |   |              | o |             |
|                                        | a |   |              | o |             |
| -   Dressings and sterile tray         | n |   |              | m |             |
|     services                           | > |   |              | > |             |
|                                        |   |   |              |   |             |
| -   Medical supplies and equipment,    | a |   |              | a |             |
|     including oxygen                   | l |   |              | n |             |
|                                        | l |   |              | d |             |
| -   Anesthetics, including nurse       | o |   |              | > |             |
|     anesthetist services               | w |   |              |   |             |
|                                        | a |   |              | b |             |
| -   Take-home items                    | n |   |              | o |             |
|                                        | c |   |              | a |             |
| ```{=html}                             | e |   |              | r |             |
| <!-- -->                               | > |   |              | d |             |
| ```                                    |   |   |              | ; |             |
| -   Medical supplies, appliances,      | ( |   |              | > |             |
|     medical equipment, and any covered | c |   |              |   |             |
|     items billed by a hospital for use | a |   |              | 2 |             |
|     at home (Note: calendar year       | l |   |              | 5 |             |
|     deductible applies.)               | e |   |              | % |             |
|                                        | n |   |              | > |             |
| -   We cover routine nursery care of   | d |   |              |   |             |
|     the newborn child during the       | a |   |              | o |             |
|     covered portion of the mother's    | r |   |              | f |             |
|     maternity stay.                    | > |   |              | > |             |
|                                        |   |   |              |   |             |
|                                        | y |   |              | t |             |
|                                        | e |   |              | h |             |
|                                        | a |   |              | e |             |
|                                        | r |   |              | > |             |
|                                        | > |   |              |   |             |
|                                        |   |   |              | P |             |
|                                        | d |   |              | l |             |
|                                        | e |   |              | a |             |
|                                        | d |   |              | n |             |
|                                        | u |   |              | > |             |
|                                        | c |   |              |   |             |
|                                        | t |   |              | a |             |
|                                        | i |   |              | l |             |
|                                        | b |   |              | l |             |
|                                        | l |   |              | o |             |
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|                                        | > |   |              | a |             |
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|                                        | p |   |              | e |             |
|                                        | p |   |              | > |             |
|                                        | l |   |              |   |             |
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|                                        | e |   |              | o |             |
|                                        | s |   |              | r |             |
|                                        | ) |   |              | > |             |
|                                        |   |   |              |   |             |
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|                                        |   |   |              | ( |             |
|                                        |   |   |              | \ |             |
|                                        |   |   |              | $ |             |
|                                        |   |   |              | 3 |             |
|                                        |   |   |              | 0 |             |
|                                        |   |   |              | 0 |             |
|                                        |   |   |              | > |             |
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|                                        |   |   |              | a |             |
|                                        |   |   |              | x |             |
|                                        |   |   |              | i |             |
|                                        |   |   |              | m |             |
|                                        |   |   |              | u |             |
|                                        |   |   |              | m |             |
|                                        |   |   |              | > |             |
|                                        |   |   |              |   |             |
|                                        |   |   |              | o |             |
|                                        |   |   |              | f |             |
|                                        |   |   |              | > |             |
|                                        |   |   |              |   |             |
|                                        |   |   |              | 2 |             |
|                                        |   |   |              | > |             |
|                                        |   |   |              |   |             |
|                                        |   |   |              | p |             |
|                                        |   |   |              | e |             |
|                                        |   |   |              | r |             |
|                                        |   |   |              | > |             |
|                                        |   |   |              |   |             |
|                                        |   |   |              | p |             |
|                                        |   |   |              | e |             |
|                                        |   |   |              | r |             |
|                                        |   |   |              | s |             |
|                                        |   |   |              | o |             |
|                                        |   |   |              | n |             |
|                                        |   |   |              | > |             |
|                                        |   |   |              |   |             |
|                                        |   |   |              | p |             |
|                                        |   |   |              | e |             |
|                                        |   |   |              | r |             |
|                                        |   |   |              | > |             |
|                                        |   |   |              |   |             |
|                                        |   |   |              | c |             |
|                                        |   |   |              | a |             |
|                                        |   |   |              | l |             |
|                                        |   |   |              | e |             |
|                                        |   |   |              | n |             |
|                                        |   |   |              | d |             |
|                                        |   |   |              | a |             |
|                                        |   |   |              | r |             |
|                                        |   |   |              | > |             |
|                                        |   |   |              |   |             |
|                                        |   |   |              | y |             |
|                                        |   |   |              | e |             |
|                                        |   |   |              | a |             |
|                                        |   |   |              | r |             |
|                                        |   |   |              | > |             |
|                                        |   |   |              |   |             |
|                                        |   |   |              | a |             |
|                                        |   |   |              | p |             |
|                                        |   |   |              | p |             |
|                                        |   |   |              | l |             |
|                                        |   |   |              | i |             |
|                                        |   |   |              | e |             |
|                                        |   |   |              | s |             |
|                                        |   |   |              | ) |             |
+----------------------------------------+---+---+--------------+---+-------------+
| Inpatient hospital -- continued on     |   |   |              |   |             |
| next page                              |   |   |              |   |             |
+----------------------------------------+---+---+--------------+---+-------------+

+----------------------------------------+--------------+--------------+
|                                        |              |              |
+----------------------------------------+--------------+--------------+
| ##### Inpatient hospital *(continued)* | ### You Pay  |              |
+----------------------------------------+--------------+--------------+
|                                        | ### Stan     | ###          |
|                                        | dard Option  |  High Option |
+----------------------------------------+--------------+--------------+
| > Maternity Care -- Inpatient          | > PPO: 15%   | > PPO:       |
| > Hospital - *continued*               | > of the     | > Nothing    |
|                                        | > Plan       | > for room   |
| -   We will cover other care of an     | > allowance  | > and board; |
|     infant who requires non-routine    | > (calendar  | > 10% of the |
|     treatment if we cover the infant   | > year       | > plan       |
|     under a Self and Family            | > deductible | > allowance  |
|     enrollment.                        | > applies)   | > for other  |
|                                        | >            | > hospital   |
|                                        | > Non-PPO:   | > services   |
|                                        | > 35% of the | > (\$100 per |
|                                        | > Plan       | > admission  |
|                                        | > allowance  | > deductible |
|                                        | > (calendar  | > up to a    |
|                                        | > year       | > maximum of |
|                                        | > deductible | > 2 per      |
|                                        | > applies)   | > person per |
|                                        |              | > calendar   |
|                                        |              | > year       |
|                                        |              | > applies)   |
|                                        |              | >            |
|                                        |              | > Non-PPO:   |
|                                        |              | > Nothing    |
|                                        |              | > for room   |
|                                        |              | > and board; |
|                                        |              | > 25% of the |
|                                        |              | > Plan       |
|                                        |              | > allowance  |
|                                        |              | > for other  |
|                                        |              | > hospital   |
|                                        |              | > services   |
|                                        |              | > (\$300 per |
|                                        |              | > admission  |
|                                        |              | > deductible |
|                                        |              | > up to a    |
|                                        |              | > maximum of |
|                                        |              | > 2 per      |
|                                        |              | > person per |
|                                        |              | > calendar   |
|                                        |              | > year       |
|                                        |              | > applies)   |
+----------------------------------------+--------------+--------------+
| > *Not covered:*                       | > *All       | > *All       |
|                                        | > charges*   | > charges*   |
| -   *Any part of a hospital admission  |              |              |
|     that is not medically necessary    |              |              |
|     (see definition), such as when you |              |              |
|     do not need acute hospital         |              |              |
|     inpatient (overnight) care, but    |              |              |
|     could receive care in some other   |              |              |
|     setting without adversely          |              |              |
|     affecting your condition or the    |              |              |
|     quality of your medical care.      |              |              |
|     Note: In this event, we pay        |              |              |
|     benefits for services and supplies |              |              |
|     other than room and board and      |              |              |
|     in-hospital physician care at the  |              |              |
|     level they would have been covered |              |              |
|     if provided in an alternative      |              |              |
|     setting*                           |              |              |
|                                        |              |              |
| -   *Custodial care; see definition*   |              |              |
|                                        |              |              |
| -   *Non-covered facilities, such as   |              |              |
|     nursing homes, schools*            |              |              |
|                                        |              |              |
| -   *Personal comfort items, such as   |              |              |
|     telephone, television, barber      |              |              |
|     services, guest meals and beds*    |              |              |
|                                        |              |              |
| ```{=html}                             |              |              |
| <!-- -->                               |              |              |
| ```                                    |              |              |
| -   *Private nursing care*             |              |              |
+----------------------------------------+--------------+--------------+

+----------------------------------------+--------------+-------------+
| ##### Outpatient h                     | ### You Pay  |             |
| ospital or ambulatory surgical center  |              |             |
+----------------------------------------+--------------+-------------+
|                                        | ### Stan     | ###         |
|                                        | dard Option  | High Option |
+----------------------------------------+--------------+-------------+
| -   Operating, recovery, and other     | PPO: 15% of  | PPO: 10% of |
|     treatment rooms                    | the Plan     | the Plan    |
|                                        | allowance    | allowance   |
| -   Prescribed drugs and medicines     | (calendar    | (calendar   |
|                                        | year         | year        |
| -   Diagnostic laboratory tests,       | deductible   | deductible  |
|     X-rays, and pathology services     | applies)     | applies)    |
|                                        |              |             |
| -   Administration of blood, blood     | Non-PPO: 35% | Non-PPO:    |
|     plasma, and other biologicals      | of the Plan  | 25% of the  |
|                                        | allowance    | Plan        |
| -   Blood and blood plasma, if not     | (calendar    | allowance   |
|     donated or replaced                | year         | (calendar   |
|                                        | deductible   | year        |
| -   Pre-surgical testing               | applies)     | deductible  |
|                                        |              | applies)    |
| -   Dressings, casts, and sterile tray |              |             |
|     services                           |              |             |
|                                        |              |             |
| -   Medical supplies, including oxygen |              |             |
|                                        |              |             |
| -   Anesthetics and anesthesia service |              |             |
|                                        |              |             |
| -   Cardiac rehabilitation             |              |             |
|                                        |              |             |
| > 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.  |              |             |
+----------------------------------------+--------------+-------------+
| ## Not covered:                        | > All        | > All       |
|                                        | > charges    | > charges   |
| -   Urgent care facilities except for  |              |             |
|     > services of covered physicians,  |              |             |
|     > xray and laboratory services.    |              |             |
|                                        |              |             |
| -   Maintenance cardiac rehabilitation |              |             |
+----------------------------------------+--------------+-------------+
| > Maternity Care -- Outpatient         | PPO: Nothing | PPO:        |
| > hospital                             |              | Nothing     |
|                                        | Non-PPO: 35% |             |
| -   Delivery room, recovery, and other | of the Plan  | Non-PPO:    |
|     treatment rooms                    | allowance    | 25% of the  |
|                                        | (calendar    | Plan        |
| -   Prescribed drugs and medicines     | year         | allowance   |
|                                        | deductible   | (calendar   |
| -   Diagnostic laboratory tests and    | applies)     | year        |
|     X-rays, and pathology services     |              | deductible  |
|                                        |              | applies)    |
| -   Administration of blood, blood     |              |             |
|     plasma, and other biologicals      |              |             |
|                                        |              |             |
| -   Blood and blood plasma, if not     |              |             |
|     donated or replaced                |              |             |
|                                        |              |             |
| -   Pre-surgical testing               |              |             |
|                                        |              |             |
| -   Dressings and sterile tray         |              |             |
|     services                           |              |             |
|                                        |              |             |
| -   Medical supplies, including oxygen |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Anesthetics and anesthesia         |              |             |
|     services                           |              |             |
+----------------------------------------+--------------+-------------+

+----------------------------------------+--------------+--------------+
| ### Extended care benefits/            | ### You Pay  |              |
| Skilled nursing care facility benefits |              |              |
+----------------------------------------+--------------+--------------+
|                                        | ### Stan     | ###          |
|                                        | dard Option  |  High Option |
+----------------------------------------+--------------+--------------+
| > *No benefits*                        | *All         | *All         |
|                                        | charges*     | charges*     |
+----------------------------------------+--------------+--------------+
| ##### Hospice care                     | ###          | ###          |
+----------------------------------------+--------------+--------------+
| > Hospice is a coordinated program of  | > PPO:       | PPO: Nothing |
| > maintenance and supportive care for  | > Nothing up | up to the    |
| > the terminally ill provided by a     | > to the     | Plan limits  |
| > medically supervised team under the  | > Plan       | (calendar    |
| > direction of a Plan-approved         | > limits     | year         |
| > independent hospice administration.  | > (calendar  | deductible   |
|                                        | > year       | applies)     |
| -   We pay \$2000 for hospice care on  | > deductible |              |
|     an outpatient basis.               | > applies)   | > Non-PPO:   |
|                                        | >            | > Nothing up |
| -   We pay \$150 per day for room and  | > Non-PPO:   | > to the     |
|     board and care while an inpatient  | > Nothing up | > Plan       |
|     in a hospice up to a maximum of    | > to the     | > limits     |
|     \$3,000.                           | > Plan       | > (calendar  |
|                                        | > limits     | > year       |
| > These benefits will be paid if the   | > (calendar  | > deductible |
| > hospice care program begins after a  | > year       | > applies)   |
| > person's primary doctor certifies    | > deductible |              |
| > terminal illness and life expectancy | > applies)   |              |
| > of six months or less and any        |              |              |
| > services or inpatient hospice stay   |              |              |
| > that is part of the program is:      |              |              |
|                                        |              |              |
| -   Provided while the person is       |              |              |
|     covered by this Plan;              |              |              |
|                                        |              |              |
| -   Ordered by the supervising doctor; |              |              |
|                                        |              |              |
| -   Charged by the hospice care        |              |              |
|     program; and                       |              |              |
|                                        |              |              |
| -   Provided within six months from    |              |              |
|     the date the person entered or     |              |              |
|     re-entered (after a period of      |              |              |
|     remission) a hospice care program. |              |              |
|                                        |              |              |
| > Remission is the halt or actual      |              |              |
| > reduction in the progression of      |              |              |
| > illness resulting in discharge from  |              |              |
| > a hospice care program with no       |              |              |
| > further expenses incurred. A         |              |              |
| > readmission within three months of a |              |              |
| > prior discharge is considered as the |              |              |
| > same period of care. A new period    |              |              |
| > begins after three months from a     |              |              |
| > prior discharge with maximum         |              |              |
| > benefits available.                  |              |              |
+----------------------------------------+--------------+--------------+
| > *Not covered:*                       | > *All       | > *All       |
|                                        | > charges*   | > charges*   |
| -   *Charges incurred during a period  |              |              |
|     of remission, charges incurred for |              |              |
|     treatment of a sickness or injury  |              |              |
|     of a family member that are        |              |              |
|     covered under another Plan         |              |              |
|     provision, charges incurred for    |              |              |
|     services rendered by a close       |              |              |
|     relative, bereavement counseling,  |              |              |
|     funeral arrangements, pastoral     |              |              |
|     counseling, financial or legal     |              |              |
|     counseling, homemaker or caretaker |              |              |
|     services.*                         |              |              |
+----------------------------------------+--------------+--------------+

+----------------------------------------+--------------+-------------+
| ##### Ambulance -- accidental injury   | ### You Pay  |             |
+----------------------------------------+--------------+-------------+
|                                        | ### Stan     | ###         |
|                                        | dard Option  | High Option |
+----------------------------------------+--------------+-------------+
| > Ambulance service within 72 hours of | PPO: Nothing | PPO:        |
| > an accident is covered as follows:   | up to the    | Nothing up  |
|                                        | Plan         | to the Plan |
| -   Local ambulance service (within    | allowance    | allowance   |
|     100 miles) to the first hospital   |              |             |
|     where treated, from that hospital  | Non-PPO:     | Non-PPO:    |
|     to the next nearest one if         | Nothing up   | Nothing up  |
|     necessary treatment is unavailable | to the Plan  | to the Plan |
|     or unsuitable at the first         | allowance    | allowance   |
|     hospital, then to either the home  |              |             |
|     (if ambulance transport is         |              |             |
|     medically necessary) or other      |              |             |
|     medical facility (if required for  |              |             |
|     the patient to receive necessary   |              |             |
|     treatment and if ambulance         |              |             |
|     transport is medically necessary). |              |             |
|                                        |              |             |
| ```{=html}                             |              |             |
| <!-- -->                               |              |             |
| ```                                    |              |             |
| -   Air ambulance to nearest facility  |              |             |
|     where necessary treatment is       |              |             |
|     available is covered if no         |              |             |
|     emergency ground transportation is |              |             |
|     available or suitable and the      |              |             |
|     patient's condition warrants       |              |             |
|     immediate evacuation. Air          |              |             |
|     ambulance will not be covered if   |              |             |
|     transport is beyond the nearest    |              |             |
|     available suitable facility, but   |              |             |
|     is requested by patient or         |              |             |
|     physician for continuity of care   |              |             |
|     or other reasons.                  |              |             |
+----------------------------------------+--------------+-------------+
| > **Ambulance -- non-accidental        |              |             |
| > injury**                             |              |             |
+----------------------------------------+--------------+-------------+
| -   Local ambulance service (within    | > PPO: 15%   | > PPO: 10%  |
|     100 miles) to the first hospital   | > of the     | > of the    |
|     where treated, from that hospital  | > Plan       | > Plan      |
|     to the next nearest one if         | > allowance  | > allowance |
|     necessary treatment is unavailable | > (calendar  | > (calendar |
|     or unsuitable at the first         | > year       | > year      |
|     hospital, then to either the home  | > deductible | >           |
|     (if ambulance transport is         | > applies)   |  deductible |
|     medically necessary) or other      | >            | > applies)  |
|     medical facility (if required for  | > Non-PPO:   | >           |
|     the patient to receive necessary   | > 35% of the | > Non-PPO:  |
|     treatment and if ambulance         | > Plan       | > 25% of    |
|     transport is medically necessary). | > allowance  | > the Plan  |
|                                        | > and any    | > allowance |
| ```{=html}                             | > difference | > and any   |
| <!-- -->                               | > between    | >           |
| ```                                    | > our        |  difference |
| -   Air ambulance to nearest facility  | > allowance  | > between   |
|     where necessary treatment is       | > and the    | > our       |
|     available is covered if no         | > billed     | > allowance |
|     emergency ground transportation is | > amount     | > and the   |
|     available or suitable and the      | > (calendar  | > billed    |
|     patient's condition warrants       | > year       | > amount    |
|     immediate evacuation. Air          | > deductible | > (calendar |
|     ambulance will not be covered if   | > applies)   | > year      |
|     transport is beyond the nearest    |              | >           |
|     available suitable facility, but   |              |  deductible |
|     is requested by patient or         |              | > applies)  |
|     physician for continuity of care   |              |             |
|     or other reasons.                  |              |             |
+----------------------------------------+--------------+-------------+
| > *Not covered:*                       | > *All       | > *All      |
|                                        | > charges*   | > charges*  |
| -   *Transportation by ambulance is    |              |             |
|     not covered when the patient does  |              |             |
|     not require the assistance of      |              |             |
|     medically trained personnel and    |              |             |
|     can be safely transferred (or      |              |             |
|     transported) by other means.*      |              |             |
+----------------------------------------+--------------+-------------+

+---+---+----------------------------------+--------------+-------+---+---+
| # |   |                                  |              |       |   |   |
| # |   |                                  |              |       |   |   |
| # |   |                                  |              |       |   |   |
| # |   |                                  |              |       |   |   |
| # |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| 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:**              |              |       | # |   |
| # | # |                                  |              |       | # |   |
| # | # | -   Please remember that all     |              |       | # |   |
|   | # |     benefits are subject to the  |              |       | # |   |
|   |   |     definitions, limitations,    |              |       |   |   |
|   | I |     and exclusions in this       |              |       | I |   |
|   |   |     brochure and are payable     |              |       |   |   |
|   | * |     only when we determine they  |              |       | * |   |
|   | * |     are medically necessary.     |              |       | * |   |
|   | M |                                  |              |       | M |   |
|   | * | -   The calendar year deductible |              |       | * |   |
|   | * |     is \$350 per person (\$700   |              |       | * |   |
|   |   |     per family) under the High   |              |       |   |   |
|   | * |     Option and \$450 per person  |              |       | * |   |
|   | * |     (\$900 per family) under the |              |       | * |   |
|   | P |     Standard Option. The         |              |       | P |   |
|   | * |     calendar year deductible     |              |       | * |   |
|   | * |     applies to almost all        |              |       | * |   |
|   |   |     benefits in this Section. We |              |       |   |   |
|   | * |     added "(No deductible)" to   |              |       | * |   |
|   | * |     show when the calendar year  |              |       | * |   |
|   | O |     deductible does not apply.   |              |       | O |   |
|   | * |                                  |              |       | * |   |
|   | * | ```{=html}                       |              |       | * |   |
|   |   | <!-- -->                         |              |       |   |   |
|   | * | ```                              |              |       | * |   |
|   | * | -   The non-PPO benefits are the |              |       | * |   |
|   | R |     standard benefits of this    |              |       | R |   |
|   | * |     Plan. PPO benefits apply     |              |       | * |   |
|   | * |     only when you use a PPO      |              |       | * |   |
|   |   |     provider. When no PPO        |              |       |   |   |
|   | * |     provider is available,       |              |       | * |   |
|   | * |     non-PPO benefits apply.      |              |       | * |   |
|   | T |                                  |              |       | T |   |
|   | * | -   Be sure to read Section 4,   |              |       | * |   |
|   | * |     *Your costs for covered      |              |       | * |   |
|   |   |     services,* for valuable      |              |       |   |   |
|   | * |     information about how cost   |              |       | * |   |
|   | * |     sharing works, with special  |              |       | * |   |
|   | A |     sections for members who are |              |       | A |   |
|   | * |     age 65 or over. Also read    |              |       | * |   |
|   | * |     Section 9 about coordinating |              |       | * |   |
|   |   |     benefits with other          |              |       |   |   |
|   | * |     coverage, including with     |              |       | * |   |
|   | * |     Medicare.                    |              |       | * |   |
|   | N |                                  |              |       | N |   |
|   | * | -   When you use a PPO hospital  |              |       | * |   |
|   | * |     the professionals who        |              |       | * |   |
|   |   |     provide services to you in a |              |       |   |   |
|   | * |     hospital may not all be      |              |       | * |   |
|   | * |     preferred providers. If they |              |       | * |   |
|   | T |     are not, they will be paid   |              |       | T |   |
|   | * |     by this plan as non-PPO      |              |       | * |   |
|   | * |     providers. However, if the   |              |       | * |   |
|   |   |     services are rendered at a   |              |       |   |   |
|   |   |     PPO hospital, we will pay    |              |       |   |   |
|   |   |     the services of              |              |       |   |   |
|   |   |     radiologists,                |              |       |   |   |
|   |   |     anesthesiologists and        |              |       |   |   |
|   |   |     pathologists who are not     |              |       |   |   |
|   |   |     preferred providers at the   |              |       |   |   |
|   |   |     preferred provider rate.     |              |       |   |   |
|   |   |     This non-standard benefit    |              |       |   |   |
|   |   |     does not include the         |              |       |   |   |
|   |   |     services of emergency room   |              |       |   |   |
|   |   |     physicians.                  |              |       |   |   |
+---+---+----------------------------------+--------------+-------+---+---+
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+---+---+----------------------------------+--------------+-------+---+---+
| # |   |                                  | **You pay**  |       |   |   |
| # |   |                                  |              |       |   |   |
| # |   |                                  | **After the  |       |   |   |
| # |   |                                  | calendar     |       |   |   |
| # |   |                                  | year         |       |   |   |
| # |   |                                  | ded          |       |   |   |
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+---+---+----------------------------------+--------------+-------+---+---+
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+---+---+----------------------------------+--------------+-------+---+---+
| # |   |                                  | > **Standard | > *   |   |   |
| # |   |                                  | > Option**   | *High |   |   |
| # |   |                                  |              | > Opt |   |   |
| # |   |                                  |              | ion** |   |   |
| # |   |                                  |              |       |   |   |
| # |   |                                  |              |       |   |   |
| # |   |                                  |              |       |   |   |
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|   |   |                                  |              |       |   |   |
| A |   |                                  |              |       |   |   |
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| y |   |                                  |              |       |   |   |
+---+---+----------------------------------+--------------+-------+---+---+
| > |   |                                  | PPO: Nothing | PPO:  |   |   |
|   |   |                                  | (No          | No    |   |   |
| I |   |                                  | deductible)  | thing |   |   |
| f |   |                                  |              | (No   |   |   |
| > |   |                                  | Non-PPO:     | d     |   |   |
|   |   |                                  | Only the     | educt |   |   |
| y |   |                                  | difference   | ible) |   |   |
| o |   |                                  | between our  |       |   |   |
| u |   |                                  | allowance    | Non   |   |   |
| > |   |                                  | and the      | -PPO: |   |   |
|   |   |                                  | billed       | Only  |   |   |
| r |   |                                  | amount (No   | the   |   |   |
| e |   |                                  | deductible)  | diffe |   |   |
| c |   |                                  |              | rence |   |   |
| e |   |                                  |              | be    |   |   |
| i |   |                                  |              | tween |   |   |
| v |   |                                  |              | our   |   |   |
| e |   |                                  |              | allo  |   |   |
| > |   |                                  |              | wance |   |   |
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| t |   |                                  |              |       |   |   |
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| t |   |                                  |              |       |   |   |
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|   |   |                                  |              |       |   |   |
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| g |   |                                  |              |       |   |   |
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| * |   |                                  |              |       |   |   |
+---+---+----------------------------------+--------------+-------+---+---+
|   |   |                                  |              |       |   |   |
+---+---+----------------------------------+--------------+-------+---+---+
| # |   |                                  | ### You Pay  |       |   |   |
| # |   |                                  |              |       |   |   |
| # |   |                                  |              |       |   |   |
| # |   |                                  |              |       |   |   |
| # |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
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| a |   |                                  |              |       |   |   |
| l |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
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| n |   |                                  |              |       |   |   |
| j |   |                                  |              |       |   |   |
| u |   |                                  |              |       |   |   |
| r |   |                                  |              |       |   |   |
| y |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| * |   |                                  |              |       |   |   |
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| n |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
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| u |   |                                  |              |       |   |   |
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| d |   |                                  |              |       |   |   |
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| * |   |                                  |              |       |   |   |
+---+---+----------------------------------+--------------+-------+---+---+
|   |   |                                  | ### Stan     | ### H |   |   |
|   |   |                                  | dard Option  | igh O |   |   |
|   |   |                                  |              | ption |   |   |
+---+---+----------------------------------+--------------+-------+---+---+
| > |   |                                  | PPO: 15% of  | PPO:  |   |   |
|   |   |                                  | the Plan     | 10%   |   |   |
| I |   |                                  | allowance    | of    |   |   |
| f |   |                                  |              | the   |   |   |
| > |   |                                  | Non-PPO: 35% | Plan  |   |   |
|   |   |                                  | of the Plan  | allo  |   |   |
| y |   |                                  | allowance    | wance |   |   |
| o |   |                                  | and any      |       |   |   |
| u |   |                                  | difference   | Non   |   |   |
| > |   |                                  | between our  | -PPO: |   |   |
|   |   |                                  | allowance    | 25%   |   |   |
| r |   |                                  | and the      | of    |   |   |
| e |   |                                  | billed       | the   |   |   |
| c |   |                                  | amount       | Plan  |   |   |
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| i |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| s |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| i |   |                                  |              |       |   |   |
| f |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| y |   |                                  |              |       |   |   |
| o |   |                                  |              |       |   |   |
| u |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| r |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| d |   |                                  |              |       |   |   |
| m |   |                                  |              |       |   |   |
| i |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
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| d |   |                                  |              |       |   |   |
| . |   |                                  |              |       |   |   |
+---+---+----------------------------------+--------------+-------+---+---+
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| * |   |                                  |              |       |   |   |
| * |   |                                  |              |       |   |   |
| M |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| d |   |                                  |              |       |   |   |
| i |   |                                  |              |       |   |   |
| c |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| l |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| m |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| r |   |                                  |              |       |   |   |
| g |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| c |   |                                  |              |       |   |   |
| y |   |                                  |              |       |   |   |
| * |   |                                  |              |       |   |   |
| * |   |                                  |              |       |   |   |
+---+---+----------------------------------+--------------+-------+---+---+
| > |   |                                  | PPO: 15% of  | PPO:  |   |   |
|   |   |                                  | the Plan     | 10%   |   |   |
| O |   |                                  | allowance    | of    |   |   |
| u |   |                                  |              | the   |   |   |
| t |   |                                  | Non-PPO: 35% | Plan  |   |   |
| p |   |                                  | of the Plan  | allo  |   |   |
| a |   |                                  | allowance    | wance |   |   |
| t |   |                                  | and any      |       |   |   |
| i |   |                                  | difference   | > Non |   |   |
| e |   |                                  | between our  | -PPO: |   |   |
| n |   |                                  | allowance    | > 25% |   |   |
| t |   |                                  | and the      | > of  |   |   |
| > |   |                                  | billed       | > the |   |   |
|   |   |                                  | amount       | >     |   |   |
| m |   |                                  |              |  Plan |   |   |
| e |   |                                  |              | >     |   |   |
| d |   |                                  |              |  allo |   |   |
| i |   |                                  |              | wance |   |   |
| c |   |                                  |              | > and |   |   |
| a |   |                                  |              | > any |   |   |
| l |   |                                  |              | >     |   |   |
| > |   |                                  |              | diffe |   |   |
|   |   |                                  |              | rence |   |   |
| o |   |                                  |              | > be  |   |   |
| r |   |                                  |              | tween |   |   |
| > |   |                                  |              | > our |   |   |
|   |   |                                  |              | >     |   |   |
| s |   |                                  |              |  allo |   |   |
| u |   |                                  |              | wance |   |   |
| r |   |                                  |              | > and |   |   |
| g |   |                                  |              | > the |   |   |
| i |   |                                  |              | > b   |   |   |
| c |   |                                  |              | illed |   |   |
| a |   |                                  |              | > a   |   |   |
| l |   |                                  |              | mount |   |   |
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| r |   |                                  |              |       |   |   |
| g |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| c |   |                                  |              |       |   |   |
| y |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| r |   |                                  |              |       |   |   |
| o |   |                                  |              |       |   |   |
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| m |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| r |   |                                  |              |       |   |   |
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| a |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| m |   |                                  |              |       |   |   |
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| n |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| . |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
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| : |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| W |   |                                  |              |       |   |   |
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|   |   |                                  |              |       |   |   |
| p |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| y |   |                                  |              |       |   |   |
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|   |   |                                  |              |       |   |   |
| H |   |                                  |              |       |   |   |
| o |   |                                  |              |       |   |   |
| s |   |                                  |              |       |   |   |
| p |   |                                  |              |       |   |   |
| i |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| l |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| b |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
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| f |   |                                  |              |       |   |   |
| i |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| s |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| i |   |                                  |              |       |   |   |
| f |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| y |   |                                  |              |       |   |   |
| o |   |                                  |              |       |   |   |
| u |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| r |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| d |   |                                  |              |       |   |   |
| m |   |                                  |              |       |   |   |
| i |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| d |   |                                  |              |       |   |   |
| . |   |                                  |              |       |   |   |
+---+---+----------------------------------+--------------+-------+---+---+
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| * |   |                                  |              |       |   |   |
| * |   |                                  |              |       |   |   |
| A |   |                                  |              |       |   |   |
| m |   |                                  |              |       |   |   |
| b |   |                                  |              |       |   |   |
| u |   |                                  |              |       |   |   |
| l |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| c |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| - |   |                                  |              |       |   |   |
| - |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| c |   |                                  |              |       |   |   |
| c |   |                                  |              |       |   |   |
| i |   |                                  |              |       |   |   |
| d |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| l |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| i |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| j |   |                                  |              |       |   |   |
| u |   |                                  |              |       |   |   |
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| y |   |                                  |              |       |   |   |
| * |   |                                  |              |       |   |   |
| * |   |                                  |              |       |   |   |
+---+---+----------------------------------+--------------+-------+---+---+
| > |   |                                  | > PPO:       | PPO:  |   |   |
|   |   |                                  | > Nothing up | No    |   |   |
| A |   |                                  | > to the     | thing |   |   |
| m |   |                                  | > Plan       | up to |   |   |
| b |   |                                  | > allowance  | the   |   |   |
| u |   |                                  | > (no        | Plan  |   |   |
| l |   |                                  | >            | allo  |   |   |
| a |   |                                  |  deductible) | wance |   |   |
| n |   |                                  |              | (no   |   |   |
| c |   |                                  | Non-PPO:     | d     |   |   |
| e |   |                                  | Nothing up   | educt |   |   |
| > |   |                                  | to the Plan  | ible) |   |   |
|   |   |                                  | allowance    |       |   |   |
| s |   |                                  | (no          | Non   |   |   |
| e |   |                                  | deductible)  | -PPO: |   |   |
| r |   |                                  |              | No    |   |   |
| v |   |                                  |              | thing |   |   |
| i |   |                                  |              | up to |   |   |
| c |   |                                  |              | the   |   |   |
| e |   |                                  |              | Plan  |   |   |
| > |   |                                  |              | allo  |   |   |
|   |   |                                  |              | wance |   |   |
| w |   |                                  |              | (no   |   |   |
| i |   |                                  |              | d     |   |   |
| t |   |                                  |              | educt |   |   |
| h |   |                                  |              | ible) |   |   |
| i |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| 7 |   |                                  |              |       |   |   |
| 2 |   |                                  |              |       |   |   |
| > |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
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|   |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
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|   |   |                                  |              |       |   |   |
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| d |   |                                  |              |       |   |   |
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|   |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| c |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| r |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| o |   |                                  |              |       |   |   |
| r |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| o |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| h |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| r |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
|   |   |                                  |              |       |   |   |
| r |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| s |   |                                  |              |       |   |   |
| o |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| s |   |                                  |              |       |   |   |
| . |   |                                  |              |       |   |   |
+---+---+----------------------------------+--------------+-------+---+---+
| A |   |                                  |              |       |   |   |
| m |   |                                  |              |       |   |   |
| b |   |                                  |              |       |   |   |
| u |   |                                  |              |       |   |   |
| l |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| c |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| - |   |                                  |              |       |   |   |
| - |   |                                  |              |       |   |   |
| c |   |                                  |              |       |   |   |
| o |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| i |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| u |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| d |   |                                  |              |       |   |   |
| o |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| n |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
| x |   |                                  |              |       |   |   |
| t |   |                                  |              |       |   |   |
| p |   |                                  |              |       |   |   |
| a |   |                                  |              |       |   |   |
| g |   |                                  |              |       |   |   |
| e |   |                                  |              |       |   |   |
+---+---+----------------------------------+--------------+-------+---+---+

+----------------------------------------+--------------+--------------+
|                                        |              |              |
+----------------------------------------+--------------+--------------+
| ##### Ambulance                        | ### You Pay  |              |
| -- non-accidental injury *(continued)* |              |              |
+----------------------------------------+--------------+--------------+
|                                        | ### Stan     | ###          |
|                                        | dard Option  |  High Option |
+----------------------------------------+--------------+--------------+
| -   Local ambulance service (within    | > PPO: 15%   | > PPO: 10%   |
|     100 miles) to the first hospital   | > of the     | > of the     |
|     where treated, from that hospital  | > Plan       | > Plan       |
|     to the next nearest one if         | > allowance  | > allowance  |
|     necessary treatment is unavailable | > (calendar  | > (calendar  |
|     or unsuitable at the first         | > year       | > year       |
|     hospital, then to either the home  | > deductible | > deductible |
|     (if ambulance transport is         | > applies)   | > applies)   |
|     medically necessary) or other      | >            | >            |
|     medical facility (if required for  | > Non-PPO:   | > Non-PPO:   |
|     the patient to receive necessary   | > 35% of the | > 25% of the |
|     treatment and if ambulance         | > Plan       | > Plan       |
|     transport is medically necessary). | > allowance  | > allowance  |
|                                        | > and any    | > and any    |
| ```{=html}                             | > difference | > difference |
| <!-- -->                               | > between    | > between    |
| ```                                    | > our        | > our        |
| -   Air ambulance to nearest facility  | > allowance  | > allowance  |
|     where necessary treatment is       | > and the    | > and the    |
|     available is covered if no         | > billed     | > billed     |
|     emergency ground transportation is | > amount     | > amount     |
|     available or suitable and the      | > (calendar  | > (calendar  |
|     patient's condition warrants       | > year       | > year       |
|     immediate evacuation. Air          | > deductible | > deductible |
|     ambulance will not be covered if   | > applies)   | > applies)   |
|     transport is beyond the nearest    |              |              |
|     available suitable facility, but   |              |              |
|     is requested by patient or         |              |              |
|     physician for continuity of care   |              |              |
|     or other reasons.                  |              |              |
+----------------------------------------+--------------+--------------+
| > *Not covered:*                       | > *All       | > *All       |
|                                        | > charges*   | > charges*   |
| -   *Transportation by ambulance is    |              |              |
|     not covered when the patient does  |              |              |
|     not require the assistance of      |              |              |
|     medically trained personnel and    |              |              |
|     can be safely transferred (or      |              |              |
|     transported) by other means.*      |              |              |
+----------------------------------------+--------------+--------------+

+---+---+-----------------------------------+-------------+---+--------+---+---+---+
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| 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 |   |                                   |             |   |        |   |   |   |
+---+---+-----------------------------------+-------------+---+--------+---+---+---+
|   | # | > You may choose to get care      |             |   |        | # |   |   |
|   | # | > In-Network or Out-of-Network.   |             |   |        | # |   |   |
|   | # | > When you receive In-Network     |             |   |        | # |   |   |
|   | # | > care, you must get              |             |   |        | # |   |   |
|   | # | > precertification for certain    |             |   |        | # |   |   |
|   | # | > services. If you do,            |             |   |        | # |   |   |
|   |   | > cost-sharing and limitations    |             |   |        |   |   |   |
|   | I | > for In-Network mental health    |             |   |        | I |   |   |
|   |   | > and substance abuse benefits    |             |   |        |   |   |   |
|   | * | > will be no greater than for     |             |   |        | * |   |   |
|   | * | > similar benefits for other      |             |   |        | * |   |   |
|   | M | > illnesses and conditions.       |             |   |        | M |   |   |
|   | * | >                                 |             |   |        | * |   |   |
|   | * | > **Here are some important       |             |   |        | * |   |   |
|   |   | > things to keep in mind about    |             |   |        |   |   |   |
|   | * | > these benefits:**               |             |   |        | * |   |   |
|   | * |                                   |             |   |        | * |   |   |
|   | P | -   Please remember that all      |             |   |        | P |   |   |
|   | * |     benefits are subject to the   |             |   |        | * |   |   |
|   | * |     definitions, limitations, and |             |   |        | * |   |   |
|   |   |     exclusions in this brochure   |             |   |        |   |   |   |
|   | * |     and are payable only when we  |             |   |        | * |   |   |
|   | * |     determine they are medically  |             |   |        | * |   |   |
|   | O |     necessary.                    |             |   |        | O |   |   |
|   | * |                                   |             |   |        | * |   |   |
|   | * | -   The calendar year deductible  |             |   |        | * |   |   |
|   |   |     is \$350 per person (\$700    |             |   |        |   |   |   |
|   | * |     per family) under the High    |             |   |        | * |   |   |
|   | * |     Option and \$450 per person   |             |   |        | * |   |   |
|   | R |     (\$900 per family) under the  |             |   |        | R |   |   |
|   | * |     Standard Option. The calendar |             |   |        | * |   |   |
|   | * |     year deductible applies to    |             |   |        | * |   |   |
|   |   |     almost all benefits in this   |             |   |        |   |   |   |
|   | * |     Section. We added "(No        |             |   |        | * |   |   |
|   | * |     deductible)" to show when the |             |   |        | * |   |   |
|   | T |     calendar year deductible does |             |   |        | T |   |   |
|   | * |     not apply.                    |             |   |        | * |   |   |
|   | * |                                   |             |   |        | * |   |   |
|   |   | ```{=html}                        |             |   |        |   |   |   |
|   | * | <!-- -->                          |             |   |        | * |   |   |
|   | * | ```                               |             |   |        | * |   |   |
|   | A | -   A High Option per admission   |             |   |        | A |   |   |
|   | * |     deductible applies of \$100   |             |   |        | * |   |   |
|   | * |     (In-Network PPO) for          |             |   |        | * |   |   |
|   |   |     inpatient hospital services   |             |   |        |   |   |   |
|   | * |     up to a maximum of two per    |             |   |        | * |   |   |
|   | * |     person, per calendar year.    |             |   |        | * |   |   |
|   | N |                                   |             |   |        | N |   |   |
|   | * | -   A per calendar year           |             |   |        | * |   |   |
|   | * |     deductible of \$500           |             |   |        | * |   |   |
|   |   |     (Out-of-Network non-PPO)      |             |   |        |   |   |   |
|   | * |     applies per person for        |             |   |        | * |   |   |
|   | * |     Inpatient Hospital and        |             |   |        | * |   |   |
|   | T |     Intensive Day Treatment.      |             |   |        | T |   |   |
|   | * |                                   |             |   |        | * |   |   |
|   | * | > • Be sure to read Section 4,    |             |   |        | * |   |   |
|   |   | > *Your costs for covered         |             |   |        |   |   |   |
|   |   | > services*, for valuable         |             |   |        |   |   |   |
|   |   | > information about how cost      |             |   |        |   |   |   |
|   |   | > sharing works. Also read        |             |   |        |   |   |   |
|   |   | > Section 9 about coordinating    |             |   |        |   |   |   |
|   |   | > benefits with other coverage,   |             |   |        |   |   |   |
|   |   | > including with Medicare.        |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   | -   **YOU MUST GET                |             |   |        |   |   |   |
|   |   |     PREAUTHORIZATION OF INPATIENT |             |   |        |   |   |   |
|   |   |     HOSPITAL SERVICES and         |             |   |        |   |   |   |
|   |   |     IN-NETWORK OUTPATIENT         |             |   |        |   |   |   |
|   |   |     INTENSIVE DAY TREATMENT.**    |             |   |        |   |   |   |
|   |   |     See the instructions after    |             |   |        |   |   |   |
|   |   |     the benefits descriptions     |             |   |        |   |   |   |
|   |   |     below.                        |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   | -   In-Network mental health and  |             |   |        |   |   |   |
|   |   |     substance abuse benefits are  |             |   |        |   |   |   |
|   |   |     below, then Out-of-Network    |             |   |        |   |   |   |
|   |   |     benefits begin on page 59.    |             |   |        |   |   |   |
+---+---+-----------------------------------+-------------+---+--------+---+---+---+
| # |   |                                   | ####        |   |        |   |   |   |
| # |   |                                   | ### You pay |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   | ##          |   |        |   |   |   |
| # |   |                                   | ##### Calen |   |        |   |   |   |
| # |   |                                   | dar year de |   |        |   |   |   |
| # |   |                                   | ductible... |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| B |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| f |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| D |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
+---+---+-----------------------------------+-------------+---+--------+---+---+---+
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| N |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| : |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| T |   |                                   |             |   |        |   |   |   |
| h |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| y |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| u |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
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| l |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
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| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
| m |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| b |   |                                   |             |   |        |   |   |   |
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| n |   |                                   |             |   |        |   |   |   |
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| t |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| h |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| S |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
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| . |   |                                   |             |   |        |   |   |   |
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| e |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| f |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| - |   |                                   |             |   |        |   |   |   |
| > |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| u |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| > |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| > |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| x |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| > |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| g |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| * |   |                                   |             |   |        |   |   |   |
+---+---+-----------------------------------+-------------+---+--------+---+---+---+
| # |   |                                   | ### You Pay |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| I |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| - |   |                                   |             |   |        |   |   |   |
| N |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| w |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| k |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| b |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| f |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| * |   |                                   |             |   |        |   |   |   |
| ( |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| u |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| ) |   |                                   |             |   |        |   |   |   |
| * |   |                                   |             |   |        |   |   |   |
+---+---+-----------------------------------+-------------+---+--------+---+---+---+
|   |   |                                   | ### Stand   |   | ###    |   |   |   |
|   |   |                                   | ard Option  |   |  High  |   |   |   |
|   |   |                                   |             |   | Option |   |   |   |
+---+---+-----------------------------------+-------------+---+--------+---+---+---+
| - |   |                                   | > \$25      |   | \$20   |   |   |   |
|   |   |                                   | > copayment |   | cop    |   |   |   |
|   |   |                                   | > per       |   | ayment |   |   |   |
|   |   |                                   | > office    |   | per    |   |   |   |
| P |   |                                   | > visit (No |   | office |   |   |   |
| r |   |                                   | >           |   | visit  |   |   |   |
| o |   |                                   | deductible) |   | (No    |   |   |   |
| f |   |                                   |             |   | deduc  |   |   |   |
| e |   |                                   |             |   | tible) |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| v |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| , |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
| u |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| g |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| v |   |                                   |             |   |        |   |   |   |
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| d |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| g |   |                                   |             |   |        |   |   |   |
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| p |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| h |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| y |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| b |   |                                   |             |   |        |   |   |   |
| y |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| v |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
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| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| t |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| , |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| h |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| s |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| w |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| k |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| - |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| M |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| m |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| g |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| m |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
+---+---+-----------------------------------+-------------+---+--------+---+---+---+
| - |   |                                   | > 15% of    |   | 10% of |   |   |   |
|   |   |                                   | > the Plan  |   | the    |   |   |   |
|   |   |                                   | > allowance |   | Plan   |   |   |   |
|   |   |                                   |             |   | all    |   |   |   |
| P |   |                                   |             |   | owance |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| y |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| h |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| g |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| - |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| I |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
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| n |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| f |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| f |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| = |   |                                   |             |   |        |   |   |   |
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| t |   |                                   |             |   |        |   |   |   |
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| l |   |                                   |             |   |        |   |   |   |
| } |   |                                   |             |   |        |   |   |   |
| < |   |                                   |             |   |        |   |   |   |
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| > |   |                                   |             |   |        |   |   |   |
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| i |   |                                   |             |   |        |   |   |   |
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| g |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
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| s |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
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| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| ` |   |                                   |             |   |        |   |   |   |
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| { |   |                                   |             |   |        |   |   |   |
| = |   |                                   |             |   |        |   |   |   |
| h |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
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| l |   |                                   |             |   |        |   |   |   |
| } |   |                                   |             |   |        |   |   |   |
| < |   |                                   |             |   |        |   |   |   |
| ! |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
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| > |   |                                   |             |   |        |   |   |   |
| ` |   |                                   |             |   |        |   |   |   |
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| ` |   |                                   |             |   |        |   |   |   |
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| L |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| b |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
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| y |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| s |   |                                   |             |   |        |   |   |   |
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| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
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| m |   |                                   |             |   |        |   |   |   |
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| i |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| f |   |                                   |             |   |        |   |   |   |
| f |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| u |   |                                   |             |   |        |   |   |   |
| g |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| b |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| r |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| y |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| u |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
+---+---+-----------------------------------+-------------+---+--------+---+---+---+
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
| # |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| I |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
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| n |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| h |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
+---+---+-----------------------------------+-------------+---+--------+---+---+---+
| > |   |                                   | > 15% of    |   | N      |   |   |   |
|   |   |                                   | > the Plan  |   | othing |   |   |   |
| R |   |                                   | > allowance |   | (No    |   |   |   |
| o |   |                                   |             |   | deduc  |   |   |   |
| o |   |                                   |             |   | tible) |   |   |   |
| m |   |                                   |             |   |        |   |   |   |
| > |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| d |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
| b |   |                                   |             |   |        |   |   |   |
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| r |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| , |   |                                   |             |   |        |   |   |   |
| > |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| u |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| h |   |                                   |             |   |        |   |   |   |
| > |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| : |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| - |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| W |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
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| , |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| i |   |                                   |             |   |        |   |   |   |
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| i |   |                                   |             |   |        |   |   |   |
| v |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
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| r |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
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| r |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
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| m |   |                                   |             |   |        |   |   |   |
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| d |   |                                   |             |   |        |   |   |   |
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| i |   |                                   |             |   |        |   |   |   |
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| n |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| - |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| G |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| n |   |                                   |             |   |        |   |   |   |
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| r |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
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| g |   |                                   |             |   |        |   |   |   |
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| c |   |                                   |             |   |        |   |   |   |
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| r |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| ; |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| a |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| M |   |                                   |             |   |        |   |   |   |
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| l |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| n |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
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| r |   |                                   |             |   |        |   |   |   |
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| d |   |                                   |             |   |        |   |   |   |
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| d |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
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|   |   |                                   |             |   |        |   |   |   |
| 7 |   |                                   |             |   |        |   |   |   |
| 0 |   |                                   |             |   |        |   |   |   |
| % |   |                                   |             |   |        |   |   |   |
| > |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| h |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| > |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| h |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| g |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| . |   |                                   |             |   |        |   |   |   |
+---+---+-----------------------------------+-------------+---+--------+---+---+---+
| > |   |                                   | > 15% of    |   | > 10%  |   |   |   |
|   |   |                                   | > the Plan  |   | > of   |   |   |   |
| O |   |                                   | > allowance |   | > the  |   |   |   |
| t |   |                                   |             |   | > Plan |   |   |   |
| h |   |                                   |             |   | > all  |   |   |   |
| e |   |                                   |             |   | owance |   |   |   |
| r |   |                                   |             |   | >      |   |   |   |
| > |   |                                   |             |   | >      |   |   |   |
|   |   |                                   |             |   | (\$100 |   |   |   |
| h |   |                                   |             |   | > per  |   |   |   |
| o |   |                                   |             |   | > adm  |   |   |   |
| s |   |                                   |             |   | ission |   |   |   |
| p |   |                                   |             |   | > dedu |   |   |   |
| i |   |                                   |             |   | ctible |   |   |   |
| t |   |                                   |             |   | > up   |   |   |   |
| a |   |                                   |             |   | > to a |   |   |   |
| l |   |                                   |             |   | > m    |   |   |   |
| > |   |                                   |             |   | aximum |   |   |   |
|   |   |                                   |             |   | > of 2 |   |   |   |
| s |   |                                   |             |   | > per  |   |   |   |
| e |   |                                   |             |   | >      |   |   |   |
| r |   |                                   |             |   | person |   |   |   |
| v |   |                                   |             |   | > per  |   |   |   |
| i |   |                                   |             |   | > ca   |   |   |   |
| c |   |                                   |             |   | lendar |   |   |   |
| e |   |                                   |             |   | > year |   |   |   |
| s |   |                                   |             |   | > ap   |   |   |   |
| > |   |                                   |             |   | plies) |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| n |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| > |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| u |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
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| s |   |                                   |             |   |        |   |   |   |
| : |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| - |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| S |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| v |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| c |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| r |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| v |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
| e |   |                                   |             |   |        |   |   |   |
| d |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| b |   |                                   |             |   |        |   |   |   |
| y |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
|   |   |                                   |             |   |        |   |   |   |
| h |   |                                   |             |   |        |   |   |   |
| o |   |                                   |             |   |        |   |   |   |
| s |   |                                   |             |   |        |   |   |   |
| p |   |                                   |             |   |        |   |   |   |
| i |   |                                   |             |   |        |   |   |   |
| t |   |                                   |             |   |        |   |   |   |
| a |   |                                   |             |   |        |   |   |   |
| l |   |                                   |             |   |        |   |   |   |
+---+---+-----------------------------------+-------------+---+--------+---+---+---+

In-Network benefits - continued on next page

+----------------------------------------+-------------+--------------+
| #                                      | ### You Pay |              |
| #### In-Network benefits *(continued)* |             |              |
+----------------------------------------+-------------+--------------+
|                                        | ### Stand   | ###          |
|                                        | ard Option  |  High Option |
+----------------------------------------+-------------+--------------+
| ##### Outpatient hospital              | #####       | #####        |
+----------------------------------------+-------------+--------------+
| > Services provided by a hospital      | > 15% of    | > 10% of the |
| > including partial hospitalization or | > the Plan  | > Plan       |
| > Intensive Day Treatment Programs     | > allowance | > allowance  |
+----------------------------------------+-------------+--------------+
| # E                                    |             |              |
| mergency room -- non-accidental injury |             |              |
+----------------------------------------+-------------+--------------+
| > Outpatient services and supplies     | > 15% of    | > 10% of the |
| > billed by a hospital for emergency   | > the Plan  | > Plan       |
| > room treatment                       | > allowance | > allowance  |
| >                                      |             |              |
| > Note: We pay Hospital benefits if    |             |              |
| > you are admitted.                    |             |              |
+----------------------------------------+-------------+--------------+
| > *Not covered: Services we determine  | > *All      | > *All       |
| > are not medically necessary.*        | > charges*  | > charges*   |
+----------------------------------------+-------------+--------------+
| > **Precertification** To be eligible  |             |              |
| > to receive these enhanced mental     |             |              |
| > health and substance abuse benefits  |             |              |
| > you must follow the network          |             |              |
| > authorization process:               |             |              |
|                                        |             |              |
| -   You must call Encompass at (888)   |             |              |
|     372-3190 to receive authorization  |             |              |
|     for inpatient care and outpatient  |             |              |
|     Intensive Day Treatment from a     |             |              |
|     Network provider. They will        |             |              |
|     authorize any covered treatment.   |             |              |
+----------------------------------------+-------------+--------------+
| > **Network limitation** If you do not |             |              |
| > obtain precertification for          |             |              |
| > inpatient care and outpatient        |             |              |
| > Intensive Day Treatment, we will     |             |              |
| > decide whether the stay was          |             |              |
| > medically necessary. If we determine |             |              |
| > the stay was medically necessary, we |             |              |
| > will pay the services less the \$500 |             |              |
| > penalty. If we determine that it was |             |              |
| > not medically necessary, we will     |             |              |
| > only pay for any covered services    |             |              |
| > that are otherwise payable on an     |             |              |
| > outpatient basis. If you remain in   |             |              |
| > the hospital beyond the days we      |             |              |
| > approved and did not get the         |             |              |
| > additional days precertified, we     |             |              |
| > will pay inpatient benefits for the  |             |              |
| > part of the admission that was       |             |              |
| > medically necessary. See Section 3   |             |              |
| > for details.                         |             |              |
+----------------------------------------+-------------+--------------+

+----------------------------------------+--------------+--------------+
| > **Out-of-Network Benefits**          |              |              |
+----------------------------------------+--------------+--------------+
| > **Here are some important things to  |              |              |
| > keep in mind about these benefits:** |              |              |
|                                        |              |              |
| -   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.               |              |              |
|                                        |              |              |
| ```{=html}                             |              |              |
| <!-- -->                               |              |              |
| ```                                    |              |              |
| -   See pages 56-58 for In-Network     |              |              |
|     benefits.                          |              |              |
|                                        |              |              |
| ```{=html}                             |              |              |
| <!-- -->                               |              |              |
| ```                                    |              |              |
| -   Be sure to read Section 4, *Your   |              |              |
|     costs for covered services,* 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.                          |              |              |
+----------------------------------------+--------------+--------------+
| ####### Benefit Description            | ###          |              |
|                                        | #### You Pay |              |
+----------------------------------------+--------------+--------------+
| ### Out-of-Network mental health       | ### Stan     | ###          |
|                                        | dard Option  |  High Option |
| > **And substance abuse benefits**     |              |              |
+----------------------------------------+--------------+--------------+
| -   **Inpatient Hospital/Facility for  | 50% of the   | 50% of the   |
|     treatment of mental health**       | Plan         | Plan         |
|                                        | allowance    | allowance    |
| ```{=html}                             | and any      | and any      |
| <!-- -->                               | difference   | difference   |
| ```                                    | between our  | between our  |
| -   100 day limit per calendar year    | allowance    | allowance    |
|                                        | and the      | and the      |
| -   Precertification required          | billed       | billed       |
|                                        | amount;      | amount;      |
| ```{=html}                             | \$500        | \$500        |
| <!-- -->                               | inpatient    | inpatient    |
| ```                                    | hospital and | hospital and |
| -   **Inpatient Hospital/Facility      | outpatient   | outpatient   |
|     treatment of alcoholism and drug   | hospital     | hospital     |
|     abuse**                            | /intensive   | /intensive   |
|                                        | day          | day          |
| ```{=html}                             | treatment    | treatment    |
| <!-- -->                               | deductible   | deductible   |
| ```                                    | applies per  | applies per  |
| -   30 day maximum per lifetime        | person, per  | person, per  |
|                                        | year         | year         |
| -   Precertification required          |              |              |
|                                        |              |              |
| ```{=html}                             |              |              |
| <!-- -->                               |              |              |
| ```                                    |              |              |
| -   **Outpatient Hospital/Intensive    |              |              |
|     Day Treatment Program for mental   |              |              |
|     health /substance abuse**          |              |              |
|                                        |              |              |
| ```{=html}                             |              |              |
| <!-- -->                               |              |              |
| ```                                    |              |              |
| -   60 day limit per calendar year     |              |              |
+----------------------------------------+--------------+--------------+
| > *Out-of-Network benefits - continued |              |              |
| > on next page*                        |              |              |
+----------------------------------------+--------------+--------------+

+----------------------------------------+--------------+--------------+
|                                        |              |              |
+----------------------------------------+--------------+--------------+
| #####                                  | ### You Pay  |              |
|  Out-of-Network Benefits *(continued)* |              |              |
+----------------------------------------+--------------+--------------+
|                                        | ### Stan     | ###          |
|                                        | dard Option  |  High Option |
+----------------------------------------+--------------+--------------+
| -   **Inpatient Visits for             | 50% of the   | 50% of the   |
|     Psychotherapy**                    | Plan         | Plan         |
|                                        | allowance    | allowance    |
| ```{=html}                             | and any      | and any      |
| <!-- -->                               | difference   | difference   |
| ```                                    | between our  | between our  |
| -   100 inpatient visits limit per     | allowance    | allowance    |
|     calendar year                      | and the      | and the      |
|                                        | billed       | billed       |
| ```{=html}                             | amount,      | amount,      |
| <!-- -->                               | \$450        | \$350        |
| ```                                    | calendar     | calendar     |
| -   **Outpatient Visits for            | year         | year         |
|     Psychotherapy and group sessions   | deductible   | deductible   |
|     and psychological testing**        | applies      | applies      |
|                                        |              |              |
| ```{=html}                             | Both Network | Both Network |
| <!-- -->                               | and          | and          |
| ```                                    | Ou           | Ou           |
| -   30 session limit per calendar year | t-of-Network | t-of-Network |
|     for treatment of mental health and | expenses     | expenses     |
|     substance abuse                    | will apply   | will apply   |
|                                        | to the       | to the       |
|                                        | mental       | mental       |
|                                        | health       | health       |
|                                        | deductible   | deductible   |
+----------------------------------------+--------------+--------------+
| > *Not covered out-of-network:*        | *All         | *All         |
|                                        | charges*     | charges*     |
| -   *Services by pastoral, marital,    |              |              |
|     drug/alcohol and other counselors  |              |              |
|     including therapy for sexual       |              |              |
|     problems*                          |              |              |
|                                        |              |              |
| -   *Treatment for learning            |              |              |
|     disabilities and mental            |              |              |
|     retardation*                       |              |              |
|                                        |              |              |
| -   *Telephone Therapy*                |              |              |
|                                        |              |              |
| -   *Travel time to the member's home  |              |              |
|     to conduct therapy*                |              |              |
|                                        |              |              |
| ```{=html}                             |              |              |
| <!-- -->                               |              |              |
| ```                                    |              |              |
| -   *Services rendered or billed by    |              |              |
|     schools, residential treatment     |              |              |
|     centers or halfway houses or       |              |              |
|     members of their staffs*           |              |              |
+----------------------------------------+--------------+--------------+
| > **Lifetime Maximum** Out-of-Network  |              |              |
| > inpatient care for the treatment of  |              |              |
| > alcoholism and drug abuse is limited |              |              |
| > to a 30 day maximum per lifetime.    |              |              |
+----------------------------------------+--------------+--------------+

> **Precertification** The medical necessity of your admission to a
> hospital or other covered facility for mental health or substance
> abuse must be precertified. Emergency admissions must be reported
> within two business days following the day of admission even if you
> have been discharged. Otherwise, the benefits will be reduced. See
> Section 3 for details.
>
> Call Encompass at (888) 372-3190 to precertify.

+-----------------------------------------------------------------------+
| > See these sections of the brochure for more valuable information    |
| > about these benefits:                                               |
|                                                                       |
| -   Section 3, *How you get care*, for information about catastrophic |
|     protection for these benefits.                                    |
|                                                                       |
| -   Section 7, *Filing a claim for covered services*, for information |
|     about submitting out-of-network claims.                           |
+-----------------------------------------------------------------------+

+---+---+----------------------------------------------------------+---+---+
| * |   |                                                          |   |   |
| * |   |                                                          |   |   |
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| ) |   |                                                          |   |   |
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| s |   |                                                          |   |   |
| * |   |                                                          |   |   |
| * |   |                                                          |   |   |
+---+---+----------------------------------------------------------+---+---+
|   | # | > **Here are some important things to keep in mind about | # |   |
|   | # | > these benefits and features you should be aware of:**  | # |   |
|   | # |                                                          | # |   |
|   | # | -   We cover prescribed drugs and medications, as        | # |   |
|   | # |     described in the chart beginning on page 65.         | # |   |
|   | # |                                                          | # |   |
|   |   | -   Please remember that all benefits are subject to the |   |   |
|   | I |     definitions, limitations, and exclusions in this     | I |   |
|   |   |     brochure and are payable only when we determine they |   |   |
|   | * |     are medically necessary.                             | # |   |
|   | * |                                                          | # |   |
|   | M | -   There is no calendar year deductible for             | # |   |
|   | * |     prescription drugs.                                  | # |   |
|   | * |                                                          | # |   |
|   |   | ```{=html}                                               | # |   |
|   | * | <!-- -->                                                 |   |   |
|   | * | ```                                                      | M |   |
|   | P | -   Be sure to read Section 4, *Your costs for covered   |   |   |
|   | * |     services,* for valuable information about how cost   | * |   |
|   | * |     sharing works, with special sections for members who | * |   |
|   |   |     are age 65 or over. Also read Section 9 about        | P |   |
|   | * |     coordinating benefits with other coverage, including | * |   |
|   | * |     with Medicare.                                       | * |   |
|   | O |                                                          |   |   |
|   | * | ```{=html}                                               | * |   |
|   | * | <!-- -->                                                 | * |   |
|   |   | ```                                                      | O |   |
|   | * | -   Under the High Option plan, if Medicare is your      | * |   |
|   | * |     primary insurance and you have both Medicare Part A  | * |   |
|   | R |     & B coverage, you pay less for your prescriptions    |   |   |
|   | * |     (see page 66).                                       | * |   |
|   | * |                                                          | * |   |
|   |   | -   Some medications are limited in quantity based on    | R |   |
|   | * |     manufacturer's and FDA guidelines.                   | * |   |
|   | * |                                                          | * |   |
|   | T | -   Some medications must be approved by GEHA before you |   |   |
|   | * |     may purchase them.                                   | * |   |
|   | * |                                                          | * |   |
|   |   | -   If you need an extra supply of medications in        | T |   |
|   | * |     emergency situations such as if you are called to    | * |   |
|   | * |     active military duty or as a part of the             | * |   |
|   | A |     government's continuity of operations, you may       |   |   |
|   | * |     receive an extra 30 day supply at retail or if you   | * |   |
|   | * |     received a 90 day supply of a specific medication    | * |   |
|   |   |     within the last thirty days, arrangements can be     | A |   |
|   | * |     made for an additional 60 days to be dispensed       | * |   |
|   | * |     through the Home Delivery Pharmacy Service. Call our | * |   |
|   | N |     office at (800) 821-6136 so that we can work with    |   |   |
|   | * |     you to find the most cost effective and efficient    | * |   |
|   | * |     manner of meeting your emergency prescription needs. | * |   |
|   |   |                                                          | N |   |
|   | * | ```{=html}                                               | * |   |
|   | * | <!-- -->                                                 | * |   |
|   | T | ```                                                      |   |   |
|   | * | -   Each new enrollee will receive a description of our  | * |   |
|   | * |     prescription drug program, a combined prescription   | * |   |
|   |   |     drug/Plan identification card, and a mail order      | T |   |
|   |   |     form, questionnaire, and reply envelope.             | * |   |
|   |   |                                                          | * |   |
|   |   | -   **Who can write your prescription.** A licensed      |   |   |
|   |   |     physician or a licensed dentist must write the       |   |   |
|   |   |     prescription. For Medco Health home delivery         |   |   |
|   |   |     prescriptions, the physician must be licensed in the |   |   |
|   |   |     United States. In addition, your mailing address     |   |   |
|   |   |     must be within the United States or include an APO   |   |   |
|   |   |     address.                                             |   |   |
|   |   |                                                          |   |   |
|   |   | ```{=html}                                               |   |   |
|   |   | <!-- -->                                                 |   |   |
|   |   | ```                                                      |   |   |
|   |   | -   **Where you can obtain them.** You may fill the      |   |   |
|   |   |     prescription at a participating network retail       |   |   |
|   |   |     pharmacy, a non-network pharmacy, or by the Medco    |   |   |
|   |   |     Health Home Delivery Pharmacy Service. We pay a      |   |   |
|   |   |     higher level of benefits when you use a network      |   |   |
|   |   |     pharmacy. For medications you may take on a regular, |   |   |
|   |   |     long-term basis we pay a higher level of benefits    |   |   |
|   |   |     through the home delivery service.                   |   |   |
+---+---+----------------------------------------------------------+---+---+
| # |   |                                                          |   |   |
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+---+---+----------------------------------------------------------+---+---+
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+---+---+----------------------------------------------------------+---+---+
| > |   |                                                          |   |   |
|   |   |                                                          |   |   |
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| * |   |                                                          |   |   |
+---+---+----------------------------------------------------------+---+---+

+-----------------------------------------------------------------------+
| ### Prescription drug benefits *(continued)*                          |
+-----------------------------------------------------------------------+
| ### High Option - three-tier drug benefit                             |
+-----------------------------------------------------------------------+
| > Under the **High Option**, we divide prescription drugs into three  |
| > categories or tiers: generic, single-source brand name, and         |
| > multi-source brand name. Multi-source brand name is not applicable  |
| > to overseas prescription drugs. When an approved generic equivalent |
| > is available, that is the drug you will receive, unless you or your |
| > physician specify that the prescription must be filled as written.  |
| > When an approved generic equivalent is not available, you will pay  |
| > the brand name single-source copayment. If an approved generic      |
| > equivalent is available, but you or your physician specify that the |
| > prescription must be filled as written, you will pay the brand name |
| > multi-source copayment.                                             |
|                                                                       |
| -   **Generic drugs:** are chemically and therapeutically equivalent  |
|     to the corresponding brand drug, but are available at a lower     |
|     price. Equivalent generic products for brand name medications     |
|     become available after a patent and other exclusivity rights for  |
|     the brand expire. The Food and Drug Administration must approve   |
|     all generic versions of a drug and assure that they meet strict   |
|     standards for quality, strength and purity. The FDA requires that |
|     generic equivalent medications contain the same active            |
|     ingredients and be equivalent in strength and dosage to brand     |
|     name drugs. The main difference between a generic and its brand   |
|     name drug is the cost of the product.                             |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **Single-source** brand name drugs are available from only one    |
|     manufacturer and are patent-protected. No generic equivalent is   |
|     available.                                                        |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **Multi-source** brand name drugs are available from more than    |
|     one manufacturer and have a least one generic equivalent          |
|     alternative available.                                            |
+-----------------------------------------------------------------------+
| ### Coordinating with other drug coverage                             |
+-----------------------------------------------------------------------+
| > If you also have drug coverage through another group health         |
| > insurance plan and we are your secondary insurance, follow these    |
| > procedures:                                                         |
| >                                                                     |
| > At participating pharmacies, do not present your GEHA drug card.    |
| > Purchase your drug and submit the bill to your primary insurance.   |
| > When they have made payment, file the claim and the Explanation of  |
| > Benefits (EOB) with GEHA (see page 75). If you use GEHA's           |
| > prescription drug card when another insurance is primary, you will  |
| > be responsible for reimbursing us any amount in excess of our       |
| > secondary benefit.                                                  |
| >                                                                     |
| > Drugs purchased at non-participating pharmacies should be submitted |
| > to our claims office (see page 76) along with the primary insurance |
| > EOB. We will accept either the drug receipts or a Medco Health drug |
| > claim form. **Submit these claims to GEHA, P.O. 4665, Independence, |
| > MO 64051-4665, when we are your secondary insurance.**              |
| >                                                                     |
| > If another insurance is primary, you should use their drug benefit. |
| > If you elect to use the Home Delivery Pharmacy service, Medco       |
| > Health will bill you directly. Pay Medco Health the amount billed   |
| > and submit the bill to your primary insurance. When your primary    |
| > insurance makes payment, file the claim and their EOB to us (see    |
| > page 75).                                                           |
| >                                                                     |
| > In some cases, Medicare covers prescription drugs and supplies. If  |
| > Medicare is your primary insurance and you use prescription drugs   |
| > or supplies covered by Medicare, we will attempt to recover the     |
| > cost of the drug or supply from Medicare. Please help us obtain     |
| > this reimbursement by signing and returning to us an authorization  |
| > form for Medicare reimbursement. This form is sent to you           |
| > automatically when you utilize medications that are allowable for   |
| > submission to Medicare. If we are unsuccessful in recovering our    |
| > payment from Medicare, we reserve the right to require you to       |
| > purchase the medication and then file a claim with Medicare. After  |
| > Medicare makes payment, you may file a claim with us for the        |
| > out-of-pocket cost, in excess of your GEHA copayment.               |
| >                                                                     |
| > Should Medicare rules change on prescription drug coverage, we      |
| > reserve the right to require you to use your Medicare coverage as   |
| > the primary insurance for these drugs.                              |
+-----------------------------------------------------------------------+
| Prescription drug benefits -- continue on next page                   |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ### Prescription drug benefits *(continued)*                          |
+-----------------------------------------------------------------------+
| ### Medco Health voluntary formulary                                  |
+-----------------------------------------------------------------------+
| > Your prescription drug program includes a voluntary "formulary"     |
| > feature. The Medco Health Drug Formulary is a list of selected FDA  |
| > approved prescription medications reviewed by an independent group  |
| > of distinguished health care professionals. Prescription drugs are  |
| > subjected to rigorous clinical analysis from the standpoint of      |
| > efficacy, safety, side effects, drug-to-drug interactions, dosage   |
| > and cost-benefit in determining whether they are included on or     |
| > excluded from the formulary.                                        |
|                                                                       |
| A formulary is a list of commonly prescribed medications from which   |
| your physician may choose to prescribe. The formulary is designed to  |
| inform you and your physician about quality medications that, when    |
| prescribed in place of other non-formulary medications, can help      |
| contain the increasing cost of prescription drug coverage without     |
| sacrificing quality. In many therapeutic categories, there are        |
| several drugs of similar effectiveness. Many doctors are often        |
| unaware of the significant variations in price among these similar    |
| drugs and, as a result, their prescribing decisions often do not      |
| consider cost. However, when the cost difference is brought to their  |
| attention, doctors will frequently prescribe the less costly          |
| medications.                                                          |
|                                                                       |
| ### Your physicia                                                     |
| ns will be contacted to discuss their prescribing decision. No change |
|  in the medication prescribed will be made without your physicians' a |
| pproval. Compliance with this formulary list is voluntary and there i |
| s no financial penalty for obtaining drugs not on the formulary list. |
|                                                                       |
| ### Any rebates or savings received by the Plan on the                |
|  cost of drugs purchased under this plan from drug manufacturers are  |
| credited to the health plan and are used to reduce health care costs. |
+-----------------------------------------------------------------------+
| ### Patient Safety                                                    |
+-----------------------------------------------------------------------+
| > **GEHA has several programs to promote patient safety. Through      |
| > these programs, we work to ensure safe and appropriate quantities   |
| > of medication are being dispensed. The result is improved care and  |
| > safety for our members. Patient safety programs include:**          |
|                                                                       |
| -   Prior approval -- Approval must be obtained for certain           |
|     prescription drugs and supplies before providing benefits for     |
|     them.                                                             |
|                                                                       |
| -   Quantity allowances -- Specific allowances are in place for       |
|     certain medications, based on manufacturer and FDA recommended    |
|     guidelines.                                                       |
|                                                                       |
| -   Pharmacy utilization -- GEHA reserves the right to maximize your  |
|     quality of care as it relates to the utilization of pharmacies.   |
|                                                                       |
| ### GEHA will participate in other approved                           |
| managed care programs, as deemed necessary, to insure patient safety. |
+-----------------------------------------------------------------------+
| > *Prescription drug benefits - continued on next page*               |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| > **Prescription drug benefits** *(continued)*                        |
+-----------------------------------------------------------------------+
| ### How to use Medco Health network pharmacies (retail)               |
+-----------------------------------------------------------------------+
| > You may fill your prescription at any participating retail          |
| > pharmacy. For the names of participating pharmacies, call (800)     |
| > 551-7675 or visit [www.medcohealth.com]{.underline}. To receive     |
| > maximum savings you must present your card at the time of each      |
| > purchase, and your enrollment information must be current and       |
| > correct. In most cases, you simply present the card together with   |
| > the prescription to the pharmacist. Each purchase is limited to a   |
| > 30-day supply. Any prescription purchased twice at retail,          |
| > regardless of the quantity purchased is considered maintenance      |
| > medication. We pay a higher level of benefits for maintenance       |
| > medication through the home delivery service.                       |
| >                                                                     |
| > Refills cannot be obtained until **75%** of the drug has been used. |
| > Refills for maintenance medications are not considered new          |
| > prescriptions except when the doctor changes the strength or 180    |
| > days has elapsed since the previous purchase. As part of the        |
| > administration of the prescription drug program, we reserve the     |
| > right to maximize your quality of care as it relates to the         |
| > utilization of pharmacies. Some medications may require prior       |
| > approval by Medco Health or GEHA.                                   |
+-----------------------------------------------------------------------+
| ### Ho                                                                |
| w to use the Medco Health Home Delivery Pharmacy Service (mail order) |
+-----------------------------------------------------------------------+
| > Through this service, you may receive up to a 90-day supply of      |
| > maintenance medications for drugs which require a prescription,     |
| > ostomy supplies, diabetic supplies and insulin, syringes and        |
| > needles for covered injectable medications, and oral                |
| > contraceptives. Some medications may not be available in a 90-day   |
| > supply from Medco Health even though the prescription is for 90     |
| > days. Even though insulin, syringes, diabetic supplies and ostomy   |
| > supplies do not require a physician's prescription, to obtain       |
| > through home delivery, you should obtain a prescription (including  |
| > the product number for ostomy and insulin pump supplies) from your  |
| > physician for a 90-day supply.                                      |
| >                                                                     |
| > Some medications may require approval by Medco Health or GEHA. Not  |
| > all drugs are available through the Home Delivery Pharmacy service. |
| > In order to use the Home Delivery Pharmacy service, your            |
| > prescriptions must be written by a physician licensed in the United |
| > States. In addition, your mailing address must be within the United |
| > States or include an APO address.                                   |
| >                                                                     |
| > Each enrollee will receive a kit that includes a brochure           |
| > describing the Home Delivery Pharmacy service, an order form, a     |
| > questionnaire, and a return envelope.                               |
| >                                                                     |
| > **To order new prescriptions,** ask your doctor to prescribe needed |
| > medication for up to a 90-day supply, plus refills, if appropriate. |
| > Complete the Health, Allergy, & Medication Questionnaire the first  |
| > time you order through this service. Complete the information on    |
| > the Ordering Medication Form, enclose your prescription and the     |
| > correct copayment.                                                  |
| >                                                                     |
| > Mail to: Medco Health                                               |
| >                                                                     |
| > P.O. Box 98830                                                      |
| >                                                                     |
| > Las Vegas, NV 89193-8830                                            |
| >                                                                     |
| > You should receive your medication within 14 days from the date you |
| > mail your prescription. You will also receive reorder instructions. |
| > If you have any questions or need an emergency consultation with a  |
| > registered pharmacist, you may call Medco Health toll-free at (800) |
| > 551-7675 available 24 hours a day, 7 days a week except             |
| > Thanksgiving and Christmas. Forms necessary for refills will be     |
| > provided each time you receive a supply of medication from the      |
| > service.                                                            |
| >                                                                     |
| > **Refilling your medication:** to be sure you never run short of    |
| > your prescription medication, you should re-order on or after the   |
| > refill date indicated on the refill slip or when you have           |
| > approximately 14 days of medication left.                           |
| >                                                                     |
| > **To order by phone:** Call Member Services at (800) 551-7675. Have |
| > your refill slip with the prescription information ready.           |
| >                                                                     |
| > **To order by mail:** Simply mail your refill slip and copayment in |
| > the return envelope.                                                |
| >                                                                     |
| > **To order online**: Go to                                          |
| > [[www.geha.com/benefit/p                                            |
| rescrip.html]{.underline}](http://www.geha.com/benefit/prescrip.html) |
| > then click on the link to Medco Health, or go to                    |
| > [[www.medcohealth.com](http://www.merck-medco.com/).]{.underline}   |
+-----------------------------------------------------------------------+
| > *Prescription drug benefits - continued on next page*               |
+-----------------------------------------------------------------------+

+-----------------------------------------+-------------+-------------+
|                                         |             |             |
+-----------------------------------------+-------------+-------------+
| ### P                                   | ### You Pay |             |
| rescription drug benefits *(continued)* |             |             |
+-----------------------------------------+-------------+-------------+
|                                         | ### Stand   | ###         |
|                                         | ard Option  | High Option |
+-----------------------------------------+-------------+-------------+
| ######## Covered medicatio              | ###         | ###         |
| ns and supplies -- when GEHA is primary |             |             |
+-----------------------------------------+-------------+-------------+
| > **Medco Health Network Pharmacy       | \$5 generic | \$5         |
| > (retail)**                            |             | generic,    |
| >                                       | 50% brand   |             |
| > All copayments are for up to a 30-day | name        | \$25        |
| > supply. If the cost of the medication |             | si          |
| > or supply is less than the applicable | Initial     | ngle-source |
| > copayment, you are only responsible   | amount      | brand name, |
| > for the cost of the medication, not   | prescribed, |             |
| > the full copayment.                   | for up to a | \$40        |
| >                                       | 30-day      | m           |
| > A generic equivalent will be          | supply      | ulti-source |
| > dispensed unless you or your          |             | brand name  |
| > physician specifies that the          |             |             |
| > prescription be dispensed as written  |             | Initial     |
| > (DAW), when a Federally approved      |             | fill not to |
| > generic drug is available. If there   |             | exceed a    |
| > is no generic equivalent available,   |             | 30-day      |
| > you pay the brand name copayment.     |             | supply, and |
|                                         |             | the first   |
|                                         |             | refill.     |
|                                         |             |             |
|                                         |             | For all     |
|                                         |             | subsequent  |
|                                         |             | refills,    |
|                                         |             | you pay the |
|                                         |             | greater of  |
|                                         |             | 50% or the  |
|                                         |             | copayments  |
|                                         |             | described   |
|                                         |             | above.      |
+-----------------------------------------+-------------+-------------+
| ######## Non-Network Retail             | \$5 generic | \$5         |
|                                         |             | generic,    |
| If a participating pharmacy is not      | 50% brand   |             |
| available where you reside or you do    | name        | \$25        |
| not use your identification card, you   |             | si          |
| must submit your claim to:              | (and any    | ngle-source |
|                                         | difference  | brand name, |
| Medco Health                            | between our |             |
|                                         | allowance   | \$40        |
| P.O. Box 2187                           | and the     | m           |
|                                         | cost of the | ulti-source |
| Lee\'s Summit, MO 64063-2187            | drug)       | brand name, |
|                                         |             |             |
| > Your claim will be calculated on the  |             | (and any    |
| > 50% coinsurance or the appropriate    |             | difference  |
| > copayments. Reimbursement will be     |             | between our |
| > based on GEHA's costs had you used a  |             | allowance   |
| > participating pharmacy. You must      |             | and the     |
| > submit original drug receipts.        |             | cost of the |
| >                                       |             | drug)       |
| > All copayments are for up to a 30-day |             |             |
| > supply. If the cost of the medication |             | Initial     |
| > or supply is less than the applicable |             | fill not to |
| > copayment, you are only responsible   |             | exceed a    |
| > for the cost of the medication.       |             | 30-day      |
| >                                       |             | supply, and |
| > Note: When a claim is submitted for   |             | the first   |
| > direct reimbursement of a compound    |             | refill.     |
| > medication, the pricing is based on   |             |             |
| > the contractual Average Wholesale     |             | For all     |
| > Price (AWP) cost of each active       |             | subsequent  |
| > prescription component submitted. The |             | refills,    |
| > professional fee and applicable sales |             | you pay the |
| > tax and copayments are also included  |             | greater of  |
| > in the pricing.                       |             | 50% or the  |
|                                         |             | copayments  |
|                                         |             | described   |
|                                         |             | above and   |
|                                         |             | any         |
|                                         |             | difference  |
|                                         |             | between our |
|                                         |             | allowance   |
|                                         |             | and the     |
|                                         |             | cost of the |
|                                         |             | drug.       |
+-----------------------------------------+-------------+-------------+
| > **Medco Health Home Delivery Pharmacy | \$15        | ### \$      |
| > Service**                             | generic     | 10 generic, |
| >                                       |             |             |
| > All copayments are for up to a 90-day | 50% brand   | #           |
| > supply. If the cost of the medication | name        | ## \$45 sin |
| > or supply is less than the applicable |             | gle-source  |
| > copayment, you are only responsible   | ###         | brand name, |
| > for the cost of the medication.       |             |             |
| >                                       |             | ### \$60 m  |
| > A generic equivalent will be          |             | ulti-source |
| > dispensed unless you or your          |             |  brand name |
| > physician specifies that the          |             |             |
| > prescription be dispensed as written  |             |             |
| > (DAW), when a Federally approved      |             |             |
| > generic drug is available. If there   |             |             |
| > is no generic equivalent available,   |             |             |
| > you pay the brand name copayment.     |             |             |
+-----------------------------------------+-------------+-------------+
| ### *Prescription                       |             |             |
| drug benefits - continued on next page* |             |             |
+-----------------------------------------+-------------+-------------+

+---+---+----------------------------------------+-------------+-------------+
|   |   |                                        |             |             |
+---+---+----------------------------------------+-------------+-------------+
| # |   |                                        | ### You Pay |             |
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+---+---+----------------------------------------+-------------+-------------+
|   |   |                                        | ### Stand   | ###         |
|   |   |                                        | ard Option  | High Option |
+---+---+----------------------------------------+-------------+-------------+
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+---+---+----------------------------------------+-------------+-------------+
| > |   |                                        | \$5 generic | \$3         |
|   |   |                                        |             | generic,    |
| * |   |                                        | 50% brand   |             |
| * |   |                                        | name        | \$10        |
| M |   |                                        |             | si          |
| e |   |                                        | Initial     | ngle-source |
| d |   |                                        | amount      | brand name, |
| c |   |                                        | prescribed, |             |
| o |   |                                        | for up to a | \$25        |
| > |   |                                        | 30-day      | m           |
|   |   |                                        | supply      | ulti-source |
| H |   |                                        |             | brand name  |
| e |   |                                        |             |             |
| a |   |                                        |             | Initial     |
| l |   |                                        |             | fill not to |
| t |   |                                        |             | exceed a    |
| h |   |                                        |             | 30-day      |
| > |   |                                        |             | supply, and |
|   |   |                                        |             | the first   |
| N |   |                                        |             | refill.     |
| e |   |                                        |             |             |
| t |   |                                        |             | For all     |
| w |   |                                        |             | subsequent  |
| o |   |                                        |             | refills,    |
| r |   |                                        |             | you pay the |
| k |   |                                        |             | greater of  |
| > |   |                                        |             | 50% or the  |
|   |   |                                        |             | copayments  |
| P |   |                                        |             | described   |
| h |   |                                        |             | above.      |
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+---+---+----------------------------------------+-------------+-------------+
| # |   |                                        | \$5 generic | \$3         |
| # |   |                                        |             | generic,    |
| # |   |                                        | 50% brand   |             |
| # |   |                                        | name        | \$10        |
| # |   |                                        |             | si          |
| # |   |                                        | (and any    | ngle-source |
| # |   |                                        | difference  | brand name, |
| # |   |                                        | between our |             |
|   |   |                                        | allowance   | \$25        |
| N |   |                                        | and the     | m           |
| o |   |                                        | cost of the | ulti-source |
| n |   |                                        | drug)       | brand name, |
| - |   |                                        |             |             |
| N |   |                                        |             | (and any    |
| e |   |                                        |             | difference  |
| t |   |                                        |             | between our |
| w |   |                                        |             | allowance   |
| o |   |                                        |             | and the     |
| r |   |                                        |             | cost of the |
| k |   |                                        |             | drug)       |
|   |   |                                        |             |             |
| R |   |                                        |             | Initial     |
| e |   |                                        |             | fill not to |
| t |   |                                        |             | exceed a    |
| a |   |                                        |             | 30-day      |
| i |   |                                        |             | supply, and |
| l |   |                                        |             | the first   |
|   |   |                                        |             | refill.     |
| I |   |                                        |             |             |
| f |   |                                        |             | For all     |
| a |   |                                        |             | subsequent  |
| p |   |                                        |             | refills,    |
| a |   |                                        |             | you pay the |
| r |   |                                        |             | greater of  |
| t |   |                                        |             | 50% or the  |
| i |   |                                        |             | copayments  |
| c |   |                                        |             | described   |
| i |   |                                        |             | above and   |
| p |   |                                        |             | any         |
| a |   |                                        |             | difference  |
| t |   |                                        |             | between our |
| i |   |                                        |             | allowance   |
| n |   |                                        |             | and the     |
| g |   |                                        |             | cost of the |
| p |   |                                        |             | drug.       |
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+---+---+----------------------------------------+-------------+-------------+
| > |   |                                        | \$15        | ### \       |
|   |   |                                        | generic     | $5 generic, |
| * |   |                                        |             |             |
| * |   |                                        | 50% brand   | #           |
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| d |   |                                        | ###         | brand name, |
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+---+---+----------------------------------------+-------------+-------------+
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+---+---+----------------------------------------+-------------+-------------+
|   |   |                                        |             |             |
+---+---+----------------------------------------+-------------+-------------+
|   | # |                                        | ### You Pay |             |
|   | # |                                        |             |             |
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+---+---+----------------------------------------+-------------+-------------+
|   |   |                                        | ### Stand   | ###         |
|   |   |                                        | ard Option  | High Option |
+---+---+----------------------------------------+-------------+-------------+
|   | # |                                        | ###         | ###         |
|   | # |                                        |             |             |
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+---+---+----------------------------------------+-------------+-------------+
|   |   | > *The following medications and       | *All        | *All        |
|   |   | > supplies are not covered under the   | charges*    | charges*    |
|   |   | > GEHA health plan.*                   |             |             |
|   |   |                                        |             |             |
|   |   | -   *Drugs and supplies for cosmetic   |             |             |
|   |   |     purposes*                          |             |             |
|   |   |                                        |             |             |
|   |   | -   *Vitamins, nutrients and food      |             |             |
|   |   |     supplements even if a physician    |             |             |
|   |   |     prescribes or administers them     |             |             |
|   |   |     including enteral formula          |             |             |
|   |   |     available without a prescription*  |             |             |
|   |   |                                        |             |             |
|   |   | -   *Nonprescription medicines*        |             |             |
|   |   |                                        |             |             |
|   |   | -   *Drugs to aid in smoking cessation |             |             |
|   |   |     except those limited to the \$100  |             |             |
|   |   |     lifetime maximum as part of the    |             |             |
|   |   |     smoking cessation benefit (see     |             |             |
|   |   |     page 36). You may not obtain       |             |             |
|   |   |     smoking cessation drugs with your  |             |             |
|   |   |     Medco Health Prescription card or  |             |             |
|   |   |     through the home delivery service. |             |             |
|   |   |     You must purchase these drugs and  |             |             |
|   |   |     file the claim with us.*           |             |             |
|   |   |                                        |             |             |
|   |   | -   *Medical supplies such as          |             |             |
|   |   |     dressings and antiseptics*         |             |             |
|   |   |                                        |             |             |
|   |   | -   *Drugs which are investigational*  |             |             |
|   |   |                                        |             |             |
|   |   | -   *Drugs prescribed for weight loss* |             |             |
|   |   |                                        |             |             |
|   |   | -   *Drugs to treat infertility*       |             |             |
|   |   |                                        |             |             |
|   |   | -   *Drugs to treat impotency*         |             |             |
+---+---+----------------------------------------+-------------+-------------+

+-----------------+----------------------------------------------------+
| > Section 5     |                                                    |
| > (g). Special  |                                                    |
| > features      |                                                    |
+=================+====================================================+
| > **Special     | > **Description**                                  |
| > features**    |                                                    |
+-----------------+----------------------------------------------------+
| > **Flexible    | Under the flexible benefits option, we determine   |
| > benefits      | the most effective way to provide services.        |
| > option**      |                                                    |
|                 | -   We may identify medically appropriate          |
|                 |     alternatives to traditional care and           |
|                 |     coordinate other benefits as a less costly     |
|                 |     alternative benefit.                           |
|                 |                                                    |
|                 | -   Alternative benefits are subject to our        |
|                 |     ongoing review.                                |
|                 |                                                    |
|                 | -   By approving an alternative benefit, we cannot |
|                 |     guarantee you will get it in the future.       |
|                 |                                                    |
|                 | -   The decision to offer an alternative benefit   |
|                 |     is solely ours, and we may withdraw it at any  |
|                 |     time and resume regular contract benefits.     |
|                 |                                                    |
|                 | -   Our decision to offer or withdraw alternative  |
|                 |     benefits is not subject to OPM review under    |
|                 |     the disputed claims process.                   |
+-----------------+----------------------------------------------------+
| > **Services    | TDD service is available at (800) 821-4833 for     |
| > for deaf and  | members who are hearing impaired.                  |
| > hearing       |                                                    |
| > impaired**    |                                                    |
+-----------------+----------------------------------------------------+
| > **High risk   | > To participate in our enhanced maternity         |
| > pregnancies** | > program, call (888) 372-3190 at any time as soon |
|                 | > as you think you or your covered dependent may   |
|                 | > be pregnant. Early participation in the program  |
|                 | > guarantees you ongoing communication with a      |
|                 | > registered nurse throughout the pregnancy.       |
|                 | > Complimentary educational materials include the  |
|                 | > book "From Here to Maternity".                   |
+-----------------+----------------------------------------------------+

+---+---+--------------------+---------+---------+----------+---+---+---+
| > |   |                    |         |         |          |   |   |   |
|   |   |                    |         |         |          |   |   |   |
| 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:**        |         |         |          |   | # |   |
|   | # |                    |         |         |          |   | # |   |
|   |   | -   Please         |         |         |          |   |   |   |
|   | I |     remember that  |         |         |          |   | I |   |
|   |   |     all benefits   |         |         |          |   |   |   |
|   | * |     are subject to |         |         |          |   | * |   |
|   | * |     the            |         |         |          |   | * |   |
|   | M |     definitions,   |         |         |          |   | M |   |
|   | * |     limitations,   |         |         |          |   | * |   |
|   | * |     and exclusions |         |         |          |   | * |   |
|   |   |     in this        |         |         |          |   |   |   |
|   | * |     brochure and   |         |         |          |   | * |   |
|   | * |     are payable    |         |         |          |   | * |   |
|   | P |     only when we   |         |         |          |   | P |   |
|   | * |     determine they |         |         |          |   | * |   |
|   | * |     are medically  |         |         |          |   | * |   |
|   |   |     necessary.     |         |         |          |   |   |   |
|   | * |                    |         |         |          |   | * |   |
|   | * | -   There is no    |         |         |          |   | * |   |
|   | O |     calendar year  |         |         |          |   | O |   |
|   | * |     deductible for |         |         |          |   | * |   |
|   | * |     dental         |         |         |          |   | * |   |
|   |   |     benefits.      |         |         |          |   |   |   |
|   | * |                    |         |         |          |   | * |   |
|   | * | -   Be sure to     |         |         |          |   | * |   |
|   | R |     read Section   |         |         |          |   | R |   |
|   | * |     4, *Your costs |         |         |          |   | * |   |
|   | * |     for covered    |         |         |          |   | * |   |
|   |   |     services,* for |         |         |          |   |   |   |
|   | * |     valuable       |         |         |          |   | * |   |
|   | * |     information    |         |         |          |   | * |   |
|   | T |     about how cost |         |         |          |   | T |   |
|   | * |     sharing works, |         |         |          |   | * |   |
|   | * |     with special   |         |         |          |   | * |   |
|   |   |     sections for   |         |         |          |   |   |   |
|   | * |     members who    |         |         |          |   | * |   |
|   | * |     are age 65 or  |         |         |          |   | * |   |
|   | A |     over. Also     |         |         |          |   | A |   |
|   | * |     read Section 9 |         |         |          |   | * |   |
|   | * |     about          |         |         |          |   | * |   |
|   |   |     coordinating   |         |         |          |   |   |   |
|   | * |     benefits with  |         |         |          |   | * |   |
|   | * |     other          |         |         |          |   | * |   |
|   | N |     coverage,      |         |         |          |   | N |   |
|   | * |     including with |         |         |          |   | * |   |
|   | * |     Medicare.      |         |         |          |   | * |   |
|   |   |                    |         |         |          |   |   |   |
|   | * | ```{=html}         |         |         |          |   | * |   |
|   | * | <!-- -->           |         |         |          |   | * |   |
|   | T | ```                |         |         |          |   | T |   |
|   | * | -   Note: We cover |         |         |          |   | * |   |
|   | * |                    |         |         |          |   | * |   |
|   |   |    hospitalization |         |         |          |   |   |   |
|   |   |     for dental     |         |         |          |   |   |   |
|   |   |     procedures     |         |         |          |   |   |   |
|   |   |     only when a    |         |         |          |   |   |   |
|   |   |     non-dental     |         |         |          |   |   |   |
|   |   |     physical       |         |         |          |   |   |   |
|   |   |     impairment     |         |         |          |   |   |   |
|   |   |     exists which   |         |         |          |   |   |   |
|   |   |     makes          |         |         |          |   |   |   |
|   |   |                    |         |         |          |   |   |   |
|   |   |    hospitalization |         |         |          |   |   |   |
|   |   |     necessary to   |         |         |          |   |   |   |
|   |   |     safeguard the  |         |         |          |   |   |   |
|   |   |     health of the  |         |         |          |   |   |   |
|   |   |     patient. We do |         |         |          |   |   |   |
|   |   |     not cover the  |         |         |          |   |   |   |
|   |   |     dental         |         |         |          |   |   |   |
|   |   |     procedure. See |         |         |          |   |   |   |
|   |   |     Section 5 (c)  |         |         |          |   |   |   |
|   |   |     for inpatient  |         |         |          |   |   |   |
|   |   |     hospital       |         |         |          |   |   |   |
|   |   |     benefits.      |         |         |          |   |   |   |
+---+---+--------------------+---------+---------+----------+---+---+---+
| > |   |                    |         |         |          |   |   |   |
|   |   |                    |         |         |          |   |   |   |
| * |   |                    |         |         |          |   |   |   |
| * |   |                    |         |         |          |   |   |   |
| A |   |                    |         |         |          |   |   |   |
| c |   |                    |         |         |          |   |   |   |
| c |   |                    |         |         |          |   |   |   |
| i |   |                    |         |         |          |   |   |   |
| d |   |                    |         |         |          |   |   |   |
| e |   |                    |         |         |          |   |   |   |
| n |   |                    |         |         |          |   |   |   |
| t |   |                    |         |         |          |   |   |   |
| a |   |                    |         |         |          |   |   |   |
| l |   |                    |         |         |          |   |   |   |
| > |   |                    |         |         |          |   |   |   |
|   |   |                    |         |         |          |   |   |   |
| i |   |                    |         |         |          |   |   |   |
| n |   |                    |         |         |          |   |   |   |
| j |   |                    |         |         |          |   |   |   |
| u |   |                    |         |         |          |   |   |   |
| r |   |                    |         |         |          |   |   |   |
| y |   |                    |         |         |          |   |   |   |
| > |   |                    |         |         |          |   |   |   |
|   |   |                    |         |         |          |   |   |   |
| b |   |                    |         |         |          |   |   |   |
| e |   |                    |         |         |          |   |   |   |
| n |   |                    |         |         |          |   |   |   |
| e |   |                    |         |         |          |   |   |   |
| f |   |                    |         |         |          |   |   |   |
| i |   |                    |         |         |          |   |   |   |
| t |   |                    |         |         |          |   |   |   |
| s |   |                    |         |         |          |   |   |   |
| * |   |                    |         |         |          |   |   |   |
| * |   |                    |         |         |          |   |   |   |
+---+---+--------------------+---------+---------+----------+---+---+---+
| > |   |                    |         |         |          |   |   |   |
|   |   |                    |         |         |          |   |   |   |
| W |   |                    |         |         |          |   |   |   |
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| > |   |                    |         |         |          |   |   |   |
|   |   |                    |         |         |          |   |   |   |
| c |   |                    |         |         |          |   |   |   |
| o |   |                    |         |         |          |   |   |   |
| v |   |                    |         |         |          |   |   |   |
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| g |   |                    |         |         |          |   |   |   |
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| l |   |                    |         |         |          |   |   |   |
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| r |   |                    |         |         |          |   |   |   |
| > |   |                    |         |         |          |   |   |   |
|   |   |                    |         |         |          |   |   |   |
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| l |   |                    |         |         |          |   |   |   |
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+---+---+--------------------+---------+---------+----------+---+---+---+
| > |   |                    |         |         |          |   |   |   |
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| * |   |                    |         |         |          |   |   |   |
| * |   |                    |         |         |          |   |   |   |
| D |   |                    |         |         |          |   |   |   |
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| s |   |                    |         |         |          |   |   |   |
| * |   |                    |         |         |          |   |   |   |
| * |   |                    |         |         |          |   |   |   |
+---+---+--------------------+---------+---------+----------+---+---+---+
| # |   |                    | > **S   |         | **High   |   |   |   |
| # |   |                    | tandard |         | Option** |   |   |   |
| # |   |                    | > O     |         |          |   |   |   |
|   |   |                    | ption** |         | > **S    |   |   |   |
|   |   |                    |         |         | cheduled |   |   |   |
| S |   |                    | **Sc    |         | > All    |   |   |   |
| e |   |                    | heduled |         | owance** |   |   |   |
| r |   |                    | Allo    |         |          |   |   |   |
| v |   |                    | wance** |         |          |   |   |   |
| i |   |                    |         |         |          |   |   |   |
| c |   |                    |         |         |          |   |   |   |
| e |   |                    |         |         |          |   |   |   |
+---+---+--------------------+---------+---------+----------+---+---+---+
|   |   |                    | ###     | **You   | ##       | * |   |   |
|   |   |                    |  We pay | pay**   | # We pay | * |   |   |
|   |   |                    |         |         |          | Y |   |   |
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|   |   |                    |         |         |          | p |   |   |
|   |   |                    |         |         |          | a |   |   |
|   |   |                    |         |         |          | y |   |   |
|   |   |                    |         |         |          | * |   |   |
|   |   |                    |         |         |          | * |   |   |
+---+---+--------------------+---------+---------+----------+---+---+---+
| > |   |                    | 50% up  | 50% up  | \$22 per | A |   |   |
|   |   |                    | to the  | to the  | visit    | l |   |   |
| D |   |                    | plan    | plan    | (maximum | l |   |   |
| i |   |                    | al      | al      | two      | c |   |   |
| a |   |                    | lowance | lowance | visits   | h |   |   |
| g |   |                    | for     | and all | per      | a |   |   |
| n |   |                    | dia     | charges | year)    | r |   |   |
| o |   |                    | gnostic | in      |          | g |   |   |
| s |   |                    | and     | excess  |          | e |   |   |
| t |   |                    | pre     | of the  |          | s |   |   |
| i |   |                    | ventive | plan    |          | i |   |   |
| c |   |                    | s       | al      |          | n |   |   |
| > |   |                    | ervices | lowance |          | e |   |   |
|   |   |                    | (       | for     |          | x |   |   |
| a |   |                    | maximum | dia     |          | c |   |   |
| n |   |                    | two     | gnostic |          | e |   |   |
| d |   |                    | visits  | and     |          | s |   |   |
| > |   |                    | per     | pre     |          | s |   |   |
|   |   |                    | year)   | ventive |          | o |   |   |
| p |   |                    |         | s       |          | f |   |   |
| r |   |                    |         | ervices |          | t |   |   |
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+---+---+--------------------+---------+---------+----------+---+---+---+
| * |   |                    |         |         |          |   |   |   |
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| n |   |                    |         |         |          |   |   |   |
| n |   |                    |         |         |          |   |   |   |
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| x |   |                    |         |         |          |   |   |   |
| t |   |                    |         |         |          |   |   |   |
| p |   |                    |         |         |          |   |   |   |
| a |   |                    |         |         |          |   |   |   |
| g |   |                    |         |         |          |   |   |   |
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| * |   |                    |         |         |          |   |   |   |
+---+---+--------------------+---------+---------+----------+---+---+---+

+---------------------------+---------+---------+---------+----------+
| > **Dental benefits**     |         |         |         |          |
| > *(continued)*           |         |         |         |          |
+---------------------------+---------+---------+---------+----------+
| ###  Service              | > **S   |         | **High  |          |
|                           | tandard |         | O       |          |
|                           | > O     |         | ption** |          |
|                           | ption** |         |         |          |
|                           |         |         | > **Sc  |          |
|                           | **Sc    |         | heduled |          |
|                           | heduled |         | > Allo  |          |
|                           | Allo    |         | wance** |          |
|                           | wance** |         |         |          |
+---------------------------+---------+---------+---------+----------+
|                           | ###     | **You   | ###     | **You    |
|                           |  We pay | pay**   |  We pay | pay**    |
+---------------------------+---------+---------+---------+----------+
| > **Amalgam               | \$21    | All     | \$21    | All      |
| > restorations**          | One     | charges | One     | charges  |
| >                         | s       | in      | s       | in       |
| > **Resin- Based          | urface, | excess  | urface, | excess   |
| > Composite               |         | of the  |         | of the   |
| > Restorations**          | \$28    | sc      | \$28    | s        |
| >                         | Two or  | heduled | Two or  | cheduled |
| > **Gold Foil             | more    | amounts | more    | amounts  |
| > Restorations**          | s       | listed  | s       | listed   |
| >                         | urfaces | to the  | urfaces | to the   |
| > **Inlay/Onlay           |         | left    |         | left     |
| > Restorations**          |         |         |         |          |
+---------------------------+---------+---------+---------+----------+
| > **Simple Extractions**  | \$21    | All     | \$21    | All      |
|                           | Simple  | charges | Simple  | charges  |
|                           | ext     | in      | ext     | in       |
|                           | raction | excess  | raction | excess   |
|                           |         | of the  |         | of the   |
|                           |         | sc      |         | s        |
|                           |         | heduled |         | cheduled |
|                           |         | amount  |         | amount   |
|                           |         | listed  |         | listed   |
|                           |         | to the  |         | to the   |
|                           |         | left    |         | left     |
+---------------------------+---------+---------+---------+----------+

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

The benefits on pages 71 and 72 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.

# [Non-Covered Prescription Drugs]{.underline} (800) 417-1893 

Certain prescription drugs not covered by GEHA's Prescription Drug
Program are available to GEHA health plan members at a discount. If your
physician writes a prescription for a non-covered drug to treat
impotency or hair loss, you may purchase it through the Home Delivery
Pharmacy Service, paying 100% of the discounted amount. To order,
complete the form called Ordering Medications from the Home Delivery
Pharmacy Service. Mail this form along with your prescription and check
or credit card number to:

Medco Health

P.O. Box 98830

Las Vegas, NV 89193-8830

If paying by a check, please call first to obtain the cost of the
medication. Full payment must be included with your order.

# [Online Shopping]{.underline} [[www.medcohealth.com]{.underline}](http://www.medcohealth.com/)

GEHA health plan members have access to special features offered on the
Medco Health Web site, [www.medcohealth.com]{.underline}. On this Web
site, you can refill mail order prescriptions and manage your mail order
account. A new feature is online shopping for thousands of
non-prescription drugstore products available from CVS, America's
leading retail pharmacy chain. Items available include nonprescription
medications, vitamins, herbal remedies and personal care products.

# 

# [CONNECTION Hearing]{.underline} (877) 674-3594 [www.miracle-ear.com]{.underline}

Free to all GEHA health plan members, **CONNECTION** Hearing offers cost
savings at participating Miracle-Ear locations nationwide. The program
provides a free hearing evaluation, a 20% discount off the retail price
of hearing aids, the Miracle-Ear Hearing Care Guarantee, a 30-day
satisfaction refund guarantee, free unlimited follow-up visits, and free
annual checkups for hearing aids. Program benefits are available to GEHA
health plan members and their families, including parents and
grandparents. Call (877) 674-3594 for a Miracle-Ear managed care program
location in your area.

**[CONNECTION Vision]{.underline} (800) 800-EYES
[www.800800eyes.com]{.underline}**

Free to all GEHA health plan members, CONNECTION Vision offers cost
savings at more than 10,000 eye care locations nationwide. This program
is offered through Coast to Coast Vision. GEHA health plan members get
discounts off the retail price of lenses, frames and specialty items
such as tints, lightweight plastics and scratch-resistant coatings.
Discounts are available for surgical procedures (including LASIK and
PRK) not covered under the GEHA health plan. For discounts on mail-order
contact lenses, call (800) 878-3901. To locate providers in your area,
call (800) 800-EYES or visit the program's Web site at
[[www.800800eyes.com]{.underline}](http://www.800800eyes.com/). When you
purchase the CONNECTION Dental *Plus* plan, but not GEHA health
insurance, you also have free access to the CONNECTION Vision program.

**[CONNECTION Dental]{.underline}** **(800) 296-0776
[www.geha.com]{.underline}**

Free to all GEHA health plan members, CONNECTION Dental can reduce your
costs for dental care. CONNECTION Dental is a network of approximately
25,000 participating dentists who have agreed to limit their charges to
a reduced fee for GEHA health plan members. As a GEHA health plan
member, you can take advantage of this program in addition to basic
dental benefits provided under the GEHA health plan. Just show your
CONNECTION ID card before you receive services. To find a participating
CONNECTION Dental provider in your area, call (800) 296-0776 or visit
[[www.geha.com]{.underline}](http://www.geha.com/) and click on Provider
Search.

**[CONNECTION Dental *Plus*]{.underline} (800) 793-9335
[www.geha.com]{.underline}**

Available for an additional premium, CONNECTION Dental *Plus* is a
supplemental dental plan that pays benefits for a wide variety of
procedures, from cleanings and X-rays to crowns, dentures and
orthodontia for children. This optional dental insurance is provided
directly by GEHA. Certain waiting periods and limitations apply.

Enrollment is open to all federal employees, retirees and annuitants,
including those who are not members of the GEHA health plan. When you
also join the GEHA health plan, you pay a lower premium for CONNECTION
Dental *Plus*. When you purchase CONNECTION Dental *Plus* you also have
free access to GEHA's CONNECTION Vision program.

+-----------+----------+----------+----------+----------+----------+
| **Covered | **       | **       | **B      |          |          |
| S         | Calendar | Provider | enefit** |          |          |
| ervices** | Year     | Partici  |          |          |          |
|           | De       | pation** |          |          |          |
|           | ductible |          |          |          |          |
|           | Per      |          |          |          |          |
|           | Person** |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           |          |          | **1^st^  | **2^nd^  | **3^rd^  |
|           |          |          | Year**   | Year**   | Year**   |
+-----------+----------+----------+----------+----------+----------+
| **Class   | \$0      | In       | 100%     | 100%     | 100%     |
| A**       |          | -Network |          |          |          |
|           |          |          |          |          |          |
| Specified |          |          |          |          |          |
| D         |          |          |          |          |          |
| iagnostic |          |          |          |          |          |
| and       |          |          |          |          |          |
| Pre       |          |          |          |          |          |
| ventative |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           |          | Out-of   | 60%      | 80%      | 80%      |
|           |          | -Network |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| #         | \$50     | In       | 70%      | 75%      | 80%      |
|  Class B  |          | -Network |          |          |          |
|           |          |          |          |          |          |
| Other     |          |          |          |          |          |
| Di        |          |          |          |          |          |
| agnostic, |          |          |          |          |          |
| Prev      |          |          |          |          |          |
| entative, |          |          |          |          |          |
| Re        |          |          |          |          |          |
| storative |          |          |          |          |          |
| &         |          |          |          |          |          |
| Specified |          |          |          |          |          |
| Oral      |          |          |          |          |          |
| Surgery   |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           |          | Out-of   | 50%      | 55%      | 60%      |
|           |          | -Network |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| # Class C | \$100    | In       | 0%       | 40%      | 50%      |
|           |          | -Network |          |          |          |
| End       |          |          | 12 Month |          |          |
| odontics, |          |          |          |          |          |
| Peri      |          |          | Waiting  |          |          |
| odontics, |          |          | Period   |          |          |
| Prost     |          |          |          |          |          |
| hodontics |          |          |          |          |          |
| & Crowns, |          |          |          |          |          |
| Inlays,   |          |          |          |          |          |
| Onlays    |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           |          | Out-of   |          | 30%      | 40%      |
|           |          | -Network |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| **Class   | \$0      | In       | 0%       | 0%       | \$50 per |
| D**       |          | -Network |          |          | month    |
|           |          |          | 24 Month | 24 Month |          |
| Orthodon  |          |          |          |          |          |
| tics-Comp |          |          | Waiting  | Waiting  |          |
| rehensive |          |          |          |          |          |
| Case      |          |          | Period   | Period   |          |
| (ages     |          |          |          |          |          |
| 6-17)     |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
|           |          | Out-of   |          |          | \$25 per |
|           |          | -Network |          |          | month    |
+-----------+----------+----------+----------+----------+----------+

This is a partial summary of the terms, conditions and limitations of
CONNECTION Dental *Plus*. To get an enrollment packet or more
information on coverage and rates, please call CONNECTION Dental *Plus*
at

\(800\) 793-9335, or visit [www.geha.com]{.underline}.

Benefits described on pages 71 and 72 are not part of the FEHB contract
or premium, and you cannot file a FEHB disputed claim about them. Fees
you pay for these services do not count toward FEHB deductibles or
catastrophic protection out-of-pocket maximums. The GEHA PPO copayment
does not apply. GEHA does not guarantee that providers are available in
all areas or that prices at a participating provider are lower than
prices that may be available from a non-participating provider.

+-----------------------------------------------------------------------+
| > 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 we
determine it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury, or condition.**

We do not cover the following:

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

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

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

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

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

-   Services, drugs, or supplies related to sex transformations; sexual
    dysfunction or sexual inadequacy;

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

-   Services or supplies for which no charge would be made if the
    covered individual had no health insurance coverage;

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

-   Services or supplies furnished by immediate relatives or household
    members, such as spouse, parents, children, brothers or sisters by
    blood, marriage or adoption;

-   Services or supplies furnished or billed by a noncovered facility,
    except that medically necessary prescription drugs and physical,
    speech and occupational therapy rendered by a qualified professional
    therapist on an outpatient basis are covered subject to plan limits;

-   Services or supplies for cosmetic purposes;

-   Surgery to correct congenital anomalies for individuals age 18 and
    older unless there is a functional deficit;

-   Services or supplies not specifically listed as covered;

-   Services or supplies not reasonably necessary for the diagnosis or
    treatment of an illness or injury, except for routine physical
    examinations and immunizations;

-   Any portion of a provider's fee or charge ordinarily due from the
    enrollee but that has been waived. If a provider routinely waives
    (does not require the enrollee to pay) a deductible, copay or
    coinsurance, we will calculate the actual provider fee or charge by
    reducing the fee or charge by the amount waived;

-   Charges the enrollee or Plan has no legal obligation to pay, such as
    excess charges for an annuitant age 65 or older who is not covered
    by Medicare Parts A and/or B (see page 20), doctor charges exceeding
    the amount specified by the Department of Health and Human Services
    when benefits are payable under Medicare (limiting charge) (see page
    21), or State premium taxes however applied;

-   Charges in excess of the "Plan allowance" as defined on page 88;

-   Biofeedback, educational, recreational or milieu therapy, either in
    or out of a hospital;

-   Inpatient private duty nursing;

-   Stand-by physicians and surgeons;

-   Clinical ecology and environmental medicine;

-   Chelation therapy except for acute arsenic, gold, or lead poisoning;

-   Treatment for impotency, even if there is an organic cause for
    impotency. (Exclusion applies to medical/surgical treatment as well
    as prescription drugs.);

-   Treatment other than surgery of temporomandibular joint dysfunction
    and disorders (TMJ);

-   Computer devices to assist with communications; or

-   Computer programs of any type, including but not limited to those to
    assist with vision therapy or speech therapy.

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

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

**How to claim benefits** To obtain claim forms or other claims filing
advice or answers about our benefits, contact us at (800) 821-6136, or
at our Web site at [[www.geha.com]{.underline}](http://www.xxx/).

> In most cases, providers and facilities file claims for you. Your
> physician must file on the form HCFA-1500, Health Insurance Claim
> Form. Your facility will file on the UB-92 form.
>
> Mail to: GEHA
>
> P.O. Box 4665
>
> Independence, MO 64051-4665
>
> For claims questions and assistance, call us at (800) 821-6136.
>
> When you must file a claim \-- such as for services you receive
> overseas or when another group health plan is primary \-- submit it on
> the HCFA-1500 or a claim form that includes the information shown
> below. Bills and receipts should be itemized and show:

-   Name of patient and relationship to enrollee;

-   Plan identification number of the enrollee;

-   Name and address of person or firm providing the service or supply;

-   Dates that services or supplies were furnished;

-   Diagnosis;

-   Type of each service or supply; and

-   The charge for each service or supply.

> Note: Canceled checks, cash register receipts, or balance due
> statements are not acceptable substitutes for itemized bills.
>
> In addition:

-   You must send a copy of the explanation of benefits (EOB) from any
    primary payer (such as the Medicare Summary Notice (MSN)) with your
    claim.

-   Bills for home nursing care must show that the nurse is a registered
    or licensed practical nurse and should include nursing notes.

-   Claims for rental or purchase of durable medical equipment; private
    duty nursing; and physical, occupational, and speech therapy require
    a written statement from the physician specifying the medical
    necessity for the service or supply and the length of time needed.

-   Claims for prescription drugs and supplies that are not purchased
    through the Prescription Drug Program must include receipts that
    include the prescription number, name of drug or supply, prescribing
    physician's name, date, and charge. A copy of the physician's script
    must be included with prescription drugs purchased outside the
    United States.

-   To control administrative costs, we will not issue benefit checks
    that do not exceed \$1.

**Records** Keep a separate record of the medical expenses of each
covered family member as deductibles and maximum allowances apply
separately to each person. Save copies of all medical bills, including
those you accumulate to satisfy a deductible. In most instances they
will serve as evidence of your claim. We will not provide duplicate or
year-end statements.

**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. Once we pay benefits, there is a three-year limitation on the
reissuance of uncashed checks.

**Overseas claims** For covered services you receive in hospitals
outside the United States and Puerto Rico and performed by physicians
outside the United States, send itemized bills that include an English
translation. . A copy of the physician's script must be included with
prescription drugs purchased outside the United States. Charges should
be converted to U.S. dollars using the exchange rate applicable at the
time the expense was incurred. If possible, include a receipt showing
the exchange rate on the date the claimed services were performed.
Covered providers outside the United States will be paid at the PPO
level of benefits. All overseas claims, including prescription drug
reimbursement, should be submitted to: GEHA, Foreign Claims Department,
P.O. Box 4665, Independence, MO 64051-4665.

**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/prior approval:

+---+------------------------------------------------------------------+
| * | **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: GEHA, P.O. Box 4665,             |
|   |     Independence, MO 64051-4665*;* and                           |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or, if applicable, arrange for the health     |
| * |     care provider to give you the care); or                      |
| * |                                                                  |
|   | (b) Write to you and maintain our denial \-- go to step 4; or    |
|   |                                                                  |
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request---go   |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us \-- if we did not       |
|   |     answer that request in some way within 30 days; or           |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: United States Office of Personnel Management,   |
|   | Insurance Services Programs, Health Insurance Group 2, 1900 E    |
|   | Street, NW, Washington, DC 20415-3620.                           |
+---+------------------------------------------------------------------+
|   |                                                                  |
+---+------------------------------------------------------------------+

  -----------------------------------------------------------------------
  Section 8. 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 (800) 821-6136 and
    we will expedite our review; or

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

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

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-   **You may call OPM\'s Health Insurance Group 2 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 have coverage

**or auto insurance** under another group health plan or have automobile
insurance that pays health care expenses without regard to fault. This
is called "double coverage."

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

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

When we are the secondary payer, we will determine our allowance. After
the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will not pay more than our allowance. There is
no change in benefit limits or maximums when we are the secondary payer.

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

-   People 65 years of age and older;

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```
-   Some people with disabilities, under 65 years of age;

```{=html}
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```
-   People with End-Stage Renal Disease (permanent kidney failure
    requiring dialysis or a transplant).

> Medicare has two parts:

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

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

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

• **The Original Medicare Plan** The Original Medicare Plan (Original
Medicare) is available

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

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

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

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

-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In most cases, your claim will be coordinated
    automatically and we will then provide secondary benefits for
    covered charges. When Medicare does not cover the charge, we will
    determine our Plan allowable and pay our benefit up to that amount.
    You will not need to do anything. To find out if you need to do
    something to file your claim, call us at (800) 821-6136 or visit our
    Web site at [www.geha.com.]{.underline}

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

-   **Inpatient Hospital Benefits:** If you are enrolled in Medicare
    Part A, we waive the deductible and coinsurance

-   **Medical and Surgery Benefits and Mental Health/Substance Abuse
    care:** If you are enrolled in Medicare Part B, we waive the
    deductible and coinsurance.

-   **Office Visits PPO Providers:** If you are enrolled in Medicare
    Part B, we waive the copayments for PPO office visits.

-   **Prescription Drugs:** If you have Medicare Parts A and B, you will
    pay a copayment for drugs through the Home Delivery Pharmacy service
    and at retail pharmacies as shown on page 66.

-   **Chiropractic Benefits:** There is no change in benefit limits or
    maximums for chiropractic care when Medicare is primary. See page 35
    for benefits.

-   **Physical, Speech and Occupational Therapy Benefits:** There is no
    change in benefit limits or maximums for therapy when Medicare is
    primary.

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

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

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

**Medicare + Choice** If you are eligible for Medicare, you may choose
to enroll in and get

> your Medicare benefits from a Medicare + Choice plan. These are health
> care choices (like HMOs) in some areas of the country. In most
> Medicare + Choice plans, you can only go to doctors, specialists, or
> hospitals that are part of the plan. Medicare + Choice plans provide
> all the benefits that Original Medicare covers. Some cover extras,
> like prescription drugs. To learn more about enrolling in a Medicare +
> Choice plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
> [[www.medicare.gov]{.underline}](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 Medicare + Choice
> plan's network and/or service area, but we will not waive any of our
> copayments, coinsurance, or deductibles. If you enroll in a Medicare +
> Choice plan, tell us. We will need to know whether you are in the
> Original Medicare Plan or in a Medicare + Choice plan so we can
> correctly coordinate benefits with Medicare.
>
> **Suspended FEHB coverage to enroll in a Medicare + Choice plan:** If
> you are an annuitant or former spouse, you can suspend your FEHB
> coverage to enroll in a Medicare + Choice plan, eliminating your FEHB
> premium. (OPM does not contribute to your Medicare + Choice plan
> premium). For information on suspending your FEHB enrollment, contact
> your retirement office. If you later want to re-enroll in the FEHB
> Program, generally you may do so only at the next Open Season unless
> you involuntarily lose coverage or move out of the Medicare + Choice
> plan's service area.

*• Private Contract with your physician A physician may ask you to sign
a private contract agreeing that you can be billed directly for services
ordinarily covered by Original Medicare. Should you sign an agreement,
Medicare will not pay any portion of the charges, and we will not
increase our payment. We will still limit our payment to the amount we
would have paid after Original Medicare\'s payment. You will be
financially responsible for the entire balance following any payment we
make.*

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

**Suspended FEHB coverage to enroll in TRICARE or CHAMPVA:** If you are
an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in one of these programs, eliminating your FEHB premium. (OPM
does not contribute to any applicable plan premiums.)

> For information on suspending your FEHB enrollment, contact your
> retirement office. If you later want to re-enroll in the FEHB Program,
> generally you may do so only at the next Open Season unless you
> involuntarily lose coverage under the program.

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

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

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

> Once OWCP or similar agency pays its maximum benefits for your
> treatment, we will cover your care.

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

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

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

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

**When others are responsible** If you or a dependent suffer injuries or
become ill because of another

**for injuries** party's act or omission, and if we pay benefits for
that injury or illness, you must agree to reimburse GEHA for those
benefits from any recovery (ies) that you or the dependent obtain. All
GEHA benefit payments in these circumstances are conditional, and remain
subject to our contractual benefit limitations, exclusions, and
maximums. By accepting these conditional benefits, you agree to:

1.  Contact GEHA's Subrogation Unit at (800) 821-4742, Ext. 5503 or 5735
    as soon after the incident as possible and provide all requested
    information. You must sign any releases GEHA requires to obtain
    information about your claim from other sources.

2.  Reimburse GEHA, in full up to the amount of benefits paid, out of
    any settlements, judgments, and/or recoveries that you obtain from
    any source, no matter how characterized, i.e., as "pain and
    suffering." GEHA enforces this right of reimbursement by asserting a
    lien against any and all recoveries received, including Medpay,
    Personal Injury Protection, No-Fault coverage, Third-Party, and
    Uninsured and Underinsured coverage. GEHA's lien consists of the
    total benefits paid to diagnose or treat the illness or injury.
    GEHA's lien applies first, regardless of the "make whole" and
    "common fund" doctrines. No reduction of GEHA's lien can occur
    without our written consent.

3.  Assign all proceeds from third parties, your own or other insurance
    to GEHA, up to the amount of benefits paid, when asked to do so.

4.  Permit GEHA to seek recovery on your behalf (including the right to
    bring suit in your name) if you do not seek damages. This is GEHA's
    right of subrogation. You must cooperate in doing what is reasonably
    necessary to assist us, and you must not take any action that may
    prejudice our rights to recover.

5.  Sign a Reimbursement Agreement if asked by GEHA to do so however, a
    Reimbursement Agreement is not necessary to enforce our lien. We may
    delay processing of your claims until we receive a signed
    Reimbursement Agreement or Assignment of the proceeds of a claim.

> GEHA's lien extends to all related expenses incurred prior to the
> settlement or judgment date, even if those expenses were not submitted
> to GEHA for payment at the time you reimbursed GEHA. The lien remains
> the member's obligation until it is satisfied in full. Failure to
> refund GEHA or cooperate with our reimbursement efforts may result in
> an overpayment that can be collected from you or any dependent.

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

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

**Accidental injury** An injury caused by an external force or element
such as a blow or fall that requires immediate medical attention. Also
included are animal bites, poisonings, and dental care required to
repair injuries to sound natural teeth as a result of an accidental
injury, not from biting or chewing.

**Admission** The period from entry (admission) into a hospital or other
covered facility until discharge. In counting days of inpatient care,
the date of entry and the date of discharge are counted as the same day.

**Assignment** An authorization by an enrollee or spouse for the Plan to
issue payment of benefits directly to the provider. The Plan reserves
the right to pay the member directly for all covered services.

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

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care. You may also be responsible for additional
amounts. See page 16-17.

**Congenital anomaly** A condition existing at or from birth which is a
significant deviation from the common form or norm. For purposes of this
Plan, congenital anomalies include cleft lips, cleft palates,
birthmarks, webbed fingers or toes and other conditions that the Plan
may determine to be congenital anomalies. Surgical correction of
congenital anomalies is limited to children under the age of 18 unless
there is a functional deficit. In no event will the term congenital
anomaly include conditions relating to teeth or intra-oral structures
supporting the teeth.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 16.

**Cosmetic** Any procedure or any portion of a procedure performed
primarily to improve physical appearance and/or treat a mental condition
through change in bodily form.

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

**Custodial care** Treatment or services, regardless of who recommends
them or where they are provided, that could be rendered safely and
reasonably by a person not medically skilled, or that are designed
mainly to help the patient with daily living activities. These
activities include but are not limited to:

(1) personal care such as help in: walking; getting in and out of bed;
    bathing; eating by spoon, tube or gastrostomy; exercise; dressing;

(2) homemaking, such as preparing meals or special diets;

(3) moving the patient;

(4) acting as companion or sitter;

(5) supervising medication that can usually be self administered; or

(6) treatment or services that any person may be able to perform with
    minimal instruction, including but not limited to recording
    temperature, pulse, and respirations, or administration and
    monitoring of feeding systems.

> The Carrier determines which services are custodial care. (Custodial
> care that lasts 90 days or more is sometimes known as long term care.)

**Deductible** A deductible is a fixed amount of covered expenses you
must incur for certain covered services and supplies before we start
paying benefits for those services. See page 16.

**Durable medical equipment** Equipment and supplies that:

(1) are prescribed by your attending doctor;

(2) are medically necessary;

(3) are primarily and customarily used only for a medical purpose;

(4) are generally useful only to a person with an illness or injury;

(5) are designed for prolonged use; and

(6) serve a specific therapeutic purpose in the treatment of an illness
    or injury.

**Effective date** The date the benefits described in this brochure are
effective:

(1) January 1 for continuing enrollments and for all annuitant
    enrollments;

(2) the first day of the first full pay period of the new year for
    enrollees who change plans or options or elect FEHB coverage during
    the open season for the first time; or

(3) for new enrollees during the calendar year, but not during the open
    season, the effective date of enrollment as determined by the
    employing office or retirement system.

**Elective surgery** Any non-emergency surgical procedure that may be
scheduled at the patient's convenience without jeopardizing the
patient's life or causing serious impairment to the patient's bodily
functions.

**Expense** An expense is "incurred" on the date the service or supply
is rendered.

**Experimental or** A drug, device, or biological product is
experimental or investigational

**investigational services** if the drug, device, or biological product
cannot be lawfully marketed

without approval of the U.S. Food and Drug Administration (FDA) and
approval for marketing has not been given at the time it is furnished.
Approval means all forms of acceptance by the FDA.

A medical treatment or procedure, or a drug, device, or biological
product is experimental or investigational if 1) reliable evidence shows
that it is the subject of ongoing phase I, II, or III clinical trials or
under study to determine its maximum tolerated dose, its toxicity, its
safety, its efficacy, or its efficacy as compared with the standard
means of treatment or diagnosis; or 2) reliable evidence shows that the
consensus of opinion among experts regarding the drug, device, or
biological product or medical treatment or procedure is that further
studies or clinical trials are necessary to determine its maximum
tolerated dose, its toxicity, its safety, its efficacy, or its efficacy
as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only published reports and articles in the
authoritative medical and scientific literature; the written protocol or
protocols used by the treating facility or the protocol(s) of another
facility studying substantially the same drug, device, or medical
treatment or procedure; or the written informed consent used by the
treating facility or by another facility studying substantially the same
drug, device, or medical treatment or procedure.

Determination of experimental/investigational status may require review
of appropriate government publications such as those of the National
Institute of Health, National Cancer Institute, Agency for Health Care
Policy and Research, Food and Drug Administration, and National Library
of Medicine. Independent evaluation and opinion by Board Certified
Physicians who are professors, associate professors, or assistant
professors of medicine at recognized United States Medical Schools may
be obtained for their expertise in subspecialty areas.

**Group health coverage** Health care coverage that a member or covered
dependent is eligible for because of employment by, membership in, or
connection with, a particular organization or group that provides
payment for hospital, medical, dental or other health care services or
supplies, including extension of any of these benefits through COBRA.

**Infertility** The inability to conceive after a year of unprotected
intercourse or the inability to carry a pregnancy to term.

**Intensive day treatment** Outpatient treatment of mental condition or
substance abuse rendered at and billed by a facility that meets the
definition of a hospital. Treatment program must be established which
consists of individual or group psychotherapy and/or psychological
testing.

**Medical necessity** Services, drugs, supplies or equipment provided by
a hospital or covered provider of the health care services that the Plan
determines:

(1) are appropriate to diagnose or treat the patient's condition,
    illness or injury;

(2) are consistent with standards of good medical practice in the United
    States;

(3) are not primarily for the personal comfort or convenience of the
    patient, the family, or the provider,

(4) are not a part of or associated with the scholastic education or
    vocational training of the patient; and

(5) in the 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, drug or equipment does not, in itself,
> make it medically necessary.

**Mental health/** Conditions and diseases listed in the most recent
edition of the

**Substance abuse** International Classification of Diseases (ICD) as
psychoses, neurotic disorders, or personality disorders; other
nonpsychotic mental disorders listed in the ICD, to be determined by the
Plan; or disorders listed in the ICD requiring treatment for abuse or
dependence upon substances such as alcohol, narcotics, or hallucinogens.

**Plan allowance** Our 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
Plan allowance as follows:

> We consult standard industry guides, such as national databases of
> prevailing health care charges from Ingenix and Medical Data Resource.
> We use the 70th percentile. This means that out of every 100 reports,
> 30 charges billed may be more, but 70 charges will be the allowed
> amount or less. Charges determined in this way include, but are not
> limited to, ambulatory surgery centers, surgery, doctor's services,
> physical therapy, speech therapy, occupational therapy, lab testing
> and X-ray expenses; and under the Standard Option diagnostic and
> preventive dental services.
>
> Plan allowance for prescription drugs is determined using average
> wholesale price data.
>
> Charges for some Plan allowances are stated in this brochure. These
> include limited benefits such as chiropractic care and routine dental
> care.
>
> Some Plan allowances may be submitted to medical consultants who
> recommend allowances based on special industry guidelines. We may also
> conduct independent surveys to determine the usual cost of a service
> or supply in a geographic area.
>
> If we negotiate a reduced fee amount on an individual claim for
> services or supplies which is lower than the Plan allowance, covered
> benefits will be limited to the negotiated amount. Your coinsurance
> will be based on the reduced fee amount. If you choose to use a
> provider other than the one we negotiated a reduction with, you will
> be responsible for the difference in these amounts.
>
> Our PPO allowances are negotiated with each provider who participates
> in the network. PPO allowances may be based on a standard reduction or
> on a negotiated fee schedule. For these allowances, the PPO provider
> has agreed to accept the negotiated reduction and you are not
> responsible for this discounted amount. In these instances, the
> benefit paid plus your coinsurance equals payment in full.
>
> For more information, see *Differences between our allowance and the
> bill* in
>
> Section 4.

**Primary care physician** For purposes of the office visit copayment
for the Standard Option benefits, primary care physicians are individual
doctors (M.D. or D.O.) whose medical practice is limited to
Family/General Practice, Internal Medicine, Pediatrics/Adolescent
Medicine or Obstetrics/Gynecology (OB/Gyn). Doctors listed in provider
directories or advertisements under any other medical specialty or
sub-specialty area (such as Internal Medicine doctors also listed under
Cardiology or Geriatrics, or Pediatric sub-specialties such as Pediatric
Allergy) are considered specialists, not primary care physicians.
Chiropractors, eye doctors, dentists, audiologists, and mental
health/substance abuse providers are not considered primary care
physicians.

**Sound natural tooth** Sound and Natural Tooth is a whole or properly
restored tooth that has no condition that would weaken the tooth, or
predispose it to injury, prior to the accident, such as decay,
periodontal disease, or other impairments. For purposes of the Plan,
damage to a restoration, such as a prosthetic crown or prosthetic dental
appliances (i.e. bridgework), would not be covered as there is no injury
to the natural tooth structure.

**Us/We** Us and we refer to Government Employees Hospital Association,
Inc.

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

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

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

**Coverage information**

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

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

-   **Where you can get** See
    [[www.opm.gov/insure/health]{.underline}](http://www.opm.gov/insure/health)
    for enrollment information as well as:

> **information about enrolling**
>
> **in the FEHB Program** • Information on the FEHB Program and plans
> available to you

-   A health plan comparison tool

-   A list of agencies who participate in Employee Express

-   A link to Employee Express

-   Information on the links to other electronic enrollment systems

> Also, your employing or retirement office can answer your questions
> and give you a *Guide to Federal Employees Health Benefits Plans,*
> brochures for other plans, and other materials you need to make an
> informed decision about your FEHB coverage. These materials tell you
>
> • When you may change your enrollment;
>
> • How you can cover your family members;
>
> • What happens when you transfer to another Federal agency, go on
> leave without pay, enter military service, or retire;
>
> • When your enrollment ends; and
>
> • When the next open season for enrollment begins.

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

-   **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 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;

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

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

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

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

**premiums start** Plan during Open Season, your coverage begins on the
first day of your

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

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

**When you lose benefits**

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

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

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

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

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

continue to get benefits under your former spouse's enrollment. This is

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

**• Temporary Continuation** If you leave Federal service, or if you
lose coverage because you no

> **of Coverage (TCC)** 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 Federal job, if you are
> a covered dependent child and you turn 22 or marry, etc.

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

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

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

**individual coverage**

> • Your coverage under TCC or the spouse equity law ends (If you
> canceled your coverage or did not pay your premium, you cannot
> convert);
>
> • You decided not to receive coverage under TCC or the spouse equity
> law; or
>
> • You are not eligible for coverage under TCC or the spouse equity
> law.

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

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

**• Getting a Certificate of** The Health Insurance Portability and
Accountability Act of 1996

**Group Health Plan Coverage** (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 Web site
> ([[www.opm.gov/insure/health);]{.underline}](http://www.opm.gov/insure/health);)
> refer to the \"TCC and HIPAA\" frequently asked questions. These
> highlight HIPAA rules, such as the requirement that Federal employees
> must exhaust any TCC eligibility as one condition for guaranteed
> access to individual health coverage under HIPAA, and have information
> about Federal and State agencies you can contact for more information.

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

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

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

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

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

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

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

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

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

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

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

-   The maximum that can be allotted for the DCFSA is \$5,000 annually.
    The minimum amount is \$250 annually. ***Note:*** The IRS limits
    contributions to a Dependent Care FSA. For single taxpayers and
    taxpayers filing a joint return, the maximum is \$5,000 per year.
    For taxpayers who file their taxes separately with a spouse, the
    maximum is \$2,500 per year. The limit includes any 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]{.underline}**](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]{.underline}](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 pages 101 and 102 and detailed throughout this brochure.
> Your HCFSA will reimburse you for such costs when they are for tax
> deductible medical care for you and your dependents that are NOT
> covered by this FEHB Plan or any other coverage that you have.
>
> Under the High Option of this Plan, typical out-of-pocket expenses
> include: **\$350 calendar year deductible, \$20 PPO copay for covered
> office visits, \$5 copay for generic drugs/\$25 single source brand
> name; \$40 multi-source brand for 30 day supply at retail for initial
> fill and first refill/subsequent fills greater of 50% or copays
> listed, and \$10 generic/\$45 single source brand name/\$60
> multi-source brand name for 90 day supply through Home Delivery.**
>
> Under the Standard Option of this Plan, typical out-of-pocket expenses
> include: **\$450 calendar year deductible, \$10 PPO copay for primary
> care physician or \$25 PPO copay for specialists for covered office
> visits, \$5 copay for generic drugs or 50% copay for brand name for 30
> day supply at retail, and \$15 copay for generic drugs/50% brand name
> for 90 day supply through Home Delivery.**
>
> 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]{.underline}](http://www.irs.gov/pub/irs-pdf/p502.pdf). 
> If you do not see your service or expense listed in Publication 502,
> please call a FSAFEDS Benefit Counselor at 1-877-FSAFEDS (372-3337),
> who will be able to answer your specific questions.

-   **Tax savings with an FSA** An FSA lets you allot money for eligible
    expenses ***before*** your agency

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

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

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

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

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

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

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

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

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

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

-   **Tax 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]{.underline}](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

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

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

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

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

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

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

**The Federal Long Term Care Insurance Program**

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

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

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

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

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

**To find out more and** Call 1-800-LTC-FEDS (1-800-582-3337) (TTY
1-800-843-3557)

**to request an application** or visit
[[www.ltcfeds.com]{.underline}](http://www.ltcfeds.com/).

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

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

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

**A**ccidental injury 41, 53-55, 85

Abortion 27, 73

Allergy tests 28

Allogeneic (donor) bone marrow transplant 42

Alternative treatment 36

Ambulance 52, 54-55

Ambulatory surgical center 11, 50 Anesthesia 45

Artificial insemination 28

Assignment 85

Assisted reproductive technology 28 Autologous bone marrow

Transplant 42

**B**iopsies 38

Blood and blood plasma 47-48, 50

Breast cancer screening 25

Breast Prosthesis 33

**C**alendar year

Deductible 16, 23, 37, 46, 53, 56

Cardiac Rehabilitation 29, 50

Casts 47, 50

Catastrophic protection out-of-pocket

maximum 17-19

Changes for 2004 9-10

Chemotherapy 29, 44-45

Childbirth 26, 48-50, 90

Children's Equity Act 91

Chiropractic 35, 80

Cholesterol tests 25

Circumcision 26

Claims 75-76

Coinsurance 16, 85

Colorectal cancer screening 25

Congenital anomalies 38, 40, 85

Contact lenses 32

Contraceptive devices and

drugs 27, 61

Conversion 92

Coordination of benefits 79-82

Cosmetic surgery 40, 85

Cost containment 13-15

Covered charges 85

Covered facilities 11-12

Covered providers 11

Crutches 33

Custodial care 34, 85-86

**D**ays certified 13-14

Deductible 16, 86

Definitions 85-89

Dental care 69, 70

Diabetic supplies 61, 64

Diagnostic services 23-24, 57

Disputed claims review 77-78

Donor expenses (transplants) 42-43, 45

Dressings 47-48, 50

Durable medical equipment 33-34, 86

**E**ducational classes and programs 36

Effective date of enrollment 86

Emergency 24, 53-55

Environmental medicine 28, 36 Experimental or investigational 86- 87

Eye exams 26, 32

Eyeglasses 32

**F**amily limit 16

Family planning 27

Fecal occult blood test 25

Federal FSA Program 94-97

Federal Long Term Care Program 98

Flexible benefits option 68

Foot care 32

Fraud 5

Freestanding ambulatory

facilities 11, 50

**G**amete intrafallopian transfer

(GIFT) 28

General exclusions 73-74

**H**earing services 31

Home health services 34-35

Home uterine devices 27

Hospice care 12, 51

Home delivery pharmacy service 61-67

Home nursing care 34-35

Hospital 12-13, 46-50

**I**mmunizations 25

Impacted teeth 41

Incidental procedures 39

Infertility 27, 87

Inhospital physician care 24, 57, 60

Inpatient Hospital Benefits 47-49

Insulin 61, 64

Intensive day treatment 56, 58-59

**L**aboratory and pathological services 24

Lifetime maximums 32, 34, 59-60

**M**agnetic Resonance Imagings (MRIs) 15, 24

Mammograms 24-25

Maternity Benefits 14, 26-27, 48-50

Medicaid 83

Medical necessity 87

Medically underserved area 11

Medicare 20-21, 79-82

Members 4, 89

Mental Health/Substance Abuse Benefits 56-60, 88

**N**ewborn care 25-26

No-fault 79, 83-84

Non-FEHB Benefits 71-72

Nurse

Licensed Practical Nurse 34

Nurse Anesthetist 11

Nurse Midwife 11

Nurse Practitioner 11

Registered Nurse 34

Nursery charges 26, 48

Nursing School Administered Clinic 11

**O**bstetrical care 26-27

Occupational therapy 30

Ocular injury 32

Office visits 23

Oral and maxillofacial surgery 41

Oral contraceptives 61, 64

Organ/tissue transplant 42-45

Orthopedic devices 33

Ostomy and catheter supplies 61, 64

Out-of-pocket expenses 16-19, 21, 62

Outpatient facility care 50

Overseas claims 76

Oxygen 33, 47-48, 50

**P**ap test 24-25

Physical examination 23

Physical therapy 30

Physician 11, 88-89

Plan allowance 17, 88

Pre-admission testing 47

Precertification 13-15, 23-24,, 37, 46, 58-60

Preferred Provider Organization (PPO) 7, 17-18

Prescription drugs 61-67

Preventive care, adult 25

Preventive care, children 25

Prior approval 15

Private room 47, 57

Prostate cancer screening 25

Prosthetic devices 33, 40

Psychologist 11, 57

Psychotherapy 57, 60

**R**adiation therapy 29

Renal dialysis 29

Room and board 47-49, 51

Routine services 25

**S**econd surgical opinion 23, 44

Sigmoidoscopy 25

Skilled nursing facility care 30-31, 51

Smoking cessation 36

Social Worker 11, 57

Speech therapy 31

Splints 47

Sterilization procedures 27-28, 39

Subrogation 83-84

Substance abuse 56-60, 88

Surgery 37

-   Anesthesia 45

```{=html}
<!-- -->
```
-   Assistant surgeon 38

```{=html}
<!-- -->
```
-   Multiple procedures 39

-   Oral 41

-   Reconstructive 38, 40

    Syringes 61, 64

    **T**emporary continuation of coverage 92

    Temporomandibular Joints 41, 74

    Transplants 42-45

Treatment therapies 29

**V**ision services 26, 31, 71

Vitamins 71

**W**ell child care 25-26

Wheelchairs 33

Workers' compensation 83

**X**-rays 24, 47-48, 50, 69

  -----------------------------------------------------------------------
  **Summary of benefits for GEHA -- Standard Option 2004**

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

-   **Do not rely on this chart alone.** All benefits 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.

-   Below, an asterisk (\*) means the item is subject to the \$450
    calendar year deductible. And, after we pay, you generally pay any
    difference between our allowance and the billed amount if you use a
    Non-PPO physician or other health care professional.

+--------------------------+-------------------------------------+-----+
| ### Benefits             | **You Pay**                         | **P |
|                          |                                     | age |
|                          |                                     | s** |
+--------------------------+-------------------------------------+-----+
| > Medical services       | > PPO: \$10 copay primary care      | >   |
| > provided by            | > physician; \$25 copay specialist  |  23 |
| > physicians:            | > for covered office visits and     | -45 |
|                          | > 15%\* of other covered            |     |
| -   Diagnostic and       | > professional services including   |     |
|     treatment services   | > X-ray and lab                     |     |
|     provided in the      | >                                   |     |
|     office               | > Non-PPO: 35%\* of covered         |     |
|     .................    | > professional services             |     |
+--------------------------+-------------------------------------+-----+
| > Services provided by a | > PPO: 15%\* of covered hospital    | >   |
| > hospital:              | > charges                           |  46 |
|                          | >                                   | -52 |
| -   Inpatient            | > Non PPO: 35%\* of covered         |     |
|     ........             | > hospital charges                  |     |
| ........................ |                                     |     |
|                          |                                     |     |
| ```{=html}               |                                     |     |
| <!-- -->                 |                                     |     |
| ```                      |                                     |     |
| -   Outpatient           |                                     |     |
|     .......              |                                     |     |
| ........................ |                                     |     |
+--------------------------+-------------------------------------+-----+
| > Emergency benefits:    | Nothing up to plan allowance of     | >   |
|                          | covered charges incurred within 72  |  53 |
| -   Accidental injury    | hours of an accident                | -55 |
|                          |                                     |     |
| -   Medical emergency    | > Regular benefits\*                |     |
|     other professional   |                                     |     |
|     services             |                                     |     |
|     ............         |                                     |     |
+--------------------------+-------------------------------------+-----+
| > Mental health and      | > In-Network: Regular cost sharing  | >   |
| > substance abuse        | >                                   |  56 |
| > treatment              | > Out-of-Network: Benefits are      | -60 |
| > ...........            | > limited                           |     |
| ........................ |                                     |     |
+--------------------------+-------------------------------------+-----+
| > Prescription drugs     | Network pharmacy: Member pays \$5   | >   |
| >                        | for generic drugs/50% brand name    |  61 |
| ........................ | for up to 30 day supply.            | -67 |
|                          |                                     |     |
|                          | Non-network pharmacy: Member pays   |     |
|                          | \$5 for generic drugs/50% brand     |     |
|                          | name and any difference between our |     |
|                          | allowance and the cost of the drug. |     |
|                          |                                     |     |
|                          | > By mail: Member pays \$15 for     |     |
|                          | > generic drugs/50% brand name for  |     |
|                          | > 90-day supply                     |     |
+--------------------------+-------------------------------------+-----+
| > Dental Care            | > 50% up to plan allowance for      | >   |
| > .........              | > diagnostic and preventive         |  69 |
| ........................ | > services and charges in excess of | -70 |
|                          | > the scheduled amounts for         |     |
|                          | > restorations and extractions      |     |
+--------------------------+-------------------------------------+-----+
| > Special features:      |                                     | >   |
| > Flexible benefits      |                                     |  68 |
| > option, services for   |                                     |     |
| > deaf and hearing       |                                     |     |
| > impaired, high-risk    |                                     |     |
| > pregnancies            |                                     |     |
+--------------------------+-------------------------------------+-----+
| > Protection against     | Nothing after \$4000/Self Only or   | >   |
| > catastrophic costs     | \$4,500/Family enrollment per year  |  17 |
| >                        | for PPO providers;                  | -19 |
| > (your catastrophic     |                                     |     |
| > protection             | > Nothing after \$5,000/Self Only   |     |
| > out-of-pocket maximum) | > or \$5,500/Family enrollment per  |     |
| >                        | > year for Non-PPO providers.       |     |
| ........................ | >                                   |     |
|                          | > Some costs do not count toward    |     |
|                          | > this protection                   |     |
+--------------------------+-------------------------------------+-----+

  -----------------------------------------------------------------------
  **Summary of benefits for GEHA -- High Option 2004**

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

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

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

```{=html}
<!-- -->
```
-   Below, an asterisk (\*) means the item is subject to the \$350
    calendar year deductible. And, after we pay, you generally pay any
    difference between our allowance and the billed amount if you use a
    Non-PPO physician or other health care professional.

+--------------------------+-------------------------------------+-----+
| ####                     | ####                                | **P |
|                          |                                     | age |
| # Benefits               | # You Pay                           | s** |
+--------------------------+-------------------------------------+-----+
| > Medical services       | PPO: \$20 copay per covered office  | >   |
| > provided by            | visit and 10%\* of other covered    |  23 |
| > physicians:            | professional services including     | -45 |
|                          | x-ray and lab                       |     |
| -   Diagnostic and       |                                     |     |
|     treatment services   | > Non-PPO: 25%\* of covered         |     |
|     provided in the      | > professional services             |     |
|     office               |                                     |     |
|     ................     |                                     |     |
+--------------------------+-------------------------------------+-----+
| > Services provided by a | > PPO: Nothing for room and board,  | >   |
| > hospital:              | > 10% of other hospital charges,    |  46 |
|                          | > inpatient \$100 per admission     | -52 |
| -   Inpatient            | > deductible applies                |     |
|     .......              | >                                   |     |
| ........................ | > Non-PPO: Nothing for room and     |     |
|                          | > board, 25% of other hospital      |     |
| -   Outpatient\*         | > charges, inpatient \$300 per      |     |
|     ...                  | > admission deductible applies      |     |
| ........................ |                                     |     |
+--------------------------+-------------------------------------+-----+
| > Emergency benefits:    | Nothing up to plan allowance of     | >   |
|                          | covered charges incurred within 72  |  53 |
| -   Accidental injury    | hours of an accident                | -55 |
|                          |                                     |     |
|    ..................... | > Regular benefits\*                |     |
|                          |                                     |     |
| -   Medical emergency    |                                     |     |
|     other professional   |                                     |     |
|     services ..........  |                                     |     |
+--------------------------+-------------------------------------+-----+
| > Mental health and      | > In-Network: Regular cost sharing  | >   |
| > substance abuse        | >                                   |  56 |
| > treatment              | > Out-of-Network: Benefits are      | -60 |
| > ...........            | > limited                           |     |
| ........................ |                                     |     |
+--------------------------+-------------------------------------+-----+
| > Prescription drugs     | > Network pharmacy: Member pays \$5 | >   |
| >                        | > for generic drugs/\$25            |  61 |
| ........................ | > single-source brand name/\$40     | -67 |
|                          | > multi-source brand name for up to |     |
|                          | > 30 day supply for the initial     |     |
|                          | > fill and first refill. Subsequent |     |
|                          | > fills are the greater of 50% or   |     |
|                          | > the copays listed above.          |     |
|                          | >                                   |     |
|                          | > Non-network pharmacy: Member pays |     |
|                          | > \$5 for generic drugs/\$25        |     |
|                          | > single-source brand name/\$40     |     |
|                          | > multi-source brand name for up to |     |
|                          | > a 30 day supply for the initial   |     |
|                          | > fill and first refill and any     |     |
|                          | > difference between our allowance  |     |
|                          | > and the cost of the drug.         |     |
|                          | > Subsequent fills are the greater  |     |
|                          | > of 50% or the copays listed above |     |
|                          | > and any difference between our    |     |
|                          | > allowance and the cost of the     |     |
|                          | > drugs.                            |     |
|                          | >                                   |     |
|                          | > By mail: Member pays \$10 for     |     |
|                          | > generic drugs/ \$45 single-source |     |
|                          | > brand name/\$60\` multi-source    |     |
|                          | > brand name for 90-day supply.     |     |
+--------------------------+-------------------------------------+-----+
| > Dental Care            | > Charges in excess of the          | >   |
| > ........               | > scheduled amounts for diagnostic  |  69 |
| ........................ | > and preventive services,          | -70 |
|                          | > restorations, and extractions     |     |
+--------------------------+-------------------------------------+-----+
| > Special features:      |                                     | >   |
| > Flexible benefits      |                                     |  68 |
| > option, services for   |                                     |     |
| > deaf and hearing       |                                     |     |
| > impaired, high-risk    |                                     |     |
| > pregnancies            |                                     |     |
+--------------------------+-------------------------------------+-----+
| > Protection against     | Nothing after \$3,000/Self Only or  | >   |
| > catastrophic costs     | \$3,500/Family enrollment per year  |  17 |
| >                        | for PPO providers;                  | -19 |
| > (your catastrophic     |                                     |     |
| > protection             | Nothing after \$4,000/Self Only or  |     |
| > out-of-pocket maximum) | \$4,500/Family enrollment per year  |     |
| >                        | for Non PPO providers.              |     |
| ........................ |                                     |     |
|                          | Some costs do not count toward this |     |
|                          | protection                          |     |
+--------------------------+-------------------------------------+-----+

**\
**

**2004 Rate Information for**

**Government Employees Hospital Association, Inc. (GEHA)**

**Benefit Plan**

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

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

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

+--------------+------+-------+-------+-------+-------+-------+-------+
|              |      | **    |       |       |       | **P   |       |
|              |      | Non-P |       |       |       | ostal |       |
|              |      | ostal |       |       |       | Prem  |       |
|              |      | Prem  |       |       |       | ium** |       |
|              |      | ium** |       |       |       |       |       |
+--------------+------+-------+-------+-------+-------+-------+-------+
|              |      | *     |       | **[Mo |       | *     |       |
|              |      | *[Biw |       | nthly |       | *[Biw |       |
|              |      | eekly |       | ]{.un |       | eekly |       |
|              |      | ]{.un |       | derli |       | ]{.un |       |
|              |      | derli |       | ne}** |       | derli |       |
|              |      | ne}** |       |       |       | ne}** |       |
+--------------+------+-------+-------+-------+-------+-------+-------+
| **Type of**  | **Co | **Go  | **Y   | **Go  | **Y   | **U   | **Y   |
|              | de** | v't** | our** | v't** | our** | SPS** | our** |
| **           |      |       |       |       |       |       |       |
| Enrollment** |      | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  |
|              |      | are** | are** | are** | are** | are** | are** |
+--------------+------+-------+-------+-------+-------+-------+-------+

+--------------+------+-------+-------+-------+-------+-------+-------+
| **High       | **3  | **    | *     | **    | **    | **    | *     |
| Option**     | 11** | \$121 | *\$76 | \$263 | \$165 | \$143 | *\$54 |
|              |      | .40** | .24** | .03** | .19** | .32** | .32** |
| **Self       |      |       |       |       |       |       |       |
| Only**       |      |       |       |       |       |       |       |
+--------------+------+-------+-------+-------+-------+-------+-------+
| **High       | **3  | **    | **    | **    | **    | **    | **    |
| Option**     | 12** | \$277 | \$153 | \$600 | \$331 | \$327 | \$103 |
|              |      | .09** | .05** | .36** | .61** | .12** | .02** |
| **Self and   |      |       |       |       |       |       |       |
| Family**     |      |       |       |       |       |       |       |
+--------------+------+-------+-------+-------+-------+-------+-------+
| **Standard   | **3  | *     | *     | **    | *     | **    | *     |
| Option**     | 14** | *\$90 | *\$30 | \$196 | *\$65 | \$107 | *\$13 |
|              |      | .75** | .25** | .63** | .54** | .39** | .61** |
| **Self       |      |       |       |       |       |       |       |
| Only**       |      |       |       |       |       |       |       |
+--------------+------+-------+-------+-------+-------+-------+-------+
| **Standard   | **3  | **    | *     | **    | **    | **    | *     |
| Option**     | 15** | \$206 | *\$68 | \$446 | \$148 | \$244 | *\$30 |
|              |      | .25** | .75** | .87** | .96** | .06** | .94** |
| **Self and   |      |       |       |       |       |       |       |
| Family**     |      |       |       |       |       |       |       |
+--------------+------+-------+-------+-------+-------+-------+-------+