## ![](media/image1.png) GHI HMO

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

**2004**

#  

**A Health Maintenance Organization**

![](media/image2.wmf)

**Serving:** Albany -- Capital District Area, New York's Hudson Valley,

New York City Area

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

**Geographic service area to enroll. See page 11 or requirements.**

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height="1.1097222222222223in"}

*This Plan has new health plan accreditation*

*from NCQA. See the 2004 Guide for more*

*information on accreditation.*

**Enrollment codes for this Plan:**

**Albany -- Capital District, Hudson Valley Area**

**X41 Self Only**

**X42 Self and Family**

**New York City Area**

**6V1 Self Only**

![](media/image4.png)**6V2 Self and Family**

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Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

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

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

# Notice of the Office of Personnel Management's

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

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  Table of Contents
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Introduction............................................................................
7

Plain
Language........................................................................
7

Stop Health Care Fraud!.................................... 7

Preventing medical
mistakes.........................................................................................................8

Section 1. Facts about this HMO plan 10

How we pay providers 10

Who provides my health
care?.........................................................................................10

Your Rights 10

Service Area 11

Section 2. How we change for
2004............................................... 12

Program-wide changes 12

Changes to this Plan 12

Section 3. How you get care ............\... 13

Identification cards 13

Where you get covered care 13

• Plan providers 13

• Plan facilities 13

What you must do to get covered care 13

• Primary care 13

• Specialty care 14

• Hospital care 14

Circumstances beyond our control 15

Services requiring our prior approval 15

Section 4. Your costs for covered services 17

• Copayments 17

• Deductible 17

• Coinsurance 17

Your catastrophic protection out-of-pocket maximum 17

Section 5.
Benefits..................................................................
18

Overview 18

(a) Medical services and supplies provided by physicians and other
    health care professionals 19

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 29

(c) Services provided by a hospital or other facility, and ambulance
    services 33

(d) Emergency services/accidents 36

(e) Mental health and substance abuse benefits 38

**Table of Contents (Continued)**

(f) Prescription drug benefits 41

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(g) Special features 45

> • Flexible benefits option

(h) Dental benefits 46

\(j\) Non-FEHB benefits
.......................................................................................
...47

Section 6. General exclusions \-- things we don\'t cover 48

Section 7. Filing a claim for covered services 49

Section 8. The disputed claims process 50

Section 9. Coordinating benefits with other coverage 52

> When you have other health coverage 52

-   What is Medicare 52

-   Should I enroll in
    Medicare?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....52

-   Medicare + Choice 55

-   TRICARE and CHAMPVA 55

-   Workers\' Compensation 55

-   Medicaid 56

-   Other Government agencies 56

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-   When others are responsible for injuries 56

Section 10. Definitions of terms we use in this brochure 57

Section 11. FEHB facts 59

Coverage information 59

• No pre-existing condition limitation 59

• Where you get information about enrolling in the FEHB Program 59

• Types of coverage available for you and your family 59

Children's Equity Act 59

• When benefits and premiums start 60

• When you retire 60

When you lose benefits 60

• When FEHB coverage ends 60

• Spouse equity coverage 61

• Temporary Continuation of Coverage (TCC) 61

• Converting to individual coverage 61

• Getting a Certificate of Group Health Plan Coverage 61

Two new Federal Programs complement FEHB
benefits.....................................................................
63

The Federal Flexible Spending Account Program-
*FSAFEDS*...................................................63

The Federal Long Term Insurance
Program........................................................................66

Index 67

Summary of benefits 68

Rates..........................................................................................................................Back
cover

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  Introduction

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This brochure describes the benefits of GHI HMO under our contract
(CS2655) with the United States Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. The address for
GHI HMO administrative offices is:

GHI HMO

789 Grant Avenue

Lake Katrine, NY 12449

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 page
12. Rates are shown at the end of this brochure.

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  Plain Language

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

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

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

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

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

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  Stop Health Care Fraud!

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

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

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

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

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

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

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

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

-   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.

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-   If the provider does not resolve the matter, call us at 877-244-4466
    and explain the situation.

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-   If we do not resolve the issue:

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

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

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

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

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

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  Preventing Medical Mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

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

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

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

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  **Section 1. Facts about this HMO plan**

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This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other providers that contract
with us. These Plan providers coordinate your health care services. The
Plan is solely responsible for the selection of these providers in your
area. Contact the Plan for a copy of their most recent provider
directory.

HMOs emphasize preventive care such as routine office visits, physical
exams, well-baby care, and immunizations, in addition to treatment for
illness and injury. Our providers follow generally accepted medical
practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to
submit claim forms or pay bills. You only pay the copayments and
coinsurance described in this brochure. When you receive emergency
services from non-Plan providers, you may have to submit claim forms.

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

How we pay providers

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

**Who provides my health care?**

GHI HMO, an individual practice prepayment plan, is a New York State
certified, for-profit community-sponsored, primary care network model
Health Maintenance Organization (HMO).

GHI HMO organizes preventative and routine health care as well as needed
services for serious illness or injury. Care and coverage is provided by
approximately two thousand nine hundred and ninety nine (2,999)
individually affiliated primary care doctors, seventy (70) area
hospital, eleven thousand nine hundred and eighty eight (11,988) local
specialist.

GHI HMO administrative offices are located at 789 Grant Avenue, Lake
Katrine, NY 12449; and at 80 Wolf Road, Albany, NY 12205. Affiliated
primary care doctors, specialists and other health care providers are
conveniently located throughout the service area.

**Your Rights**

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

-   Years in existence - GHI HMO is a subsidiary of GHI, the largest,
    not-for-profit health services corporation operating state-wide in
    New York, and has been operating in 26 counties of NYS since July
    1999.

-   Company profit status - GHI HMO is a for-profit HMO.

-   Drug Formulary - GHI HMO offers an open drug formulary.

-   Percentage of Board Certified Physicians - 86% of GHI HMO physicians
    are Board Certified*.*

If you want more information about us, call 1-877-244-4466, or write to
GHI HMO, Customer Service, PO Box 4332, Kingston, NY 12402. You may also
contact us by fax at (845) 334-8823 or visit our website at
http://www.ghi.com.

**Service Area**

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

Albany -- Capital District Area: Albany, Broome, Columbia, Delaware,
Fulton, Greene, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady,
Schoharie, Warren and Washington Counties.

Hudson Valley Area: Dutchess, Orange, Putnam, Rockland, Sullivan, and
Ulster Counties.

New York City Area: Bronx, Brooklyn, Manhattan, Nassau, Queens,
Richmond, Suffolk and Westchester.

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

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

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program -- *FSAFEDS* and the Federal Long Term Care Insurance
    Program See page 63.

-   We added information regarding Preventing medical mistakes. See page
    8.

-   We added information regarding enrolling in Medicare. See page 52.

-   We revised the Medicare Primary Payer Chart. See page 54.

**Changes to this Plan**

-   Your share of the non-Postal premium will increase by 22.4% for Self
    Only or 11.2% for Self and Family for Code 6V.

-   Your share of the non-Postal premium will increase by 24.4% for Self
    Only or 74.3% for Self and Family for Code X4.

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  Section 3. How you get care
  -----------------------------------------------------------------------

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

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
1-877-244-4466 or write to us at GHI HMO, Customer Service, PO Box 4332,
Kingston, NY 12402.

**Where you get covered care** You get care from " Participating Plan
providers" and "Participating Plan facilities." You will only pay
copayments, or coinsurance, and you will not have to file claims

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

We list Plan providers in the provider directory, which we update
periodically. The directory is divided alphabetically by county. Primary
Care Physicians are listed first, Specialty Care Physicians are listed
second and all other providers (ancillary) are listed third under each
county. The list is also on our website www.ghi.com.

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

It depends on the type of care you need. First, you and each family
member must choose a primary care physician. This decision is important
since your primary care physician provides or arranges for most of your
health care. Primary care physicians are listed in our provider
directory and also on our web site. You may also call our Customer
Service Department (1-877-244-4466) and they may assist you in selecting
a provider near your home or office.

**•Primary care** Your primary care physician can be a family
practitioner, internist or pediatrician. Your primary care physician
will provide most of your health care, or give you a referral to see a
specialist.

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

**• Specialty care** Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your
primary care physician, you must return to the primary care physician
after the consultation, unless your primary care physician authorized a
certain number of visits without additional referrals. The primary care
physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives
you a referral. However, you may see your OB/GYN twice a year without a
referral and a participating optometrist for a routine vision exam
annually without a referral.

> Here are other things you should know about specialty care:

• If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician will
work with specialists to develop a treatment plan that allows you to see
your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our criteria when
creating your treatment plan (the physician may have to get an
authorization or approval beforehand).

• If you are seeing a specialist when you enroll in our Plan, talk to
your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a
specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment from
a specialist who does. Generally, we will not pay for you to see a
specialist who does not participate with our Plan.

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

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

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

> − drop out of the Federal Employees Health Benefits (FEHB) Program and
> you enroll in another FEHB Plan; or
>
> − reduce our service area and you enroll in another FEHB Plan,

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

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

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

If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 1-877-244-4466. If you
are new to the FEHB Program, we will arrange for you to receive care.

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

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

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

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

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

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

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

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

We call this review and approval process precertification. Your
physician must obtain prior authorization from the GHI HMO Medical
Director. These services may include but are not limited to:

> a\. Specialist Referrals
>
> b\. Ambulatory Surgery
>
> c\. Hospital/Nursing Home admissions and any care rendered during stay
>
> d\. Physical Therapy and Cardiac Rehabilitation

e.  Home Care and Hospice

f.  Durable Medical Equipment over \$250 and all Orthotics

g\. Non-Participating Providers

> h\. Member requests for experimental or investigative health care
>
> services.
>
> i\. Mental Health and Substance Abuse (MH/SA)
>
> GHI HMO may request supporting documentation from your provider to
> substantiate Medical Necessity of the requested service. All inpatient
> admissions are reviewed to evaluate that the services are covered
> services, Medically Necessary and being rendered at the appropriate
> level of care.
>
> You have the right to designate a representative for utilization
> review. GHI HMO will notify you and your provider, by phone and in
> writing for prospective, concurrent and retrospective utilization
> review decisions.
>
> If we deny services or won't pay your claim, you may ask us to
> reconsider our decision. Your request must:

1.  Be in writing

2.  Refer to specific brochure wording in explaining why you believe our

> decision is wrong; and

3.  Be made within six months from the date of our initial denial or

> refusal. We many extend this time limit if you show that you were
>
> unable to make a timely request due to reasons beyond your control.
>
> We have 30 days from the date we receive your reconsideration request
> to:

1.  Maintain our denial in writing;

2.  Pay the claim;

3.  Arrange for a health care provider to give you the service; or

4.  Ask for more information

> If we ask your medical provider for more information, we will send you
> a copy of our request. We must make a decision within 30 days after we
> receive the additional information. If we do not receive the requested
> information within 60 days, we will make our decision based on the
> information we already have.

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

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

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

**• Copayments** A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of
\$10 per office visit and when you go in the hospital, you pay nothing.

**•Deductible** We do not have a deductible

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

Example: In our plan you pay 50% of our allowance for infertility
services. Also, you pay 20% for durable medical equipment up to a
maximum of \$1500 per person, per year.

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

**out-of-pocket maximum**

+-----------------------------------------------------------------------+
| **Section 5. Benefits -- OVERVIEW**                                   |
|                                                                       |
| ***(See page 12 for how our benefits changed this year and page 68    |
| 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 following subsections. To obtain claims forms, claims
filing advice, or more information about our benefits, contact us at
*1-877-2GH-IHMO or 1-877-244-4466* or at our website at
[www.ghi.com]()*.*

(a) Medical services and supplies provided by physicians and other
    health care professionals.........................19-28

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 29-32

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

(c) Services provided by a hospital or other facility, and ambulance
    services 33-35

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

(d) Emergency services/accidents 36-37

> •Medical emergency •Ambulance

(e) Mental health and substance abuse benefits 38-40

(f) Prescription drug benefits 41-44

(g) Special features 45

• Flexible benefits option

•Services for the deaf and hearing impaired

•Center of Excellence for transplant/heart surgeries

•PHIP -- Personal Health Improvement Program

(h) Dental benefits 46

Summary of benefits 68

+---+---+-------------------------------------+----------------+---+----+
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| * |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+
|   | * | **Here are some important things to |                | * |    |
|   | * | keep in mind about these            |                | * |    |
|   | I | benefits:**                         |                | I |    |
|   | * |                                     |                | * |    |
|   | * | -   Please remember that all        |                | * |    |
|   |   |     benefits are subject to the     |                |   |    |
|   | * |     definitions, limitations, and   |                | * |    |
|   | * |     exclusions in this brochure and |                | * |    |
|   | M |     are payable only when we        |                | M |    |
|   | * |     determine they are medically    |                | * |    |
|   | * |     necessary.                      |                | * |    |
|   |   |                                     |                |   |    |
|   | * | -   Plan physicians must provide or |                | * |    |
|   | * |     arrange your care.              |                | * |    |
|   | P |                                     |                | P |    |
|   | * | -   We have no calendar year        |                | * |    |
|   | * |     deductible*.*                   |                | * |    |
|   |   |                                     |                |   |    |
|   | * | ```{=html}                          |                | * |    |
|   | * | <!-- -->                            |                | * |    |
|   | O | ```                                 |                | O |    |
|   | * | -   Be sure to read Section 4,      |                | * |    |
|   | * |     *Your costs for covered         |                | * |    |
|   |   |     services,* for valuable         |                |   |    |
|   | * |     information about how cost      |                | * |    |
|   | * |     sharing works. Also read        |                | * |    |
|   | R |     Section 9 about coordinating    |                | R |    |
|   | * |     benefits with other coverage,   |                | * |    |
|   | * |     including with Medicare.        |                | * |    |
|   |   |                                     |                |   |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | T |                                     |                | T |    |
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|   | * |                                     |                | * |    |
|   | A |                                     |                | A |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
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|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
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|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | T |                                     |                | T |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | **You pay**    |   |    |
|   |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| # |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$10 per     |   |    |
|   |   |                                     | > office visit |   |    |
| P |   |                                     | >              |   |    |
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| y |   |                                     |                |   |    |
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| l |   |                                     |                |   |    |
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| m |   |                                     |                |   |    |
| i |   |                                     |                |   |    |
| t |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+

*Diagnostic and treatment services \-- Continued on next page*

+---------------------------------------------+------------------------+
| ### **Diagno                                | **You pay**            |
| stic and treatment services** *(Continued)* |                        |
+---------------------------------------------+------------------------+
| > At Home                                   | > Nothing              |
| >                                           | >                      |
| > *Not covered:*                            | > *All Charges*        |
|                                             |                        |
| -   *Routine foot care and foot orthotics*  |                        |
|                                             |                        |
| -   *Physical examinations that are not     |                        |
|     necessary for medical reasons, such as  |                        |
|     those required for obtaining or         |                        |
|     continuing employment or insurance,     |                        |
|     attending school or camp, or travel*    |                        |
|                                             |                        |
| -   *Long-term rehabilitative therapy*      |                        |
|                                             |                        |
| -   *Homemaker services*                    |                        |
+---------------------------------------------+------------------------+
| # Lab, X-ray and other diagnostic tests     |                        |
+---------------------------------------------+------------------------+
| > Tests, such as:                           | > Nothing if you       |
|                                             | > receive these        |
| -   Blood tests                             | > services during your |
|                                             | > office visit;        |
| -   Urinalysis                              | > otherwise, \$10 per  |
|                                             | > office visit         |
| -   Non-routine pap tests                   |                        |
|                                             |                        |
| -   Pathology                               |                        |
|                                             |                        |
| -   Non-routine mammograms                  |                        |
|                                             |                        |
| -   Ultrasound                              |                        |
|                                             |                        |
| -   Electrocardiogram and EEG               |                        |
+---------------------------------------------+------------------------+
| -   CAT Scans/MRI                           | > \$10 copay           |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   X-ray                                   |                        |
+---------------------------------------------+------------------------+
| ##### Preventive care, adult                |                        |
+---------------------------------------------+------------------------+
| Routine screenings, such as:                | > \$10 per office      |
|                                             | > visit                |
| -   Total Blood Cholesterol -- once every   |                        |
|     three years                             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Colorectal Cancer Screening, including  |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Fecal occult blood test                 |                        |
|                                             |                        |
| -   Sigmoidoscopy, screening - every five   |                        |
|     years starting at age 50                |                        |
|                                             |                        |
| Routine Prostate Specific Antigen (PSA) -   |                        |
| one annually for men age 40 and older       |                        |
+---------------------------------------------+------------------------+
|                                             |                        |
+---------------------------------------------+------------------------+
| > Routine pap test                          | > \$10 per office      |
| >                                           | > visit                |
| > Note: The pap test is covered if the      |                        |
| > office visit is on the same day the       |                        |
| > office copay still applies; see           |                        |
| > *Diagnostic and Treatment* on page 19.    |                        |
+---------------------------------------------+------------------------+

> *Preventive Care - Adult \-- continued on next page*

+---------------------------------------------+------------------------+
| ##### Preventive care, adult *(Continued)*  | > **You pay**          |
+---------------------------------------------+------------------------+
| > Routine mammogram --covered for women age | > Nothing              |
| > 35 and older, as follows:                 |                        |
|                                             |                        |
| -   From age 35 through 39, one during this |                        |
|     five year period                        |                        |
|                                             |                        |
| -   From age 40 through 64, one every       |                        |
|     calendar year                           |                        |
|                                             |                        |
| -   At age 65 and older, one every two      |                        |
|     consecutive calendar years              |                        |
+---------------------------------------------+------------------------+
| > *Not covered: Physical exams required for | > *All charges*        |
| > obtaining or continuing employment or     |                        |
| > insurance, attending schools or camp, or  |                        |
| > travel.*                                  |                        |
+---------------------------------------------+------------------------+
| > Routine immunizations, limited to:        | > \$10 per office      |
|                                             | > visit                |
| -   Tetanus-diphtheria (Td) booster -- once |                        |
|     every 10 years, ages19 and over (except |                        |
|     as provided for under Childhood         |                        |
|     immunizations)                          |                        |
|                                             |                        |
| -   Influenza vaccines, annually            |                        |
|                                             |                        |
| -   Pneumococcal vaccine, age 65 and over   |                        |
+---------------------------------------------+------------------------+
| ##### Preventive care, children             |                        |
+---------------------------------------------+------------------------+
| -   Childhood immunizations recommended by  | > Nothing              |
|     the American Academy of Pediatrics      |                        |
+---------------------------------------------+------------------------+
| -   Examinations, such as:                  | > \$10 per office      |
|                                             | > visit                |
| > − Eye exams through age 19 to determine   |                        |
| > the need for vision correction.           |                        |
| >                                           |                        |
| > − Ear exams through age 19 to determine   |                        |
| > the need for hearing correction by a      |                        |
| > primary care physician                    |                        |
+---------------------------------------------+------------------------+
| > − Examinations done on the day of         | > Nothing              |
| > immunizations (under age 22)              |                        |
| >                                           |                        |
| > − Well-child care charges for routine     |                        |
| > examinations, immunizations and care      |                        |
| > (under age 22)                            |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Maternity care                     | > **You pay**          |
+---------------------------------------------+------------------------+
| > Complete maternity (obstetrical) care,    | > \$10 initial visit   |
| > such as:                                  | > only, nothing for    |
|                                             | > other pre and        |
| -   Prenatal care                           | > postnatal visits.    |
|                                             |                        |
| -   Delivery                                |                        |
|                                             |                        |
| > • Postnatal care                          |                        |
| >                                           |                        |
| > Note: Here are some things to keep in     |                        |
| > mind:                                     |                        |
|                                             |                        |
| -   You do not need to precertify your      |                        |
|     normal delivery; see page 15 for other  |                        |
|     circumstances, such as extended stays   |                        |
|     for you or your baby.                   |                        |
|                                             |                        |
| -   You may remain in the hospital up to 48 |                        |
|     hours after a regular delivery and 96   |                        |
|     hours after a cesarean delivery. We     |                        |
|     will extend your inpatient stay if      |                        |
|     medically necessary.                    |                        |
|                                             |                        |
| -   We cover routine nursery care of the    |                        |
|     newborn child during the covered        |                        |
|     portion of the mother's maternity stay. |                        |
|     We will cover other care of an infant   |                        |
|     who requires non-routine treatment only |                        |
|     if we cover the infant under a Self and |                        |
|     Family enrollment. Circumcision is a    |                        |
|     surgical benefit.                       |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   We pay hospitalization and surgeon      |                        |
|     services (delivery) the same as for     |                        |
|     illness and injury. See Hospital        |                        |
|     benefits (Section 5c) and Surgery       |                        |
|     benefits (Section 5b)*.*                |                        |
+---------------------------------------------+------------------------+
| > *Not covered: Routine sonograms to        | > *All charges*        |
| > determine fetal age, size or sex.*        |                        |
+---------------------------------------------+------------------------+
| ########  Family planning                   |                        |
+---------------------------------------------+------------------------+
| > A range of voluntary family planning      | > \$10 per office      |
| > services, limited to:                     | > visit                |
|                                             |                        |
| -   Voluntary sterilization (See Surgical   |                        |
|     procedures Section 5 (b))               |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Surgically implanted contraceptives     |                        |
|     (such as Norplant)                      |                        |
|                                             |                        |
| -   Injectable contraceptive drugs (such as |                        |
|     Depo provera)                           |                        |
|                                             |                        |
| -   Intrauterine devices (IUDs)             |                        |
|                                             |                        |
| -   Diaphragms                              |                        |
|                                             |                        |
| > NOTE: We cover oral contraceptives under  |                        |
| > the prescription drug benefit.            |                        |
+---------------------------------------------+------------------------+
| > *Not covered: reversal of voluntary       | > *All charges*        |
| > surgical sterilization, genetic           |                        |
| > counseling*                               |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Infertility services               | **You pay**            |
+---------------------------------------------+------------------------+
| > Diagnosis of infertility                  | > \$10 per office      |
|                                             | > visit                |
+---------------------------------------------+------------------------+
| > Treatment of Infertility, such as:        | 50% of charges         |
| >                                           |                        |
| > • Artificial insemination                 |                        |
|                                             |                        |
| -   *intravaginal insemination (IVI)*       |                        |
|                                             |                        |
| -   *intracervical insemination (ICI)*      |                        |
|                                             |                        |
| -   *intrauterine insemination (IUI)*       |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Assisted reproductive technology (ART) |                        |
|     procedures, such as:*                   |                        |
|                                             |                        |
| > *− in vitro fertilization*                |                        |
| >                                           |                        |
| > *− embryo transfer, gamete GIFT and       |                        |
| > zygote ZIFT*                              |                        |
| >                                           |                        |
| > *− Zygote transfer*                       |                        |
|                                             |                        |
| -   *Services and supplies related to       |                        |
|     excluded ART procedures*                |                        |
|                                             |                        |
| -   *Fertility Drugs*                       |                        |
|                                             |                        |
| -   *Cost of donor sperm*                   |                        |
|                                             |                        |
| -   *Cost of donor egg*                     |                        |
+---------------------------------------------+------------------------+
| > **Allergy care**                          |                        |
+---------------------------------------------+------------------------+
| > Testing and treatment                     | > \$10 per office      |
| >                                           | > visit                |
| > Allergy injection                         |                        |
+---------------------------------------------+------------------------+
| > Allergy serum                             | > Nothing              |
+---------------------------------------------+------------------------+
| > *Not covered: provocative food testing    | > *All charges*        |
| > and sublingual allergy desensitization*   |                        |
+---------------------------------------------+------------------------+
| ######## Diabetic supplies and equipment    |                        |
+---------------------------------------------+------------------------+
| ######## Blood glucose m                    | \$10 copay for         |
| onitors, data management systems, test stri | supplies               |
| ps for glucose monitoring, insulin, injecti |                        |
| on aids, cartridges for legally blind, syri |                        |
| nges, insulin pumps, insulin infusion devic |                        |
| es, oral agents for controlling blood sugar |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Treatment therapies                | **You pay**            |
+---------------------------------------------+------------------------+
| -   Chemotherapy and radiation therapy      | > Nothing              |
|                                             |                        |
| > Note: High dose chemotherapy in           |                        |
| > association with autologous bone marrow   |                        |
| > transplants are limited to those          |                        |
| > transplants listed under Organ/Tissue     |                        |
| > Transplants on page 31.                   |                        |
|                                             |                        |
| -   Respiratory and inhalation therapy      |                        |
|                                             |                        |
| -   Dialysis - hemodialysis and peritoneal  |                        |
|     dialysis                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Intravenous (IV)/Infusion Therapy --    |                        |
|     Home IV and antibiotic therapy          |                        |
+---------------------------------------------+------------------------+
| -   Growth hormone therapy (GHT)            | > \$10 copay for       |
|                                             | > prescriptions        |
| Note: -- Growth hormone is covered under    |                        |
| the prescription drug benefit.              |                        |
|                                             |                        |
| Note: -- We will only cover GHT when we     |                        |
| preauthorize the treatment. Call or have    |                        |
| your physician call 1-877-2GH-IHMO or 1-    |                        |
| 877-244-4466 for preauthorization. We will  |                        |
| ask you to submit information that          |                        |
| establishes that the GHT is medically       |                        |
| necessary. Ask us to authorize GHT before   |                        |
| you begin treatment; otherwise, we will     |                        |
| only cover GHT services from the date you   |                        |
| submit the information. If you do not ask   |                        |
| or if we determine GHT is not medically     |                        |
| necessary, we will not cover the GHT or     |                        |
| related services and supplies. This benefit |                        |
| is provided under our Prescription Drug     |                        |
| Benefits. See *Services requiring our prior |                        |
| approval* in Section 3.                     |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Treatment for experimental or          |                        |
|     investigational procedures*             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Therapy necessary for transsexual      |                        |
|     surgery*                                |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Physical and occupational therapies**   | **You pay**            |
+---------------------------------------------+------------------------+
| -   Up to two consecutive months per        | > \$10 per office      |
|     condition if significant improvement    | > visit                |
|     can be expected within two months for   | >                      |
|     the following services:                 | > \$10 per outpatient  |
|                                             | > visit                |
| > \-- qualified physical therapists;        | >                      |
| >                                           | > Nothing per visit    |
| > \-- occupational therapists.              | > during covered       |
| >                                           | > inpatient admission  |
| > Note: We only cover therapy to restore    |                        |
| > bodily function when there has been a     |                        |
| > total or partial loss of bodily function  |                        |
| > due to illness or injury. Physical and    |                        |
| > occupational therapy is provided on an    |                        |
| > inpatient or outpatient basis for up to   |                        |
| > two consecutive months per condition if   |                        |
| > significant improvement can be expected   |                        |
| > within two months; you pay \$10 copay per |                        |
| > outpatient visit. Speech therapy is       |                        |
| > limited to treatment if certain speech    |                        |
| > impairments of organic origin.            |                        |
| > Occupational therapy is limited to        |                        |
| > services that assist the member to        |                        |
| > achieve and maintain self-care and        |                        |
| > improved functioning in other activities  |                        |
| > of daily living.                          |                        |
|                                             |                        |
| -   Cardiac rehabilitation following a      |                        |
|     heart transplant, bypass surgery or a   |                        |
|     myocardial infarction, is provided for  |                        |
|     up to 30 visits within 60 days.         |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| > • l*ong term rehabilitative therapy*      |                        |
| >                                           |                        |
| > • e*xercise programs*                     |                        |
+---------------------------------------------+------------------------+
| > **Speech therapy**                        |                        |
+---------------------------------------------+------------------------+
| -   Up to two consecutive months per        | > \$10 per office      |
|     condition when medically necessary.     | > visit                |
+---------------------------------------------+------------------------+
| > **Hearing services (testing, treatment,   |                        |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| -   First hearing aid and testing only when | > \$10 per office      |
|     necessitated by accidental injury       | > visit                |
|                                             |                        |
| -   Hearing testing for children through    |                        |
|     age 17 (see *Preventive care,           |                        |
|     children*)                              |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| > • *all other hearing testing*             |                        |
| >                                           |                        |
| > • *hearing aids, testing and examinations |                        |
| > for them*                                 |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Vision services (testing, treatment,    | **You pay**            |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| -   Eye exam to determine the need for      | > \$10 per office      |
|     vision correction (see preventive care) | > visit                |
|                                             |                        |
| -   Annual eye refractions                  |                        |
|                                             |                        |
| > Note: See preventive care, children for   |                        |
| > eye exam                                  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Eyeglasses or contact lenses*          |                        |
|                                             |                        |
| -   *Eye exercises and orthoptics*          |                        |
|                                             |                        |
| -   *Radial keratotomy and other refractive |                        |
|     surgery*                                |                        |
+---------------------------------------------+------------------------+
| ######## Foot care                          |                        |
+---------------------------------------------+------------------------+
| > Routine foot care when you are under      | > \$10 per office      |
| > active treatment for a metabolic or       | > visit                |
| > peripheral vascular disease, such as      |                        |
| > diabetes.                                 |                        |
| >                                           |                        |
| > See orthopedic and prosthetic devices for |                        |
| > information on podiatric shoe inserts.    |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Cutting, trimming or removal of corns, |                        |
|     calluses, or the free edge of toenails, |                        |
|     and similar routine treatment of        |                        |
|     conditions of the foot, except as       |                        |
|     stated above*                           |                        |
|                                             |                        |
| -   *Treatment of weak, strained or flat    |                        |
|     feet or bunions or spurs; and of any    |                        |
|     instability, imbalance or subluxation   |                        |
|     of the foot (unless the treatment is by |                        |
|     open cutting surgery)*                  |                        |
+---------------------------------------------+------------------------+
| > **Orthopedic and prosthetic devices**     |                        |
+---------------------------------------------+------------------------+
| -   Artificial limbs and eyes; stump hose   | > 20% coinsurance up   |
|                                             | > to the Plan\'s       |
| -   Externally worn breast prostheses and   | > maximum benefit of   |
|     surgical bras, including necessary      | > \$1,500 per person,  |
|     replacements, following a mastectomy    | > per calendar year    |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Internal prosthetic devices, such as    |                        |
|     artificial joints, pacemakers, cochlear |                        |
|     implants, and surgically implanted      |                        |
|     breast implant following mastectomy.    |                        |
|     Note: We pay internal prosthetic        |                        |
|     devices as hospital benefits; see       |                        |
|     Section 5 (c) for payment information.  |                        |
|     See 5(b) for coverage of the surgery to |                        |
|     insert the device.                      |                        |
|                                             |                        |
| > • Corrective orthopedic appliances for    |                        |
| > non-dental treatment of temporomandibular |                        |
| > joint (TMJ) paid dysfunction syndrome.    |                        |
+---------------------------------------------+------------------------+

> *Orthopedic and prosthetic devices - Continued on next page*

+---------------------------------------------+------------------------+
| > **Orthopedic and prosthetic devices**     | **You pay**            |
| > (*Continued)*                             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *[O]{.smallcaps}rthopedic and           |                        |
|     corrective shoes*                       |                        |
|                                             |                        |
| -   *Arch supports*                         |                        |
|                                             |                        |
| -   *Foot orthotics*                        |                        |
|                                             |                        |
| -   *Heel pads and heel cups*               |                        |
|                                             |                        |
| -   *Lumbosacral supports*                  |                        |
|                                             |                        |
| -   *Corsets, trusses, elastic stockings,   |                        |
|     support hose, and other supportive      |                        |
|     devices*                                |                        |
|                                             |                        |
| -   *Prosthetic replacements provided less  |                        |
|     than 3 years after the last one we      |                        |
|     covered*                                |                        |
+---------------------------------------------+------------------------+
| ######## Durable medical equipment (DME)    |                        |
+---------------------------------------------+------------------------+
| > Rental or purchase, as determined by GHI  | > 20% coinsurance up   |
| > HMO, including repair and adjustment, of  | > to the Plan\'s       |
| > durable medical equipment prescribed by   | > maximum benefit of   |
| > your Plan physician, such as oxygen and   | > \$1,500 per person,  |
| > dialysis equipment. Under this benefit,   | > per calendar year    |
| > we also cover:                            |                        |
|                                             |                        |
| -   hospital beds;                          |                        |
|                                             |                        |
| -   standard wheelchairs;                   |                        |
|                                             |                        |
| -   apnea monitors;                         |                        |
|                                             |                        |
| -   nebulizers;                             |                        |
|                                             |                        |
| -   crutches and;                           |                        |
|                                             |                        |
| -   walkers;                                |                        |
|                                             |                        |
| > Note: Call us at 1-877-244-4466 as soon   |                        |
| > as your Plan physician prescribes this    |                        |
| > equipment. We will arrange with a health  |                        |
| > care provider to rent or sell you durable |                        |
| > medical equipment and will tell you more  |                        |
| > about this service when you call.         |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Motorized wheel chairs*                |                        |
|                                             |                        |
| -   *Hearing aids*                          |                        |
+---------------------------------------------+------------------------+
| ######## Home health services               |                        |
+---------------------------------------------+------------------------+
| -   Home health care ordered by a Plan      | > Nothing              |
|     physician and provided by a registered  |                        |
|     nurse (R.N.), licensed practical nurse  |                        |
|     (L.P.N.), or other Home Health Care     |                        |
|     Agency personnel licensed vocational    |                        |
|     nurse (L.V.N.), or home health aide.    |                        |
|                                             |                        |
| -   Services include oxygen therapy,        |                        |
|     intravenous therapy and medications.    |                        |
+---------------------------------------------+------------------------+

> *Home health services - Continued on next page*

+--------------------------------------------+-------------------------+
| > **Home health services** (Continued**)** | **You pay**             |
+--------------------------------------------+-------------------------+
| > Not covered:                             | > *All charges*         |
|                                            |                         |
| -   *Nursing care requested by, or for the |                         |
|     convenience of, the patient or the     |                         |
|     patient's family;*                     |                         |
|                                            |                         |
| -   *Home health care primarily for        |                         |
|     personal assistance that does not      |                         |
|     include a medical component and is not |                         |
|     diagnostic, therapeutic, or            |                         |
|     rehabilitative.*                       |                         |
+--------------------------------------------+-------------------------+
| ######## Chiropractic                      | []{.mark}               |
+--------------------------------------------+-------------------------+
| -   Manipulation of the spine and          | > \$10 per office visit |
|     extremities                            |                         |
|                                            |                         |
| -   Adjunctive procedures such as          |                         |
|     ultrasound, electrical muscle          |                         |
|     stimulation, vibratory therapy, and    |                         |
|     cold pack application                  |                         |
|                                            |                         |
| -   Chiropractic services when authorized  |                         |
|     by PCP                                 |                         |
+--------------------------------------------+-------------------------+
| ######## Alternative treatments            |                         |
+--------------------------------------------+-------------------------+
| ## *Not covered:*                          | > *All charges*         |
|                                            |                         |
| ## *Acupuncture services*                  |                         |
|                                            |                         |
| ## *Naturopathic services*                 |                         |
|                                            |                         |
| ## *Hypnotherapy*                          |                         |
|                                            |                         |
| ## *Biofeedback*                           |                         |
+--------------------------------------------+-------------------------+
| #### **Educational classes and programs**  |                         |
+--------------------------------------------+-------------------------+
| > No Benefit                               |                         |
+--------------------------------------------+-------------------------+

+---+---+-------------------------------------+----------------+---+---+
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| S |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| 5 |   |                                     |                |   |   |
| ( |   |                                     |                |   |   |
| b |   |                                     |                |   |   |
| ) |   |                                     |                |   |   |
| . |   |                                     |                |   |   |
| S |   |                                     |                |   |   |
| u |   |                                     |                |   |   |
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| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
|   | * | > **Here are some important things  |                | * |   |
|   | * | > to keep in mind about these       |                | * |   |
|   | I | > benefits:**                       |                | I |   |
|   | * |                                     |                | * |   |
|   | * | -   Please remember that all        |                | * |   |
|   |   |     benefits are subject to the     |                |   |   |
|   | * |     definitions, limitations, and   |                | * |   |
|   | * |     exclusions in this brochure and |                | * |   |
|   | M |     are payable only when we        |                | M |   |
|   | * |     determine they are medically    |                | * |   |
|   | * |     necessary.                      |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Plan physicians must provide or |                | * |   |
|   | * |     arrange your care.              |                | * |   |
|   | P |                                     |                | P |   |
|   | * | -   *We have no calendar year       |                | * |   |
|   | * |     deductible.*                    |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Be sure to read Section 4,      |                | * |   |
|   | * |     *Your costs for covered         |                | * |   |
|   | O |     services,* for valuable         |                | O |   |
|   | * |     information about how cost      |                | * |   |
|   | * |     sharing works. Also read        |                | * |   |
|   |   |     Section 9 about coordinating    |                |   |   |
|   | * |     benefits with other coverage,   |                | * |   |
|   | * |     including with Medicare.        |                | * |   |
|   | R |                                     |                | R |   |
|   | * | > • The amounts listed below are    |                | * |   |
|   | * | > for the charges billed by a       |                | * |   |
|   |   | > physician or other health care    |                |   |   |
|   | * | > professional for your surgical    |                | * |   |
|   | * | > care. Look in Section 5 (c) for   |                | * |   |
|   | T | > charges associated with facility  |                | T |   |
|   | * | > (i.e. hospital, surgical center,  |                | * |   |
|   | * | > etc).                             |                | * |   |
|   |   | >                                   |                |   |   |
|   | * | > • **YOUR PHYSICIAN MUST GET PRIOR |                | * |   |
|   | * | > AUTHORIZATION OF SOME SURGICAL    |                | * |   |
|   | A | > PROCEDURES**. Please refer to the |                | A |   |
|   | * | > precertification information      |                | * |   |
|   | * | > shown in Section 3 to be sure     |                | * |   |
|   |   | > which services require prior      |                |   |   |
|   | * | > authorization and identify which  |                | * |   |
|   | * | > surgeries require prior           |                | * |   |
|   | N | > authorization .                   |                | N |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | T |                                     |                | T |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | **You pay**    |   |   |
|   |   |                                     |                |   |   |
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+---+---+-------------------------------------+----------------+---+---+
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+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | > \$10 per     |   |   |
|   |   |                                     | > office       |   |   |
| A |   |                                     | > visit;       |   |   |
| > |   |                                     | > nothing for  |   |   |
|   |   |                                     | > hospital     |   |   |
| c |   |                                     | > visits       |   |   |
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|   |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| F |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
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| e |   |                                     |                |   |   |
| . |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+

+---------------------------------------------+------------------------+
| > **Reconstructive surgery**                | > **You pay**          |
+---------------------------------------------+------------------------+
| -   Surgery to correct a functional defect  | > \$10 per office      |
|                                             | > visit; nothing for   |
| -   Surgery to correct a condition caused   | > hospital visits      |
|     by injury or illness if:                |                        |
|                                             |                        |
| > − the condition produced a major effect   |                        |
| > on the member's appearance and            |                        |
| >                                           |                        |
| > − the condition can reasonably be         |                        |
| > expected to be corrected by such surgery  |                        |
|                                             |                        |
| -   Surgery to correct a condition that     |                        |
|     existed at or from birth and is a       |                        |
|     significant deviation from the common   |                        |
|     form or norm. Examples of congenital    |                        |
|     anomalies are: protruding ear           |                        |
|     deformities; cleft lip; cleft palate;   |                        |
|     birth marks; webbed fingers; and webbed |                        |
|     toes.                                   |                        |
+---------------------------------------------+------------------------+
| -   All stages of breast reconstruction     | > See above            |
|     surgery following a mastectomy, such    |                        |
|     as:                                     |                        |
|                                             |                        |
| > − surgery to produce a symmetrical        |                        |
| > appearance on the other breast;           |                        |
| >                                           |                        |
| > − treatment of any physical               |                        |
| > complications, such as lymphedemas;       |                        |
| >                                           |                        |
| > − breast prostheses and surgical bras and |                        |
| > replacements (see Prosthetic devices)     |                        |
| >                                           |                        |
| > Note: If you need a mastectomy, you may   |                        |
| > choose to have the procedure performed on |                        |
| > an inpatient basis and remain in the      |                        |
| > hospital up to 48 hours after the         |                        |
| > procedure                                 |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Cosmetic surgery -- any surgical       |                        |
|     procedure (or any portion of a          |                        |
|     procedure) performed primarily to       |                        |
|     improve physical appearance through     |                        |
|     change in bodily form, except repair of |                        |
|     accidental injury*                      |                        |
|                                             |                        |
| -   *Surgeries related to sex               |                        |
|     transformation*                         |                        |
+---------------------------------------------+------------------------+
| > **Oral and maxillofacial surgery**        |                        |
+---------------------------------------------+------------------------+
| > Oral surgical procedures, limited to:     | > \$10 per office      |
|                                             | > visit                |
| -   Reduction of fractures of the jaws or   |                        |
|     facial bones;                           |                        |
|                                             |                        |
| -   Surgical correction of cleft lip, cleft |                        |
|     palate or severe functional             |                        |
|     malocclusion;                           |                        |
|                                             |                        |
| -   Removal of stones from salivary ducts;  |                        |
|                                             |                        |
| -   Excision of leukoplakia or              |                        |
|     malignancies;                           |                        |
|                                             |                        |
| -   Excision of cysts and incision of       |                        |
|     abscesses when done as independent      |                        |
|     procedures;                             |                        |
|                                             |                        |
| -   Temporanmandibular Joint treatment      |                        |
|     (TMJ); and                              |                        |
|                                             |                        |
| -   Other surgical procedures that do not   |                        |
|     involve the teeth or their supporting   |                        |
|     structures.                             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Oral implants and transplants*         |                        |
|                                             |                        |
| -   *Procedures that involve the teeth or   |                        |
|     their supporting structures (such as    |                        |
|     the periodontal membrane, gingiva, and  |                        |
|     alveolar bone)*                         |                        |
|                                             |                        |
| -   *All other procedures involving the     |                        |
|     teeth or intra-oral areas surrounding   |                        |
|     the teeth are not covered, including    |                        |
|     any dental care involved in the         |                        |
|     treatment of temporomandibular joint    |                        |
|     (TMJ) pain dysfunction syndrome.*       |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| **Organ/tissue transplants**                | > **You pay**          |
+---------------------------------------------+------------------------+
| > Limited to:                               | > Nothing              |
|                                             |                        |
| -   Cornea                                  |                        |
|                                             |                        |
| -   Heart                                   |                        |
|                                             |                        |
| -   Heart/lung                              |                        |
|                                             |                        |
| -   Kidney                                  |                        |
|                                             |                        |
| -   Kidney/Pancreas                         |                        |
|                                             |                        |
| -   Liver                                   |                        |
|                                             |                        |
| -   Lung: Single --Double                   |                        |
|                                             |                        |
| -   Pancreas                                |                        |
|                                             |                        |
| -   Allogenic (donor) bone marrow           |                        |
|     transplants                             |                        |
|                                             |                        |
| -   Autologous bone marrow transplants      |                        |
|     (autologous stem cell and peripheral    |                        |
|     stem cell support) for the following    |                        |
|     conditions: acute lymphocytic or        |                        |
|     non-lymphocytic leukemia; advanced      |                        |
|     Hodgkin\'s lymphoma; advanced           |                        |
|     non-Hodgkin\'s lymphoma; advanced       |                        |
|     neuroblastoma; breast cancer; multiple  |                        |
|     myeloma; epithelial ovarian cancer; and |                        |
|     testicular, mediastinal,                |                        |
|     retroperitoneal and ovarian germ cell   |                        |
|     tumors                                  |                        |
|                                             |                        |
| -   Intestinal transplants (small           |                        |
|     intestine) and the small intestine with |                        |
|     the liver or small intestine with       |                        |
|     multiple organs such as the liver,      |                        |
|     stomach, and pancreas                   |                        |
|                                             |                        |
| -   National Transplant Program (NTP) --    |                        |
|     GHI HMO will cover transplants approved |                        |
|     as safe and effective for a specific    |                        |
|     disease by the Federal Drug             |                        |
|     Administration (FDA) or National        |                        |
|     Institute of Health or which GHI HMO's  |                        |
|     Medical Director determines is          |                        |
|     medically necessary, appropriate and    |                        |
|     advisable on a case-by-case basis. GHI  |                        |
|     HMO will cover the medical and hospital |                        |
|     services, and related organ acquisition |                        |
|     costs. Eligibility for transplants      |                        |
|     shall be determined solely by GHI HMO's |                        |
|     Medical Director upon recommendation of |                        |
|     an Enrollee's Primary Care Physician.   |                        |
|     Eligibility for transplants must be     |                        |
|     approved in advance of surgery by GHI   |                        |
|     HMO's Medical Director. Additionally,   |                        |
|     all transplants must be performed at    |                        |
|     hospitals specifically approved and     |                        |
|     designated by GHI HMO to perform these  |                        |
|     procedures. Specialty physician experts |                        |
|     from our designated centers of          |                        |
|     excellence will provide clinical review |                        |
|     and support to the Medical Director's   |                        |
|     decision.                               |                        |
|                                             |                        |
| > Limited Benefits -- Treatment for breast  |                        |
| > cancer, multiple myeloma, and epithelial  |                        |
| > ovarian cancer may be provided in an NCI- |                        |
| > or NIH-approved clinical trial at a       |                        |
| > Plan-designated center of excellence and  |                        |
| > if approved by the Plan's medical         |                        |
| > director in accordance with the Plan's    |                        |
| > protocols.                                |                        |
| >                                           |                        |
| > Note: We cover related medical and        |                        |
| > hospital expenses of the donor when we    |                        |
| > cover the recipient.                      |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | > *All Charges*        |
|                                             |                        |
| • *Donor screening tests and donor search   |                        |
| expenses, except those*                     |                        |
|                                             |                        |
| *performed for the actual donor*            |                        |
|                                             |                        |
| • *Implants of artificial organs*           |                        |
|                                             |                        |
| • *Transplants not listed as covered*       |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Anesthesia**                            | > **You pay**          |
+---------------------------------------------+------------------------+
| Professional services provided in --        | > Nothing              |
|                                             |                        |
| -   Hospital (inpatient)                    |                        |
+---------------------------------------------+------------------------+
| Professional services provided in --        | > Nothing              |
|                                             |                        |
| -   Hospital outpatient department          |                        |
|                                             |                        |
| -   Skilled nursing facility                |                        |
|                                             |                        |
| -   Ambulatory surgical center              |                        |
|                                             |                        |
| -   Office                                  |                        |
+---------------------------------------------+------------------------+

+----+---+-----------------------------------+--------------+---+-----+
| >  |   |                                   |              |   |     |
|  * |   |                                   |              |   |     |
| *S |   |                                   |              |   |     |
| ec |   |                                   |              |   |     |
| ti |   |                                   |              |   |     |
| on |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  5 |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| (c |   |                                   |              |   |     |
| ). |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| Se |   |                                   |              |   |     |
| rv |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| pr |   |                                   |              |   |     |
| ov |   |                                   |              |   |     |
| id |   |                                   |              |   |     |
| ed |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| by |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ho |   |                                   |              |   |     |
| sp |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  o |   |                                   |              |   |     |
| th |   |                                   |              |   |     |
| er |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  f |   |                                   |              |   |     |
| ac |   |                                   |              |   |     |
| il |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| y, |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| mb |   |                                   |              |   |     |
| ul |   |                                   |              |   |     |
| an |   |                                   |              |   |     |
| ce |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| se |   |                                   |              |   |     |
| rv |   |                                   |              |   |     |
| ic |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| ** |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
|    | * | > **Here are some important       |              | * |     |
|    | * | > things to remember about these  |              | * |     |
|    | I | > benefits:**                     |              | I |     |
|    | * |                                   |              | * |     |
|    | * | -   Please remember that all      |              | * |     |
|    |   |     benefits are subject to the   |              |   |     |
|    | * |     definitions, limitations, and |              | * |     |
|    | * |     exclusions in this brochure   |              | * |     |
|    | M |     and are payable only when we  |              | M |     |
|    | * |     determine they are medically  |              | * |     |
|    | * |     necessary.                    |              | * |     |
|    |   |                                   |              |   |     |
|    | * | -   Plan physicians must provide  |              | * |     |
|    | * |     or arrange your care and you  |              | * |     |
|    | P |     must be hospitalized in a     |              | P |     |
|    | * |     Plan facility.                |              | * |     |
|    | * |                                   |              | * |     |
|    |   | ```{=html}                        |              |   |     |
|    | * | <!-- -->                          |              | * |     |
|    | * | ```                               |              | * |     |
|    | O | -   *We have no calendar year     |              | O |     |
|    | * |     deductible.*                  |              | * |     |
|    | * |                                   |              | * |     |
|    |   | ```{=html}                        |              |   |     |
|    | * | <!-- -->                          |              | * |     |
|    | * | ```                               |              | * |     |
|    | R | -   Be sure to read Section 4,    |              | R |     |
|    | * |     *Your costs for covered       |              | * |     |
|    | * |     services,* for valuable       |              | * |     |
|    |   |     information about how cost    |              |   |     |
|    | * |     sharing works. Also read      |              | * |     |
|    | * |     Section 9 about coordinating  |              | * |     |
|    | T |     benefits with other coverage, |              | T |     |
|    | * |     including with Medicare.      |              | * |     |
|    | * |                                   |              | * |     |
|    |   | -   The amounts listed below are  |              |   |     |
|    | * |     for the charges billed by the |              | * |     |
|    | * |     facility (i.e., hospital or   |              | * |     |
|    | A |     surgical center) or ambulance |              | A |     |
|    | * |     service for your surgery or   |              | * |     |
|    | * |     care. Any costs associated    |              | * |     |
|    |   |     with the professional charge  |              |   |     |
|    | * |     (i.e., physicians, etc.) are  |              | * |     |
|    | * |     covered in Sections 5(a) or   |              | * |     |
|    | N |     (b).                          |              | N |     |
|    | * |                                   |              | * |     |
|    | * | ```{=html}                        |              | * |     |
|    |   | <!-- -->                          |              |   |     |
|    | * | ```                               |              | * |     |
|    | * | -   **YOUR PHYSICIAN MUST GET     |              | * |     |
|    | T |     PRIOR AUTHORIZATION OF        |              | T |     |
|    | * |     HOSPITAL STAYS.** Please      |              | * |     |
|    | * |     refer to Section 3 to be sure |              | * |     |
|    |   |     which services require prior  |              |   |     |
|    |   |     authorization                 |              |   |     |
|    |   |     precertification              |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| >  |   |                                   | **You pay**  |   |     |
|  * |   |                                   |              |   |     |
| *B |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
| ef |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  D |   |                                   |              |   |     |
| es |   |                                   |              |   |     |
| cr |   |                                   |              |   |     |
| ip |   |                                   |              |   |     |
| ti |   |                                   |              |   |     |
| on |   |                                   |              |   |     |
| ** |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| #  |   |                                   | ########     |   |     |
| ## |   |                                   |              |   |     |
| ## |   |                                   |              |   |     |
| ## |   |                                   |              |   |     |
| #  |   |                                   |              |   |     |
| In |   |                                   |              |   |     |
| pa |   |                                   |              |   |     |
| ti |   |                                   |              |   |     |
| en |   |                                   |              |   |     |
| t  |   |                                   |              |   |     |
| ho |   |                                   |              |   |     |
| sp |   |                                   |              |   |     |
| it |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+
| >  |   |                                   | > Nothing    |   |     |
| Ro |   |                                   |              |   |     |
| om |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| nd |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| bo |   |                                   |              |   |     |
| ar |   |                                   |              |   |     |
| d, |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| su |   |                                   |              |   |     |
| ch |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| as |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| -  |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  w |   |                                   |              |   |     |
| ar |   |                                   |              |   |     |
| d, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| se |   |                                   |              |   |     |
| mi |   |                                   |              |   |     |
| pr |   |                                   |              |   |     |
| iv |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| e, |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| or |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  i |   |                                   |              |   |     |
| nt |   |                                   |              |   |     |
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| si |   |                                   |              |   |     |
| ve |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
| ca |   |                                   |              |   |     |
| re |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| cc |   |                                   |              |   |     |
| om |   |                                   |              |   |     |
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| ar |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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|    |   |                                   |              |   |     |
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| HI |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|  H |   |                                   |              |   |     |
| MO |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
|    |   |                                   |              |   |     |
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| ed |   |                                   |              |   |     |
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| al |   |                                   |              |   |     |
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| ce |   |                                   |              |   |     |
| ss |   |                                   |              |   |     |
| ar |   |                                   |              |   |     |
| y, |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  y |   |                                   |              |   |     |
| ou |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  p |   |                                   |              |   |     |
| ay |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  t |   |                                   |              |   |     |
| he |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ad |   |                                   |              |   |     |
| di |   |                                   |              |   |     |
| ti |   |                                   |              |   |     |
| on |   |                                   |              |   |     |
| al |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ch |   |                                   |              |   |     |
| ar |   |                                   |              |   |     |
| ge |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  a |   |                                   |              |   |     |
| bo |   |                                   |              |   |     |
| ve |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  t |   |                                   |              |   |     |
| he |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  s |   |                                   |              |   |     |
| em |   |                                   |              |   |     |
| ip |   |                                   |              |   |     |
| ri |   |                                   |              |   |     |
| va |   |                                   |              |   |     |
| te |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
| ro |   |                                   |              |   |     |
| om |   |                                   |              |   |     |
| >  |   |                                   |              |   |     |
|  r |   |                                   |              |   |     |
| at |   |                                   |              |   |     |
| e. |   |                                   |              |   |     |
+----+---+-----------------------------------+--------------+---+-----+

*Inpatient hospital continued on next page.*

+---------------------------------------------+------------------------+
| ######## Inpatient hospital *(Continued)*   | ######## You pay       |
+---------------------------------------------+------------------------+
| #### Oth                                    | > Nothing              |
| er hospital services and supplies, such as: |                        |
|                                             |                        |
| -   Operating, recovery, maternity, and     |                        |
|     other treatment rooms                   |                        |
|                                             |                        |
| -   Prescribed drugs and medicines          |                        |
|                                             |                        |
| -   Diagnostic laboratory tests and X-rays  |                        |
|                                             |                        |
| -   Administration of blood and blood       |                        |
|     products                                |                        |
|                                             |                        |
| -   Blood or blood plasma, if not donated   |                        |
|     or replaced                             |                        |
|                                             |                        |
| -   Dressings, splints, casts, and sterile  |                        |
|     tray services                           |                        |
|                                             |                        |
| -   Medical supplies and equipment,         |                        |
|     including oxygen                        |                        |
|                                             |                        |
| -   Anesthetics, including nurse            |                        |
|     anesthetist services                    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Take-home items                         |                        |
|                                             |                        |
| -   Medical supplies, appliances, medical   |                        |
|     equipment, and any covered items billed |                        |
|     by a hospital for use at home           |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Custodial care*                        |                        |
|                                             |                        |
| -   *Non-covered facilities, such as        |                        |
|     nursing homes, schools*                 |                        |
|                                             |                        |
| -   *Personal comfort items, such as        |                        |
|     telephone, television, barber services, |                        |
|     guest meals and beds*                   |                        |
|                                             |                        |
| -   *Private nursing care*                  |                        |
+---------------------------------------------+------------------------+
| #### **Outpatie                             | ####                   |
| nt hospital or ambulatory surgical center** |                        |
+---------------------------------------------+------------------------+
| > • Operating, recovery, and other          | > Nothing              |
| > treatment rooms                           |                        |
|                                             |                        |
| #### Prescribed drugs and medicines         |                        |
|                                             |                        |
| -   Diagnostic laboratory tests, X-rays,    |                        |
|     and pathology services                  |                        |
|                                             |                        |
| -   Administration of blood, blood plasma,  |                        |
|     and other biologicals                   |                        |
|                                             |                        |
| -   Blood and blood plasma, if not donated  |                        |
|     or replaced                             |                        |
|                                             |                        |
| -   Pre-surgical testing                    |                        |
|                                             |                        |
| -   Dressings, casts, and sterile tray      |                        |
|     services                                |                        |
|                                             |                        |
| -   Medical supplies, including oxygen      |                        |
|                                             |                        |
| -   Anesthetics and anesthesia service      |                        |
|                                             |                        |
| > NOTE: -- We cover hospital services and   |                        |
| > supplies related to dental procedures     |                        |
| > when necessitated by a non-dental         |                        |
| > physical impairment if in connection with |                        |
| > an accidental injury to sound natural     |                        |
| > teeth within twelve (12) months of the    |                        |
| > accident, or in the judgement of GHI      |                        |
| > HMO's Medical Director, a hazardous       |                        |
| > concurrent medical condition requires     |                        |
| > hospitalization. Hospital care is only    |                        |
| > available when a medical condition        |                        |
| > necessitates such care. We do not cover   |                        |
| > the dental procedures.                    |                        |
|                                             |                        |
| #######                                     |                        |
+---------------------------------------------+------------------------+
| #                                           | > *All charges*        |
|                                             |                        |
| # *Not covered: blood and bl                |                        |
| ood derivatives not replaced by the member* |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Extended care bene                 | ######## You pay       |
| fits/skilled nursing care facility benefits |                        |
+---------------------------------------------+------------------------+
| > Skilled nursing facility (SNF):           | > Nothing              |
| >                                           |                        |
| > Limited to 120 days per person per        |                        |
| > calendar year :                           |                        |
|                                             |                        |
| -   Bed, board and general nursing care     |                        |
|                                             |                        |
| -   Drugs, biologicals, supplies and        |                        |
|     equipment ordinarily provided or        |                        |
|     arranged by the skilled nursing         |                        |
|     facility when prescribed by your plan   |                        |
|     doctor.                                 |                        |
+---------------------------------------------+------------------------+
| > Not covered: custodial care               | > *All charges*        |
+---------------------------------------------+------------------------+
| #### **Hospice care**                       | ####                   |
+---------------------------------------------+------------------------+
| > Supportive and palliative care for the    | > Nothing              |
| > terminally ill member is covered in the   |                        |
| > home or hospice facility. Services        |                        |
| > include inpatient and outpatient care and |                        |
| > family counseling. Benefits are limited   |                        |
| > to 210 days; bereavement counseling       |                        |
| > services are covered up to five (5) days. |                        |
+---------------------------------------------+------------------------+
| > *Not covered: Independent nursing,        | > *All charges*        |
| > homemaker services*                       |                        |
+---------------------------------------------+------------------------+
| ######## Ambulance                          | ########               |
+---------------------------------------------+------------------------+
| -   Local professional ambulance service    | > Nothing              |
|     when medically appropriate              |                        |
+---------------------------------------------+------------------------+

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

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

+-----------------------------------------------+----------------------+
| ###  **Mental health                          | **You pay**          |
|  and substance abuse benefits** (*Continued*) |                      |
+-----------------------------------------------+----------------------+
| -   Diagnostic test                           | > Nothing if you     |
|                                               | > receive these      |
| -   Lab work                                  | > services during    |
|                                               | > your office visit  |
|                                               | > otherwise, \$10    |
|                                               | > per office visit   |
+-----------------------------------------------+----------------------+
| -   X-rays                                    | > \$10 per office    |
|                                               | > visit              |
+-----------------------------------------------+----------------------+
| -   Services provided by a hospital or other  | > Nothing            |
|     facility                                  |                      |
|                                               |                      |
| ```{=html}                                    |                      |
| <!-- -->                                      |                      |
| ```                                           |                      |
| -   Services in approved alternative care     |                      |
|     settings such as:                         |                      |
|                                               |                      |
| ```{=html}                                    |                      |
| <!-- -->                                      |                      |
| ```                                           |                      |
| -   partial hospitalization                   |                      |
|                                               |                      |
| -   residential treatment                     |                      |
|                                               |                      |
| -   full-day hospitalization                  |                      |
|                                               |                      |
| -   facility based intensive outpatient       |                      |
|     treatment                                 |                      |
+-----------------------------------------------+----------------------+
| ## *Not cover                                 | > *All charges*      |
| ed in the network: The same exclusions contai |                      |
| ned in this brochure that apply to other bene |                      |
| fits apply to these mental health and substan |                      |
| ce abuse benefits, unless the services are in |                      |
| cluded in a treatment plan that we approve.*  |                      |
|                                               |                      |
| ## *Note                                      |                      |
| : OPM will base its review of disputes about  |                      |
| treatment plans on the treatment plan\'s clin |                      |
| ical appropriateness. OPM will generally not  |                      |
| order us to pay or provide one clinically app |                      |
| ropriate treatment plan in favor of another.* |                      |
+-----------------------------------------------+----------------------+

*Network mental health and substance abuse benefits \-- Continued on
next page.*

> **Preauthorization** To be eligible to receive these benefits you must
> follow your treatment plan and all of our network authorization
> processes.
>
> Merit Behavioral Health Care an affiliate of Magellan Behavioral
> Health has been contracted to manage your behavioral health benefits.
> In order to access your benefits, please call the Merit Behavioral
> Health Care toll free number at 1-800-836-2256. You will be connected
> to a customer service representative who will be able to assist you in
> identifying a behavioral health care provider in your area or to
> verify if your current provider is a participating provider in the
> Behavioral Health network.
>
> If participating, the customer service representative will verify
> benefits/eligibility and an authorization for treatment will be sent
> out to your provider. They will continue to follow their contractual
> obligations and submit treatment plan reports for continued
> authorization. The treatment reports will be reviewed by a New York
> State licensed clinician to determine if the treatment you are
> receiving meets medical necessity criteria for the level of care and
> the intensity of treatment you are receiving.
>
> If non-participating, the customer service representative will either
> offer you a provider participating in the network that specializes in
> your area of need or will offer to forward a treatment report to you.
> You will be responsible for your provider completing the forms in
> their entirety and returning them to the address provided. The
> treatment reports will be reviewed by a New York State licensed
> clinician to determine if the treatment you are receiving meets
> medical necessity criteria for the level of care and the intensity of
> treatment you are receiving.
>
> Treatment will not be interrupted if the licensed clinician reviewer
> finds your treatment to be needed and appropriately provided. At that
> point, your non-participating provider will be required to sign an ad
> hoc agreement, which will allow you to continue in treatment. Your
> non-participating provider will be required to accept contracted
> rates. They will be required to follow all the same contract
> requirements as a participating provider.
>
> Inpatient and alternative levels of care, which are more intense, than
> routine outpatient therapy must be called in by using the same toll
> free number. New York State licensed staff is available 24 hours a
> day, 7 days a week, 365 days a year.
>
> Participating provider directories can be obtained by calling the
> Customer Service department at GHI HMO at 1-877-244-4466 or view the
> directory on our website at [www.ghi.com](http://www.ghihmo.com/).

**How to submit claims** There are no claim forms. You must work through
participating providers. In the event you are in the transitional
period, you must notify the Plan and have the provider contact the Plan.
If you have mistakenly received a bill for covered services or your
provider needs to contact GHI HMO, please contact customer service at
1-877-244-4466. Mail billing statements to GHI HMO, Attn: Claims, PO BOX
4332, Kingston, NY 12402.

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

+------+----+-------------------------------------------------+---+-----+
| *    |    |                                                 |   |     |
| *Sec |    |                                                 |   |     |
| tion |    |                                                 |   |     |
| 5    |    |                                                 |   |     |
| (f). |    |                                                 |   |     |
| Pres |    |                                                 |   |     |
| crip |    |                                                 |   |     |
| tion |    |                                                 |   |     |
| drug |    |                                                 |   |     |
| be   |    |                                                 |   |     |
| nefi |    |                                                 |   |     |
| ts** |    |                                                 |   |     |
+------+----+-------------------------------------------------+---+-----+
|      | *  | **Here are some important things to keep in     | * |     |
|      | *I | mind about your prescription drug benefits:**   | * |     |
|      | ** |                                                 | I |     |
|      |    | -   GHI HMO covers your prescription            | * |     |
|      | *  |     medications, as described in the chart      | * |     |
|      | *M |     beginning on the next page.                 |   |     |
|      | ** |                                                 | * |     |
|      |    | -   All prescription drug benefits are subject  | * |     |
|      | *  |     to the definitions, limitations and         | M |     |
|      | *P |     exclusions in this brochure. In addition,   | * |     |
|      | ** |     these benefits are payable only when        | * |     |
|      |    |     determined by GHI HMO that they are         |   |     |
|      | *  |     medically necessary.                        | * |     |
|      | *O |                                                 | * |     |
|      | ** | -   *We have no calendar year deductible*       | P |     |
|      |    |                                                 | * |     |
|      | *  | -   Please refer to Section 4, *Your costs for  | * |     |
|      | *R |     covered services*, for valuable information |   |     |
|      | ** |     about cost sharing, as well as the special  | * |     |
|      |    |     sections for members who are 65 years of    | * |     |
|      | *  |     age or over. In addition, Section 9 details | O |     |
|      | *T |     how you can coordinate your prescription    | * |     |
|      | ** |     drug benefits with other coverage,          | * |     |
|      |    |     including Medicare.                         |   |     |
|      | *  |                                                 | * |     |
|      | *A |                                                 | * |     |
|      | ** |                                                 | R |     |
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|      |    |                                                 | N |     |
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|      |    |                                                 | * |     |
|      |    |                                                 | T |     |
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|      |    |                                                 | * |     |
+------+----+-------------------------------------------------+---+-----+
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+------+----+-------------------------------------------------+---+-----+
|      | *  |                                                 |   |     |
|      | Pr |                                                 |   |     |
|      | es |                                                 |   |     |
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|      | .* |                                                 |   |     |
+------+----+-------------------------------------------------+---+-----+

+-------------------------------------------+--------------------------+
| > **Benefit Description**                 | **You pay**              |
+-------------------------------------------+--------------------------+
| > **Covered medications and supplies**    |                          |
+-------------------------------------------+--------------------------+
| > The following drug categories are       |                          |
| > available for dispensing through        |                          |
| > Express Scripts PERxCare Retail         |                          |
| > Pharmacy Program. For a complete        |                          |
| > formulary listing call 1-877-244-4466   |                          |
| > (GHI HMO) or Express Scripts at         |                          |
| > 1-877-534-3682.                         |                          |
|                                           |                          |
| -   Anti-infectives                       |                          |
|                                           |                          |
| -   Cardiovascular                        |                          |
|                                           |                          |
| -   Endocrine                             |                          |
|                                           |                          |
| -   Gastrointestinal                      |                          |
|                                           |                          |
| -   Psychotherapeutics                    |                          |
|                                           |                          |
| -   NSAIDS (Pain relievers)               |                          |
|                                           |                          |
| -   Respiratory                           |                          |
+-------------------------------------------+--------------------------+
| > We cover the following medications and  | Retail Pharmacy:         |
| > supplies prescribed by a Plan physician |                          |
| > and obtained from a Plan pharmacy or    | \$10 co pay - generic    |
| > through our mail order program:         |                          |
|                                           | \$20 co pay -- preferred |
| -   Prescription drugs prescribed by a    | brand                    |
|     Plan or referral doctor and obtained  |                          |
|     at a Plan retail pharmacy will be     | \$30 co pay --           |
|     dispensed for up to a 30-day supply   | non-preferred brand      |
|     or 100 unit supply, whichever is      |                          |
|     less, 240 milligrams of liquid (8     | (30-day supply)          |
|     oz.); 60 grams of ointment, creams or |                          |
|     topical preparation; or one           | Mail Order:              |
|     commercially prepared unit (i.e. one  |                          |
|     inhaler, one vial ophthalmic          | \$20 co pay -- generic   |
|     medication or insulin).               |                          |
|                                           | \$40 co pay -- preferred |
| ```{=html}                                | brand                    |
| <!-- -->                                  |                          |
| ```                                       | \$50 co pay --           |
| -   Contraceptive drugs and devices       | non-preferred brand      |
|                                           |                          |
| ```{=html}                                | (90-day supply for       |
| <!-- -->                                  | maintenance medications) |
| ```                                       |                          |
| -   Insulin                               |                          |
|                                           |                          |
| -   Disposable needles and syringes for   |                          |
|     the administration of covered         |                          |
|     medications                           |                          |
|                                           |                          |
| -   Drugs and medicines that by Federal   |                          |
|     law of the United States require a    |                          |
|     physician's prescription for their    |                          |
|     purchase, except as excluded below.   |                          |
|                                           |                          |
| > − Prescription drugs for diet or weight |                          |
| > control including anorexic              |                          |
| >                                         |                          |
| > agent                                   |                          |
| >                                         |                          |
| > − Drugs utilized for treatment of       |                          |
| > sexual dysfunction are limited to 6     |                          |
| > doses per month                         |                          |
| >                                         |                          |
| > − Prescription drugs not obtained at a  |                          |
| > GHI HMO participating                   |                          |
| >                                         |                          |
| > pharmacy or Mail Order Pharmacy         |                          |
| >                                         |                          |
| > − Initial prescriptions or refills in   |                          |
| > excess of a 30 consecutive day          |                          |
| >                                         |                          |
| > supply or one month's cycle of any oral |                          |
| > contraceptive drug                      |                          |
| >                                         |                          |
| > (Mail order available for up to a 90    |                          |
| > day supply)                             |                          |
| >                                         |                          |
| > − Drugs related to non-covered medical  |                          |
| > services                                |                          |
| >                                         |                          |
| > − OTC drugs                             |                          |
| >                                         |                          |
| > − Contraceptive devices such as condoms |                          |
| > and spermacidal                         |                          |
| >                                         |                          |
| > agents                                  |                          |
| >                                         |                          |
| > − Drugs not approved by the FDA         |                          |
| >                                         |                          |
| > − Medications for cosmetic purposes     |                          |
| > only                                    |                          |
+-------------------------------------------+--------------------------+

> Covered medications and supplies \-- continued on next page

+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      | > **You pay**          |
| > *(continued)*                             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All Charges*        |
|                                             |                        |
| -   *Drugs and supplies for cosmetic        |                        |
|     purposes*                               |                        |
|                                             |                        |
| -   *Drugs to enhance athletic performance* |                        |
|                                             |                        |
| -   *Fertility drugs*                       |                        |
|                                             |                        |
| -   *Drugs obtained at a non-Plan pharmacy; |                        |
|     except for out-of-area emergencies*     |                        |
|                                             |                        |
| -   *Vitamins, nutrients and food           |                        |
|     supplements even if a physician         |                        |
|     prescribes or administers them*         |                        |
|                                             |                        |
| -   *Nonprescription medicines*             |                        |
+---------------------------------------------+------------------------+

+-----------------------+----------------------------------------------+
| > Section 5 (g).      |                                              |
| > Special features    |                                              |
+=======================+==============================================+
| > **Feature**         | > **Description**                            |
+-----------------------+----------------------------------------------+
| > **Services for deaf | We provide a TDD Line for the deaf and       |
| > and hearing         | hearing impaired,                            |
| > impaired**          |                                              |
|                       | 1-877-208-7920                               |
+-----------------------+----------------------------------------------+
| > **Centers of        | Life Trac -- National Ancillary providers    |
| > excellence for      | for organ transplants utilizing 31 Centers   |
| > transplants/heart   | of Excellence throughout the United States   |
| > surgery/etc.**      |                                              |
+-----------------------+----------------------------------------------+
| > **PHIP - Personal   | GHI HMO is now offering the Personal Health  |
| > Health Improvement  | Improvement Program (PHIP) to our members.   |
| > Program**           | PHIP is a behavioral medicine intervention   |
|                       | for the following types of patients:         |
|                       |                                              |
|                       | > \(1\) those with stress related illnesses  |
|                       | > such as headaches, back pain, fatigue,     |
|                       | > insomnia, and gastrointestinal discomfort. |
|                       | >                                            |
|                       | > \(2\) those learning to deal with a        |
|                       | > chronic disease such as multiple           |
|                       | > sclerosis, fibromyalgia and diabetes.      |
|                       | >                                            |
|                       | > \(3\) patients whose mood (anxiety,        |
|                       | > depression, etc.) seems to influence their |
|                       | > physical health.                           |
|                       |                                              |
|                       | PHIP is based on the mind-body theory that   |
|                       | mood and physical health are closely         |
|                       | correlated. It helps patients reduce         |
|                       | suffering and the symptoms of chronic        |
|                       | illnesses by allowing participants to become |
|                       | aware of how their bodily reactions are      |
|                       | related to behavioral patterns, including    |
|                       | coping styles. By making such connections,   |
|                       | participants learn to adopt new behaviors    |
|                       | that will relieve their pain or discomfort.  |
|                       |                                              |
|                       | The program consists of six weekly two hour  |
|                       | classes led by a trained facilitator. The    |
|                       | classes consist of a combination of group    |
|                       | discussion and specific exercises designed   |
|                       | to help participants become aware of their   |
|                       | own reactions to daily life. Participants    |
|                       | are provided with a workbook and home-study  |
|                       | questions, as well as an audiotape to guide  |
|                       | them through an awareness exercise that they |
|                       | are asked to do daily.                       |
+-----------------------+----------------------------------------------+

+---+---+---------------------------------------+----------+---+--------+
| > |   |                                       |          |   |        |
|   |   |                                       |          |   |        |
| S |   |                                       |          |   |        |
| e |   |                                       |          |   |        |
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| t |   |                                       |          |   |        |
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| n |   |                                       |          |   |        |
| > |   |                                       |          |   |        |
|   |   |                                       |          |   |        |
| 5 |   |                                       |          |   |        |
| > |   |                                       |          |   |        |
|   |   |                                       |          |   |        |
| ( |   |                                       |          |   |        |
| h |   |                                       |          |   |        |
| ) |   |                                       |          |   |        |
| . |   |                                       |          |   |        |
| > |   |                                       |          |   |        |
|   |   |                                       |          |   |        |
| D |   |                                       |          |   |        |
| e |   |                                       |          |   |        |
| n |   |                                       |          |   |        |
| t |   |                                       |          |   |        |
| a |   |                                       |          |   |        |
| l |   |                                       |          |   |        |
| > |   |                                       |          |   |        |
|   |   |                                       |          |   |        |
| b |   |                                       |          |   |        |
| e |   |                                       |          |   |        |
| n |   |                                       |          |   |        |
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| f |   |                                       |          |   |        |
| i |   |                                       |          |   |        |
| t |   |                                       |          |   |        |
| s |   |                                       |          |   |        |
+===+===+=======================================+==========+===+========+
|   | * | **Here are some important things to   |          | * |        |
|   | * | keep in mind about these benefits:**  |          | * |        |
|   | I |                                       |          | I |        |
|   | * | -   Please remember that all benefits |          | * |        |
|   | * |     are subject to the definitions,   |          | * |        |
|   |   |     limitations, and exclusions in    |          |   |        |
|   | * |     this brochure and are payable     |          | * |        |
|   | * |     only when we determine they are   |          | * |        |
|   | M |     medically necessary.              |          | M |        |
|   | * |                                       |          | * |        |
|   | * | -   GHI HMO does not provide dental   |          | * |        |
|   |   |     benefits.                         |          |   |        |
|   | * |                                       |          | * |        |
|   | * | -   We cover hospitalization for      |          | * |        |
|   | P |     dental procedures only when a     |          | P |        |
|   | * |     nondental physical impairment     |          | * |        |
|   | * |     exists which makes                |          | * |        |
|   |   |     hospitalization necessary to      |          |   |        |
|   | * |     safeguard the health of the       |          | * |        |
|   | * |     patient; we do not cover the      |          | * |        |
|   | O |     dental procedure unless it is     |          | O |        |
|   | * |     described below.                  |          | * |        |
|   | * |                                       |          | * |        |
|   |   | ```{=html}                            |          |   |        |
|   | * | <!-- -->                              |          | * |        |
|   | * | ```                                   |          | * |        |
|   | R | -   Be sure to read Section 4, *Your  |          | R |        |
|   | * |     costs for covered services,* for  |          | * |        |
|   | * |     valuable information about how    |          | * |        |
|   |   |     cost sharing works. Also read     |          |   |        |
|   | * |     Section 9 about coordinating      |          | * |        |
|   | * |     benefits with other coverage,     |          | * |        |
|   | T |     including with Medicare.          |          | T |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
|   |   |                                       |          |   |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
|   | A |                                       |          | A |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
|   |   |                                       |          |   |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
|   | N |                                       |          | N |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
|   |   |                                       |          |   |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
|   | T |                                       |          | T |        |
|   | * |                                       |          | * |        |
|   | * |                                       |          | * |        |
+---+---+---------------------------------------+----------+---+--------+
| # |   |                                       | > **You  |   |        |
| # |   |                                       | > pay**  |   |        |
| # |   |                                       |          |   |        |
|   |   |                                       |          |   |        |
| * |   |                                       |          |   |        |
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| t |   |                                       |          |   |        |
| * |   |                                       |          |   |        |
| * |   |                                       |          |   |        |
+---+---+---------------------------------------+----------+---+--------+
| > |   |                                       | >        |   |        |
|   |   |                                       |  Nothing |   |        |
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+---+---+---------------------------------------+----------+---+--------+
| > |   |                                       |          |   |        |
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| * |   |                                       |          |   |        |
| * |   |                                       |          |   |        |
+---+---+---------------------------------------+----------+---+--------+
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| . |   |                                       |          |   |        |
+---+---+---------------------------------------+----------+---+--------+

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

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

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

GHI HMO Good Health Incentives Program. At GHI HMO we have your best
health in mind. That's why we are making available to you the Good
Health Incentives Program, which offers special discounts on a wide
variety of health-related products and services.

**General Nutrition Centers (GNC) --** Offering a wide variety of
discounts on vitamins and health products (participating GNC stores
only). For a 15% discount coupon -- web site:
[www.gnc.com](http://www.gnc.com/).

**Wellquest Fitness Network -- Discount Health Club Membership** -- No
long-term contracts, lower enrollment fees and monthly dues, opportunity
to switch primary clubs at any time. Telephone 1-800-595-8448. Web site:
[www.wellquestonline.com](http://www.wellquestonline.com/).

**Weight Watchers Online** **-- Internet Weight Loss Program Discount**
-- Offering the best weight-loss tools on the Internet, accessible from
your home or office. To receive \$10 off a 3-month subscription -- web
site:
[www.weightwatchers.com/cs/ghi/](http://www.weightwatchers.com/cs/ghi/).

**Weight Watchers Weight Loss Program Discount** -- Free registration
anytime. Telephone: 1-800-651-6000. Web site:
[www.weightwatchers.com](http://www.weightwatchers.com/cs/ghi/).

**My Medical CD^TM^** -- 33% savings on personal medical data credit
card size disc, reimbursable for participants in a Flexible Spending
Account Program, instant access to your medical information. Telephone:
1-866-MY MED CD (1-866-696-3323). Web site:
[www.mymedicalcd.com](http://www.mymedicalcd.com/).

**Davis Vision -- Laser Vision Correction Services Discount** -- Laser
Vision Correction up to 25% off usual and customary fee (in-network
only). Telephone: 1-800-584-2866 (refer to client control number 7810).
Web site: [www.davisvision.com](http://www.davisvision.com/).

**Davis Vision Affinity Discount Program** -- Significant discounts on
examinations, eyewear and contact lenses (in-network only) up to 20%
savings. Telephone: 1-877-92DAVIS (refer to client control number 7810).
Web site: [www.davisvision.com](http://www.davisvision.com/).

**American Specialty Health Networks (ASHN)** --

**Acupuncture Therapy Discount Access Program** -- Significant savings
on acupuncture therapy services.

**Massage Therapy Discount Access Program** - Significant savings on
acupuncture therapy services.

**Registered Dietician Discount Program** -- Significant savings up to
25% discount.

Telephone: 1-877-327-2746. Web site:
[www.healthyroads.com](http://www.healthyroads.com/)

**HEARx** -- Hearing Aid and Product Discount -- Complimentary hearing
screening, extended family member discounts, a \$200 discount off the
price of any single hearing aid. Telephone: 1-800-323-3277. Web site:
[www.hearx.com](http://www.hearx.com/).

**CARExpress Benefits Network Discount Health Programs** -- Discount
program for prescription drugs, vision, and dental care, medical
supplies and home nursing care (in-network only). Telephone:
1-866-305-7283. Web site:
[www.carexpress.org](http://www.carexpress.org/).

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

> The exclusions in this section apply to all benefits. **Although we
> may list a specific service as a benefit, we will not cover it unless
> your Plan doctor determines it is medically necessary to prevent,
> diagnose, or treat your illness, disease, injury or condition and we
> agree, as discussed under *Services Requiring our Prior Approval* on
> page 15*.***
>
> We do not cover the following:

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

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

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

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

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

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

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

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

-   Services related to the professional fee for treatment of cavities
    and extractions, care of gums or bones supporting the teeth,
    orthodontia, false teeth, odontoma (tumors that are of dental origin
    and comprised of hard dental tissue), or any other dental services;
    or

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

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

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

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

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

**Medical, Hospital & Drug benefits** In most cases, providers and
facilities file claims for you. Physicians must file on the form
HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at
1-877-244-4466.

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

-   Covered member's name and ID number;

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

-   Dates you received the services or supplies;

-   Diagnosis;

-   Type of each service or supply;

-   The charge for each service or supply;

-   A copy of the explanation of benefits, payments, or denial from any
    primary payer \--such as the Medicare Summary Notice (MSN); and

```{=html}
<!-- -->
```
-   Receipts, if you paid for your services.

> **Submit your claims to: GHI HMO Claims Department**
>
> **PO Box 4141**
>
> **Kingston, NY 12402**

**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.

> If a claim is denied, you will receive notice of the decision,
> including reasons for the denial and the provisions of the contract on
> which the denial was based. If you disagree with the plans decision,
> you may request reconsideration in accordance with the disputed claims
> procedure described on page 50.

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

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

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

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

+----+-----------------------------------------------------------------+
| ** | **Description**                                                 |
| St |                                                                 |
| ep |                                                                 |
| ** |                                                                 |
+----+-----------------------------------------------------------------+
| *  | 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: GHI HMO, PO Box 4332, Kingston, |
|    |     NY 12402; 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       |
| *3 | receive it within 60 days of our request. We will then decide   |
| ** | within 30 more days.                                            |
|    |                                                                 |
|    | If we do not receive the information within 60 days, we will    |
|    | decide within 30 days of the date the information was due. We   |
|    | will base our decision on the information we already have.      |
|    |                                                                 |
|    | We will write to you with our decision.                         |
+----+-----------------------------------------------------------------+
| *  | If you do not agree with our decision, you may ask OPM to       |
| *4 | review it.                                                      |
| ** |                                                                 |
+----+-----------------------------------------------------------------+
|    | You must write to OPM within:                                   |
|    |                                                                 |
|    | -   90 days after the date of our letter upholding our initial  |
|    |     decision; or                                                |
|    |                                                                 |
|    | -   120 days after you first wrote to us \-- if we did not      |
|    |     answer that request in some way within 30 days; or          |
|    |                                                                 |
|    | -   120 days after we asked for additional information.         |
+----+-----------------------------------------------------------------+
|    | Write to OPM at: United States Office of Personnel Management,  |
|    | Insurance Services Programs, Health Insurance Group 3, 1900 E   |
|    | Street, NW, Washington, D.C. 20415-3630.                        |
+----+-----------------------------------------------------------------+

+---+------------------------------------------------------------------+
|   | **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;       |
|   |                                                                  |
|   | ```{=html}                                                       |
|   | <!-- -->                                                         |
|   | ```                                                              |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | ```{=html}                                                       |
|   | <!-- -->                                                         |
|   | ```                                                              |
|   | -   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 you were denied precertification or prior       |
|   | approval. This is the only deadline that may not be extended.    |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support their disputed claim decision. This           |
|   | information will become part of the court record.                |
+---+------------------------------------------------------------------+
|   | You may not sue until you have completed the disputed claims     |
|   | process. Further, Federal law governs your lawsuit, benefits,    |
|   | and payment of benefits. The Federal court will base its review  |
|   | on the record that was before OPM when OPM decided to uphold or  |
|   | overturn our decision. You may recover only the amount of        |
|   | benefits in dispute.                                             |
+---+------------------------------------------------------------------+

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

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at

1-877-244-4466 and we will expedite our review; or

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

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

expedited treatment too, or

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

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

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

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

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

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

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

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

• People 65 years of age and older

• Some people with disabilities, under 65 years of age

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

> Medicare has two parts:

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

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

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

for Medicare benefits 3 months before you turn age 65. It's easy. Just

call the Social Security Administration toll-free number 1-800-772-1213

to set up an appointment to apply. If you do not apply for one or both

Parts of Medicare, you can still be covered under the FEHB Program.

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

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

**(Part A or Part B)** 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. Your care must continue to be authorized and arranged by your Plan
PCP.

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

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

• When Original Medicare is the primary payer, Medicare processes

your claim first. In most cases, your claims will be coordinated

automatically and we will pay the balance of covered charges. You

will not need to do anything. To find out if you need to do something

about filing your claims, call us at 1-877-244-4466 or visit our website

at [www.ghi.com](http://www.ghihmo.com/).

**We do not waive any costs if the Original Medicare Plan is your
primary payer**.

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

Medicare always make 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 | **The |        |
| or over and have Medicare and you...**              | pr    |        |
|                                                     | imary |        |
|                                                     | payer |        |
|                                                     | for   |        |
|                                                     | the   |        |
|                                                     | indiv |        |
|                                                     | idual |        |
|                                                     | with  |        |
|                                                     | Med   |        |
|                                                     | icare |        |
|                                                     | is    |        |
|                                                     | ...** |        |
+-----------------------------------------------------+-------+--------+
|                                                     | **    | **This |
|                                                     | Medic | Plan** |
|                                                     | are** |        |
+-----------------------------------------------------+-------+--------+
| 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 |  for  |
|     employment status                               | Part  | other  |
|                                                     | B     | se     |
|                                                     | ser   | rvices |
|                                                     | vices |        |
+-----------------------------------------------------+-------+--------+
| 7)  Are a former Federal employee receiving         | \*\* |        |
|     Workers' Compensation and the Office of         |       |        |
|     Workers' Compensation Programs has determined   |       |        |
|     that you are unable to return to duty)          |       |        |
+-----------------------------------------------------+-------+--------+
| B.  **When you or a covered family member...**      |       |        |
+-----------------------------------------------------+-------+--------+
| ###### Have Medicare solely                         |       |       |
|  based on end stage renal disease (ESRD) and**...** |       |        |
|                                                     |       |        |
| ###### It is within the fi                          |       |        |
| rst 30 months of eligibility for or entitlement to  |       |        |
| Medicare due to ESRD (30-month coordination period) |       |        |
+-----------------------------------------------------+-------+--------+
| -   It is beyond the 30-month coordination period   |      |        |
|     and you or a family member are still entitled   |       |        |
|     to Medicare due to ESRD                         |       |        |
+-----------------------------------------------------+-------+--------+
| 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**...**                     |      | []{    |
|                                                     |       | .mark} |
|     -   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](http://www.medicare.gov/).

> If you enroll in a Medicare managed care 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 is
primary, even out of the managed care plan\'s network and/or service
area (if you use our Plan providers), but we will not waive any of our
copayments or coinsurance. If you enroll in a Medicare + Choice plan,
tell us. We will need to know whether you are in the Original Medicare
Plan or in a Medicare + Choice plan so we can correctly coordinate
benefits with Medicare.

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

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

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

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

> • you need because of a workplace-related illness or injury that the
> Office of Workers' Compensation Programs (OWCP) or a similar Federal
> or State agency determines they must provide; or
>
> • OWCP or a similar agency pays for through a third-party injury
> settlement or other similar proceeding that is based on a claim you
> filed under OWCP or similar laws.

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

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

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

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

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

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

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

If you do not seek damages you must agree to let us try. This is called
subrogation. You must assist us in receiving our excess payment, for
example, by completing and filing claim forms with other Health Plans
and endorsing checks over to us. If you need more information, contact
us for our subrogation procedures.

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

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

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

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care. See page 17.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 17.

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

**Custodial care** Any service which can be learned and provided by an
average individual who does not have medical training. Examples of
Custodial Care include:

a.  Assistance in meeting activities of daily living such as feeding,
    dressing and personal hygiene;

b.  Administration of oral medications, routine changing of dressing, or
    preparation of special diets;

c.  Assistance in walking or getting out of bed;

d.  Child care necessitated by the incapacity of a parent; or

e.  Respite Care

> Custodial care that last 90 days or more is sometimes know as Long
> term care.

**Experimental or** Any drug, device or medical treatment or procedure
is experimental or

**investigational services** investigational:

-   If the drug or device has not been approved by the Food and Drug
    Administration (FDA)

```{=html}
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```
-   If reliable evidence, (reports in respected medical and scientific
    literature) shows that the opinion of experts is that further study
    is needed to decide how a drug, device or medical treatments or
    procedures compares with the standard method of treatment or
    diagnosis.

**Medical necessity** Medically necessary health care services are those
necessary to preserve and maintain an Enrollee's health in accordance
with acceptable standards of medical practice and received in an
appropriate setting. The GHI HMO Medical Director shall determine
whether a particular health care service rendered to an Enrollee is
Medical Necessary for the purpose of determining whether such health
care services are covered services and not for the purpose of practicing
medicine or determining a course of treatment, which course is to be
determined by the Participating Physician.

**Plan allowance** The plan allowance is a fee negotiated between the
providers of service and the plan. These agreed upon fees are considered
to be payment in full for services rendered by all participating
providers. Your coinsurance (50% for infertility services, and 20% for
durable medical equipment) will be applied to these negotiated fees.

**Us/We** Us and we refer to GHI HMO

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

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

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

**Coverage Information**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

> • If you have no FEHB coverage, your employing office will enroll you
> for Self and Family coverage in the Blue Cross and Blue Shield Service
> Benefit Plan\'s Basic Option,
>
> • if you have a Self Only enrollment in a fee-for-service plan or in
> an HMO that serves the area where your children live, your employing
> office will change your enrollment to Self and Family in the same
> option of the same plan; or
>
> • if you are enrolled in an HMO that does not serve the area where the
> children live, your employing office will change your enrollment to
> Self and Family in the Blue Cross and Blue Shield Service Benefit
> Plan\'s Basic Option.

As long as the court/administrative order is in effect, and you have at

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

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

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

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

**When you lose benefits**

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

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

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

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

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

**•Temporary Continuation**

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

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

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

**•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. []{.mark}

[]{.mark}

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);](http://www.opm.gov/insure/health);) refer
to the \"TCC and HIPAA\" frequently asked question. 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

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

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

```{=html}
<!-- -->
```
-   **Enroll during Open Season** You **must make an election** to
    enroll in an FSA during the FEHB Open Season. Even if

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

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

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

> **What is SHPS?** SHPS is a third-party administrator hired by OPM to
> manage the FSAFEDS Program.
>
> SHPS is the largest FSA administrator in the nation and will be
> responsible for
>
> enrollment, claims processing, customer service, and day-to-day
> operations of
>
> FSAFEDS.

**Who is eligible to enroll?** If you are a Federal employee eligible
for FEHB -- even if you're not enrolled in FEHB--

> you can choose to participate in either, or both, of the flexible
> spending accounts. If you
>
> are not eligible for FEHB, you are not eligible to enroll for a Health
> Care FSA. However, almost all Federal employees are eligible to enroll
> for the Dependent Care FSA. The only exception is intermittent (also
> called when actually employed \[WAE\]) employees expected to work less
> than 180 days during the year.
>
> *Note:* FSAFEDS is the FSA Program established for all Executive
> Branch employees and Legislative Branch employees whose employers
> signed on. Under IRS law, FSAs are not available to annuitants. In
> addition, the U.S. Postal Service and the Judicial Branch, among
> others, are Federal agencies that have their own plans with slightly
> different rules, but the advantages of having an FSA are the same no
> matter what agency you work for.

-   **How much should I** Plan carefully when deciding how much to
    contribute to an FSA. Because of the tax

**contribute to my FSA?** benefits of an FSA, the IRS places strict
guidelines on them. You need to estimate how

> much you want to allocate to an FSA because current IRS regulations
> require you forfeit any funds remaining in your account(s) at the end
> of the FSA plan year. This is referred to as the "use-it-or-lose-it"
> rule. You will have until April 29, 2004 to submit claims for your
> eligible expenses incurred during 2003 if you enrolled in FSAFEDS when
> it was initially offered. You will have until April 30, 2005 to submit
> claims for your eligible expenses incurred from January 1 through
> December 31, 2004 if you elect FSAFEDS during this Open Season.
>
> The **FSAFEDS Calculator** at
> [www.fsafeds.com](http://www.fsafeds.com/) will help you plan your FSA
> allocations and provide an estimate of your tax savings based on your
> individual situation.

-   **What can my HCFSA** Every FEHB health plan includes cost sharing
    features, such as deductibles you must **pay for?** meet before the
    Plan provides benefits, coinsurance or copayments that you pay when

> you and the Plan share costs, and medical services and supplies that
> are not covered by the Plan and for which you must pay. These
> out-of-pocket costs are summarized on page 17 and detailed throughout
> this brochure. Your HCFSA will reimburse you for such costs when they
> are for tax deductible medical care for you and your dependents that
> is NOT covered by this FEHB Plan or any other coverage that you have.
>
> Under this Plan, typical out-of-pocket expenses include: The most
> frequent/significant expenses are, Physician Visits Copayments,
> Prescription Drug Copayments and Emergency Room Copayments. The common
> but significant expenses that are not covered under this plan are,
> Eyeglasses/Contact Lenses, Fertility Drugs and Dental.
>
> The IRS governs expenses reimbursable by a HCFSA. See Publication 502
> for a comprehensive list of tax-deductible medical expenses.  **Note:
> While you will see insurance premiums listed in Publication 502, they
> are NOT a reimbursable expense for FSA purposes**.  Publication 502
> can be found on the IRS Web site at
> <http://www.irs.gov/pub/irs-pdf/p502.pdf>.  If you do not see your
> service or expense listed in Publication 502, please call a FSAFEDS
> Benefit Counselor at 1-877-FSAFEDS (372-3337), who will be able to
> answer your specific questions.

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

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

  ----------------------------------------- -------------- --------------
  **Annual Tax Savings Example**            **With 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 receive

**deductions** reimbursement for them from your HCFSA or DCFSA. Below
are some guidelines that

> may help you decide whether to participate in FSAFEDS.

**Health care expenses** The HCFSA is tax-free from the first dollar. In
addition, you may be reimbursed from

> the HCFSA at any time during the year for expenses up to the annual
> amount you\'ve
>
> elected to contribute.
>
> Only health care expenses exceeding 7.5% of your adjusted gross income
> are eligible to be deducted on your Federal income tax return. Using
> the example listed in the above chart, only health care expenses
> exceeding \$3,750 (7.5% of \$50,000) would be eligible to be deducted
> on your Federal income tax return. In addition, money set aside
> through a HCFSA is also exempt from FICA taxes. This exemption is not
> available on your Federal income tax return.

**Dependent care expenses** The DCFSA generally allows many families to
save more than they would with the

> Federal tax credit for dependent care expenses. Note that you may only
> be reimbursed from the DCFSA up to your current account balance. If
> you file a claim for more than your current balance, it will be held
> until additional payroll allotments have been added to your account.
>
> Visit [www.fsafeds.com](http://www.fsafeds.com/) and download the
> Dependent Care Tax Credit Worksheet from the Quick Links box to help
> you determine what is best for your situation. You may also wish to
> consult a tax professional for more details.

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

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

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

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

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

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

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

**The Federal Long Term Care Insurance Program**

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

Program:

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

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

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

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

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

**to request an application** or visit
[www.ltcfeds.com](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 | **I**mmunizations 21  | Surgery 29            |
| 46                    |                       |                       |
|                       | Infertility 23        | -   Anesthesia 32     |
| Allergy tests 23      |                       |                       |
|                       | In hospital physician | ```{=html}            |
| Alternative treatment | care 19               | <!-- -->              |
| 28                    |                       | ```                   |
|                       | Insulin 23            | -   Oral 30           |
| Allogenetic (donor)   |                       |                       |
| bone marrow           | Inpatient Hospital    | -   Outpatient 34     |
|                       | Benefits 33           |                       |
| transplant 31         |                       | -   Reconstructive 30 |
|                       | **L**aboratory and    |                       |
| Ambulance 35          | pathological services |     Syringes 23       |
|                       | 20                    |                       |
| Anesthesia 32         |                       |     **T**emporary     |
|                       | **M**ail Order        |     continuation of   |
| Autologous bone       | Prescription          |     coverage 61       |
| marrow transplant     |                       |                       |
| 24,31                 | Drugs 42,43           |     Transplants 31    |
|                       |                       |                       |
| **B**iopsies 29       | Mammograms 19,20,21   | Treatment therapies   |
|                       |                       | 24                    |
| Blood and blood       | Maternity Benefits 22 |                       |
| plasma 34             |                       | **V**ision services   |
|                       | Medicaid 56           | 26                    |
| **C**asts 34          |                       |                       |
|                       | Medically necessary   | **W**ell child care   |
| Catastrophic          | 15                    | 19,21                 |
| protection 17         |                       |                       |
|                       | Medicare 52           | Wheelchairs 27        |
| Changes for 2004 12   |                       |                       |
|                       | Mental                | Workers' compensation |
| Chemotherapy 24       | Conditions/Substance  | 55                    |
|                       | Abuse Benefits 38     |                       |
| Chiropractic 19,28    |                       | **X**-rays 20         |
|                       | MRI 20                |                       |
| Cholesterol tests 20  |                       |                       |
|                       | **N**ewborn care 22   |                       |
| Claims 40,49,50       |                       |                       |
|                       | Nursery care 22       |                       |
| Coinsurance 17        |                       |                       |
|                       | **O**bstetrical care  |                       |
| Colorectal cancer     | 22                    |                       |
| screening 20          |                       |                       |
|                       | Occupational therapy  |                       |
| Congenital anomalies  | 25                    |                       |
| 29                    |                       |                       |
|                       | Office visits 19      |                       |
| Contraceptive devices |                       |                       |
| and drugs 43          | Oral and              |                       |
|                       | maxillofacial surgery |                       |
| Coordination of       | 30                    |                       |
| benefits 52           |                       |                       |
|                       | Orthopedic devices 26 |                       |
| Copayments 17         |                       |                       |
|                       | Out of Pocket maximum |                       |
| Covered providers 13  | 17                    |                       |
|                       |                       |                       |
| Crutches 27           | Outpatient facility   |                       |
|                       | care 34               |                       |
| **D**eductible 17     |                       |                       |
|                       | Oxygen 27             |                       |
| Definitions 57        |                       |                       |
|                       | **P**ap test 19,20    |                       |
| Dental care 46        |                       |                       |
|                       | Physical examination  |                       |
| Diabetic Supplies 23  | 19                    |                       |
|                       |                       |                       |
| Diagnostic services   | Physical therapy 25   |                       |
| 19                    |                       |                       |
|                       | Physician 13          |                       |
| Disputed claims       |                       |                       |
| review 50             | Pre-admission testing |                       |
|                       | 34                    |                       |
| Donor expenses        |                       |                       |
| (transplants) 31      | Preauthorization      |                       |
|                       | 15,40                 |                       |
| Dressings 34          |                       |                       |
|                       | Preventive care,      |                       |
| Durable medical       | adult 20              |                       |
| equipment (DME) 27    |                       |                       |
|                       | Preventive care,      |                       |
| **E**ffective date of | children 21           |                       |
| enrollment 60         |                       |                       |
|                       | Prescription drugs 41 |                       |
| Emergency 36          |                       |                       |
|                       | Prior approval 15,40  |                       |
| Experimental or       |                       |                       |
|                       | Prostate cancer       |                       |
| investigational 48    | screening 20          |                       |
|                       |                       |                       |
| **F**amily planning   | Prosthetic devices 26 |                       |
| 22                    |                       |                       |
|                       | Psychologist 38       |                       |
| Fecal occult blood    |                       |                       |
| test 20               | **R**adiation therapy |                       |
|                       | 24                    |                       |
| Foot care 26          |                       |                       |
|                       | Renal dialysis 24     |                       |
| **G**eneral           |                       |                       |
| Exclusions 48         | Room and board 33     |                       |
|                       |                       |                       |
| **H**earing services  | **S**econd surgical   |                       |
| 25                    | opinion 19            |                       |
|                       |                       |                       |
| Home health services  | Skilled nursing       |                       |
| 27                    | facility care 35      |                       |
|                       |                       |                       |
| Hospice care 35       | Speech therapy 25     |                       |
|                       |                       |                       |
| Hospital 14,33        | Sterilization         |                       |
|                       | procedures 29         |                       |
|                       |                       |                       |
|                       | Subrogation 56        |                       |
|                       |                       |                       |
|                       | Substance abuse 38    |                       |
+-----------------------+-----------------------+-----------------------+

  -----------------------------------------------------------------------
  **Summary of benefits for the GHI HMO -- 2004**

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

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

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

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

+-------------------------------------------+----------------------+---+
| **Benefits**                              | **You Pay**          | * |
|                                           |                      | * |
|                                           |                      | P |
|                                           |                      | a |
|                                           |                      | g |
|                                           |                      | e |
|                                           |                      | * |
|                                           |                      | * |
+-------------------------------------------+----------------------+---+
| Medical services provided by physicians:  | Office visit copay:  | 1 |
|                                           | \$10 primary care;   | 9 |
| -   Diagnostic and treatment services     | \$10 specialist      |   |
|     provided in the office                |                      |   |
+-------------------------------------------+----------------------+---+
| Services provided by a hospital:          | > Nothing            | > |
|                                           | >                    |   |
| -   Inpatient                             | > \$10 copay         | 3 |
|                                           |                      | 3 |
| -   Outpatient                            |                      |   |
|                                           |                      |   |
| -   Lab                                   |                      |   |
|     ..................................    |                      |   |
| ......................................... |                      |   |
|                                           |                      |   |
| -   X-Ray...............................  |                      |   |
| ......................................... |                      |   |
+-------------------------------------------+----------------------+---+
| Emergency benefits:                       | > \$35 per visit     | > |
|                                           | >                    |   |
| -   In-area                               | > \$35 per visit     | 3 |
|                                           |                      | 6 |
| -   Out-of-area                           |                      |   |
+-------------------------------------------+----------------------+---+
| > Mental health and substance abuse       | > Regular cost       | > |
| > treatment                               | > sharing            |   |
|                                           |                      | 3 |
|                                           |                      | 8 |
+-------------------------------------------+----------------------+---+
| Prescription drugs                        | Retail Pharmacy:     | > |
|                                           |                      |   |
|                                           | \$10 co pay -        | 4 |
|                                           | generic              | 1 |
|                                           |                      |   |
|                                           | \$20 co pay --       |   |
|                                           | preferred brand      |   |
|                                           |                      |   |
|                                           | \$30 co pay --       |   |
|                                           | non-preferred brand  |   |
|                                           |                      |   |
|                                           | Mail Order:          |   |
|                                           |                      |   |
|                                           | \$20 co pay --       |   |
|                                           | generic              |   |
|                                           |                      |   |
|                                           | \$40 co pay --       |   |
|                                           | preferred brand      |   |
|                                           |                      |   |
|                                           | \$50 copay --        |   |
|                                           | non-preferred brand  |   |
+-------------------------------------------+----------------------+---+
| Dental Care                               | > Accidental injury  | > |
|                                           | > to sound natural   |   |
|                                           | > teeth only. You    | 4 |
|                                           | > pay nothing        | 6 |
+-------------------------------------------+----------------------+---+
| Vision Care                               | > One refraction     | > |
|                                           | > annually. You pay  |   |
|                                           | > \$10 copay per     | 2 |
|                                           | > office visit       | 6 |
+-------------------------------------------+----------------------+---+
| > Special features:                       |                      | > |
|                                           |                      |   |
| -   Services for deaf and hearing         |                      | 4 |
|     impaired                              |                      | 5 |
|                                           |                      |   |
| -   Centers of Excellence for             |                      |   |
|     transplants/heart surgeries           |                      |   |
|                                           |                      |   |
| -   PHIP -- Personal Health Improvement   |                      |   |
|     Project                               |                      |   |
+-------------------------------------------+----------------------+---+
| Protection against catastrophic costs     | Your out-of-pocket   | > |
|                                           | expenses for         |   |
| (your catastrophic protection             | benefits under this  | 1 |
| out-of-pocket maximum)                    | Plan are limited to  | 7 |
|                                           | the stated           |   |
|                                           | copayments which are |   |
|                                           | required for few     |   |
|                                           | benefits             |   |
+-------------------------------------------+----------------------+---+

**2004 Rate Information for**

**GHI HMO**

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

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

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

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

Bronx/Brooklyn/Manhattan/Nassau/Queens/Richmond/Suffolk/Westchester

  --------------- --------- -------------- -------------- -------------- -------------- -------------- --------------
  **Self Only**   **6V1**   **\$121.40**   **\$54.90**    **\$263.03**   **\$118.95**   **\$143.32**   **\$ 32.98**

  **Self and      **6V2**   **\$277.09**   **\$160.92**   **\$600.36**   **\$348.66**   **\$327.12**   **\$110.89**
  Family**                                                                                             
  --------------- --------- -------------- -------------- -------------- -------------- -------------- --------------

Albany/Broome/Columbia/Delaware/Dutchess/Fulton/Greene/Montgomery/Orange/Otsego/Putnam/Rensselaer/

Rockland/Saratoga/Schenectday/Schoharie/Sullivan/Ulster/Warrren/Washington

  --------------- --------- -------------- -------------- -------------- -------------- -------------- -------------
  **Self Only**   **X41**   **\$121.40**   **\$ 43.54**   **\$263.03**   **\$ 94.34**   **\$143.32**   **\$21.62**

  **Self and      **X42**   **\$277.09**   **\$146.50**   **\$600.36**   **\$317.42**   **\$327.12**   **\$96.47**
  Family**                                                                                             
  --------------- --------- -------------- -------------- -------------- -------------- -------------- -------------