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  ![](media/image1.png){width="1.0166666666666666in"   ![](media/image2.png){width="1.8118055555555554in"   **2004**            
  height="1.1034722222222222in"}                       height="0.43819444444444444in"}\                                         
                                                       \                                                                        
                                                       [http://www.bcbsmo.com](http://www.bcbsmo.com/)                          

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![](media/image3.wmf){width="1.6937007874015748in"
height="1.7618110236220472in"}**A Health Maintenance Organization**

**Serving: St. Louis, Central, and Southwest areas in Missouri\
and St. Clair and Madison counties in Illinois**

**Enrollment in this plan is limited. You must live in our\
Geographic service area to enroll. See page 10 for requirements.**

![](media/image4.wmf){width="0.88125in" height="0.88125in"}

**Enrollment code:\
9G1 Self Only\
9G2 Self and Family**

  ------------------------------------------ -- ---- ----------------------------------------------------
  ![](media/image5.png)                              ![](media/image6.png){width="1.2868055555555555in"
                                                     height="0.9159722222222222in"}

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

RI-73-516

![](media/image7.png){width="4.84375in" height="1.1354166666666667in"}

Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

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

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

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

# Privacy Practices

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

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

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

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

-   To the Secretary of the United States 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

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

  -----------------------------------------------------------------------
  Table of Contents
  -----------------------------------------------------------------------

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

Introduction............................................................................
5

Plain
Language........................................................................
5

Stop Health Care Fraud! 5

Preventing medical mistakes 6

Section 1. Facts about this HMO plan 8

How we pay providers 8

Who provides my health care? 8

Your Rights 8

Service Area 10

Section 2. How we change for
2004............................................... 11

Program-wide changes 11

Changes to this Plan 11

Section 3. How you get care ............\... 12

Identification cards 12

Where you get covered care 12

• Plan providers 12

• Plan facilities 12

What you must do to get covered care 12

• Primary care 12

• Specialty care 12

• Hospital care 14

Circumstances beyond our control 14

Services requiring our prior approval 14

Section 4. Your costs for covered services 15

• Copayments 15

• Deductible 15

• Coinsurance 15

Your catastrophic protection out-of-pocket maximum 15

Section 5.
Benefits..................................................................
16

Overview 16

(a) Medical services and supplies provided by physicians and other
    health care professionals 17

(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 34

(d) Emergency services/accidents 37

(e) Mental health and substance abuse benefits 40

(f) Prescription drug benefits 42

(g) Special features 46

-   Flexible Benefits Option

-   Services for deaf and hearing impaired

-   Away From Home Care

-   Blue Quality

-   RightSteps^^

-   TakeCharge^^ Asthma Program

-   TakeCharge^^ Diabetes Program

-   TakeCharge^®^ Congestive Heart Failure Program

-   Postpartum Depression Screening Program

(h) Dental benefits 48

(i) 

(j) Non-FEHB benefits available to Plan members 49

Section 6. General exclusions \-- things we don\'t cover 50

Section 7. Filing a claim for covered services 51

Section 8. The disputed claims process 53

Section 9. Coordinating benefits with other coverage 55

When you have other health coverage

• What is Medicare? 55

• Should I enroll in Medicare?. 55

• Medicare + Choice 58

• TRICARE and CHAMPVA 58

• Workers' Compensation 59

• Medicaid 59

• Other Government agencies 59

• When others are responsible for injuries 59

Section 10. Definitions of terms we use in this brochure 60

Section 11. FEHB facts 62

Coverage information 62

• No pre-existing condition limitation 62

• Where you can get information about enrolling in the FEHB Program 62

• Types of coverage available for you and your family 62

• Children's Equity Act 62

• When benefits and premiums start 63

• When you retire 63

When you lose benefits 63

• When FEHB coverage ends 63

• Spouse equity coverage 64

• Temporary Continuation of Coverage (TCC) 64

• Converting to individual coverage 64

• Getting a Certificate of Group Health Plan Coverage 64

Two new Federal Programs complement FEHB benefits 66

The Federal Flexible Spending Account Program - *FSAFEDS* 66

The Federal Long-Term Care Insurance Program 69

Index 71

Summary of benefits 72

Rates Back cover

Blue Cross and Blue Shield of Missouri is the name RightCHOICE^®^
Managed Care, Inc. (RIT) uses to do business in most of Missouri. In
Missouri, RIT administers the FEHB program. HMO Missouri, Inc. does
business as BlueCHOICE. RIT and HMO Missouri, Inc. are independent
licensees of the Blue Cross and Blue Shield Association.

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

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

This brochure describes the benefits of BlueCHOICE HMO under our
contract (CS 2838) with the United States Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. This
Plan is underwritten by the Healthy Alliance Life Insurance Company. The
address for administrative offices is:

BlueCHOICE

1831 Chestnut Street

St. Louis, Missouri 63103-2275

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 11. Rates are shown at the end of this brochure.

+-----------------------------------------------------------------------+
| > Plain Language                                                      |
+-----------------------------------------------------------------------+

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

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

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

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

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

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

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

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

```{=html}
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```
-   Let only the appropriate medical professionals review your medical
    record or recommend services.

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

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

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

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

```{=html}
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```
-   Call the provider and ask for an explanation. There may be an error.

-   If the provider does not resolve the matter, call us at 800/932-4480
    and explain the situation.

-   If we do not resolve the issue:

```{=html}
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```
-   Do not maintain as a family member on your policy:

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

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

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

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

  -----------------------------------------------------------------------
  Preventing Medical Mistakes

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

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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?

```{=html}
<!-- -->
```
-   [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 health care providers and
    improve the quality of care you receive.

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

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

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

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

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

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

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

This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other providers that contract
with us. These Plan providers coordinate your health care services. The
Plan is solely responsible for the selection of these providers in your
area. Contact us for a copy of our 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 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, hospitals and
other types of providers 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. We reimburse primary care physicians
through capitation, which includes the majority of services the primary
care physician renders. We compensate certain services, such as
immunizations or cardiac diagnostic testing in the office as fee for
service.*\
\
***Who provides my health care?**

This plan is an individual-practice Plan. All participating doctors
practice in their own offices in the community. Unless it is an
emergency, benefits are available only from doctors, hospitals and other
health care providers that are in the BlueCHOICE network. The Plan
arranges with doctors and hospitals to provide medical care for both the
prevention of disease and the treatment of serious illness.\
\
You must select a primary care doctor for each covered family member.
Approximately 1,500 primary care physicians participate in BlueCHOICE.
For most care, you must contact your primary care doctor for a referral
or authorization before seeing any other doctor for specialty care or
nonemergency hospital services. A wide variety of specialists are
participating Plan doctors. Many are Board certified as indicated in the
BlueCHOICE directory. If you need hospital care, your Plan primary
doctor will admit you to a participating hospital where he/she has
admitting privileges.

**Your Rights**

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

-   
-   
-   

**About the plan and care management**: Blue Cross and Blue Shield of
Missouri has over 60 years of experience in the health insurance
industry. We began as St. Louis Blue Cross in 1936. In 1945, Missouri
Medical Service, commonly known as Blue Shield, began business in the
St. Louis area. The two companies merged in 1986, forming Blue Cross and
Blue Shield of Missouri, a not-for-profit health service corporation. In
1994, Blue Cross and Blue Shield of Missouri formed a new managed care
company, Alliance Blue Cross Blue Shield.\
\
Effective November 30, 2000, Blue Cross and Blue Shield of Missouri and
its for-profit managed care subsidiary, Alliance Blue Cross Blue Shield,
merged into a single, for-profit, publicly traded Delaware corporation.
The insurance-related business that was part of the old Blue Cross and
Blue Shield of Missouri has been transferred to and assumed by Healthy
Alliance Life Insurance Co., a wholly owned subsidiary of Blue Cross and
Blue Shield of Missouri, as part of the reorganization.\
\
BlueCHOICE, the for-profit HMO subsidiary of Blue Cross and Blue Shield
of Missouri, began operations in 1988. Blue Cross and Blue Shield of
Missouri, BlueCHOICE and Healthy Alliance Life Insurance Co. are
independent licensees of the Blue Cross and Blue Shield Association.

On Jan. 31, 2002, RightCHOICE Managed Care Inc. and WellPoint Health
Networks Inc. merged. WellPoint, which is based in Thousand Oaks,
Calif., serves the health care needs of 12 million members and more than
45 million specialty members through Blue Cross of California, Blue
Cross of Georgia, UNICARE and Blue Cross and Blue Shield of Missouri and
its subsidiaries.

Utilization management services include:

-   Precertifications of medical/surgical, mental health,
    rehabilitation, skilled nursing, outpatient and home health care

-   Concurrent review of medical/surgical, mental health,
    rehabilitation, skilled nursing, outpatient and home health care

-   Retrospective review

-   Discharge planning

-   Alternative care planning

-   Individual case management

-   Appeal for denial of payment due to lack of medical necessity

-   Medical review

Our contracts with network providers require them to handle all
certifications for BlueCHOICE members. You will not have to be concerned
about managed care procedures as long as your receive care from network
providers.

We offer special programs to help members with health conditions such as
asthma, diabetes and high-risk pregnancy. These are voluntary programs
to help members manage their particular health condition. These programs
are explained in Section 5(g).

**Accreditation status**: BlueCHOICE is accredited by the National
Committee for Quality Assurance (NCQA). The comprehensive review process
evaluates how well a plan manages its benefits. The accreditation
process evaluates more than 60 standards in the following six
categories:

-   quality management and improvement

-   physician qualifications and evaluation

-   members' rights and responsibilities

-   preventive health services

-   utilization management and

-   medical records

**Networks, providers and facilities**: The BlueCHOICE network includes
approximately 1,500 primary physicians, 6,800 specialists and 68
hospitals. Approximately 79 percent of network physicians are Board
Certified and 85 percent are accepting new patients. The physician's
Board status and whether or not he/she is accepting new patients are
included in the BlueCHOICE provider directory.

***We have established credentialing polices that require us to select
and recredential physicians every three years***, based on an evaluation
of their experience and training, board certification and staff
privileges at network hospitals. Our program goals are to support the
development and maintenance of credentialing and recredentialing
standards for our participating providers, review the qualifications of
potential participating providers against established standards, and to
reassess the qualifications and performance of our network providers.

***Our credentialing criteria for network hospitals*** include
accreditation by the Joint Committee on Accreditation of Health Care
Organizations (JCAHO), Medicare certification, effective utilization
management pricing, geographic location, scope of services and
utilization experience.

If you want more information about us, call 1-800-932-4480, visit our
Web site at [www.bcbsmo.com](http://www.bcbsmo.com/)., or write us at
471 Siemers, Cape Girardeau MO 63701. For the hearing impaired (TDD),
call 1-800-822-1215.

**Service Area**

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

The *St. Louis Area*, including the *Missouri* counties of Crawford,
Franklin, Gasconade, Jefferson, Lincoln, Montgomery, Pike, St. Charles,
St. Francois, St. Louis (City and County), Ste. Genevieve, Warren and
Washington; *the Central Missouri Area* counties of Audrain, Boone,
Callaway, Camden, Chariton, Cole, Cooper, Howard, Macon, Maries, Miller,
Moniteau, Monroe, Morgan, Osage, Phelps, Pulaski, and Randolph; *the
Southwest Missouri Area* counties of Barry, Barton, Cedar, Christian,
Dade, Dallas, Douglas, Greene, Hickory, Jasper, Laclede, Lawrence,
McDonald, Newton, Ozark, Polk, Stone, Taney, Texas, Webster and Wright.

You may also enroll with us if you live in the Illinois counties of
Madison or St. Clair.

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

-   If you or a covered family member move outside our service area, you
    can enroll in another plan. If your dependents live out of the area
    (for example, if your child goes to college in another state), you
    should consider enrolling in a fee-for-service plan or an HMO that
    has agreements with affiliates in other areas. If you or a family
    member move, you do not have to wait until Open Season to change
    plans. Contact your employing or retirement office. As a BlueCHOICE
    member, you may have access to physician care through the
    BlueCard^®^ Traditional network. This nationwide network is made up
    of 9,500 hospitals and 764,000 physicians that participate with Blue
    Cross and Blue Shield Plans across the country. Benefits are easy to
    use -- a "suitcase" logo on members' ID cards will identify them as
    BlueCard members. To locate a BlueCard provider outside the
    BlueCHOICE service area, members simply call the toll-free BlueCard
    Access number on their ID card (1-800-810-blue) or visit the
    **BlueCard Hospital and Doctor Finder** at
    **[www.BCBS.com]{.underline}**. Members should contact their primary
    care physician just as they would if they were at home. The primary
    care physician will provide a non-network referral and coordinate
    care with the out-of-area provider as appropriate.

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

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Programs - *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 66.

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

-   We added information regarding enrolling in Medicare. See page 55.

-   We revised the Medicare Primary Payer Chart. See page 57.

    **Changes to this Plan**

```{=html}
<!-- -->
```
-   Your share of the non-Postal premium will increase by 10.1% for Self
    Only and for Self and Family.

-   Coverage for treatment received at an outpatient hospital or
    ambulatory surgical center will be covered at 100%. (Section 5(c))

-   Coverage for preventive dental benefits will be eliminated. A
    non-FEHB dental program will be offered in its place. (Section 5(i))

-   Diabetic supplies and equipment will be covered as a Durable Medical
    Equipment (DME) benefit for a \$10 copay. Coverage will continue to
    be provided for diabetic supplies and equipment under prescription
    drug benefits. (Section 5(a))

-   Coverage for nutritional formula and low-protein modified food
    products for PKU or other inherited disease of amino and organic
    acids will be covered as a DME benefit for members through age 5
    only. (Section 5(a))

-   A referral from your primary care physician is no longer needed to
    receive most outpatient mental health and substance abuse treatment
    from network providers. However, precertification is still needed
    for inpatient, residential care, and certain outpatient treatment.
    (Section 5(e))

-   We clarified that preauthorization is needed for certain outpatient
    diagnostic services, including MRI (magnetic resonance imaging), MRA
    (magnetic resonance angiography) and PET (positron emission
    tomography) procedures. (Section 3 and Section 5(a))

-   We clarified that coverage is provided for sonograms in addition to
    ultrasound testing. We also clarified that we do not cover
    ultrasound/sonogram tests for routine purposes, except one routine
    ultrasound/sonogram for a normal pregnancy; nor do we cover a
    routine ultrasound/sonogram to determine fetal age, size or sex.
    (Section 5(a))

-   We clarified that we cover osteoporosis screening as part of
    diagnostic and treatment services for preventive care for adults.
    (Section 5(a))

-   We clarified that we will cover sacral nerve stimulators when
    medically necessary to treat urge incontinence, urge frequency or
    urinary retention without mechanical obstruction. (Section 5(a))

-   We clarified that Human Leukocyte Antigen (HLA) testing is covered,
    where the member is recipient. (Section 5(b))

-   We clarified that our formulary for covered medications and supplies
    is updated throughout the year, and may be obtained by calling
    Client Services at 1-800-932-4480 or by checking our Web site,
    [www.bcbsmo.com](http://www.bcbsmo.com/).

-   We added information about two value-added programs: for disease
    management, the congestive heart failure program; and for our
    postpartum depression screening program. (Section 5 (g))

-   We clarified the coverage and exclusions for care associated with
    phase III or IV clinical trials for cancer treatment. (Section 5(a)
    and Section 6)

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

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

**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

1-800-932-4480**.** You may also request replacement cards through our
Web site at [www.bcbsmo.com](http://www.bcbsmo.com/).

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

**• Plan providers** Plan providers are primary care physicians,
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
annually. The BlueCHOICE directory is also on our Web site**,**
[www.bcbsmo.com](http://www.bcbsmo.com/). The online directory is
updated daily.

**•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
annually. The list is also on our Web site.

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. *\
\
*Use the directory or Web site to select a physician convenient to you.
Write the physician's office code number in the space provided on your
Provider Selection Card. You'll find the office code number listed
before each primary care physician's name. See the Selection Card for
instructions.

**•Primary care** Your primary care physician can be a family or general
practitioner, internist, pediatrician or geriatrician. 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.
We will send you a new ID card with your new doctor's name and phone
number on the front.

**• 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 a network OB/GYN for any medically
necessary OB/GYN care without a referral. And you may go to a network
eye care provider for one routine vision exam each calendar year 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
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.

If you think you have a mental health or substance abuse problem, we
encourage you to see your primary care physician. If you do not wish to
go through your primary care physician, you may choose to receive care
from another network provider without a referral.

Inpatient, residential treatment and certain outpatient treatment for
mental health and substance abuse require precertification. Your network
provider is responsible for contacting us to obtain precertification.

**• 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 1-800-932-4480. If you
are new to the FEHB Program, we will arrange for you to receive care.

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

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

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

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

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

**Circumstances 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.

Your primary care physician has authority to refer you for most
services.

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

We call this review and approval process precertification and
recertification. Your physician must obtain precertification before you
can receive certain types of care, such as:

-   Inpatient hospital care

-   Outpatient hospital care

-   Care in a freestanding surgery center or skilled nursing facility

-   Home health care

-   Certain types of outpatient diagnostic services, including MRI
    (magnetic resonance imaging), MRA (magnetic resonance angiography)
    and PET (positron emission tomography) procedures.

Your physician must obtain recertification if your care needs to
continue longer than originally certified.\
**\
**Your BlueCHOICE primary care physician or specialist will handle all
certification requirements for you. However, if you receive emergency
care at a non-network facility, you will need to contact us for
approval. Please see Section 5(d) for further information.**\
**

  -----------------------------------------------------------------------
  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.

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

**•Coinsurance** We do not have coinsurance.

> **\
> **\
> After you pay 100% of your annual premium in copayments for one family
> member (per person), or 100% of your annual premium for two or more
> family members (self and family), you do not have to make any further
> payments for certain services for the rest of the year. This is called
> a catastrophic limit. However, copayments for your prescription drugs
> and dental services do not count toward these limits and you must
> continue to make these payments.

Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the limits.

+-----------------------------------------------------------------------+
| **Section 5. Benefits -- OVERVIEW**                                   |
|                                                                       |
| ***(See page 11 for how our benefits changed this year and pages      |
| 72-73 for a benefits summary.)***                                     |
+-----------------------------------------------------------------------+

**Note**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
1-800-932-4480 or at our Web site at
[www.bcbsmo.com](http://www.bcbsmo.com/).

(a) Medical services and supplies provided by physicians and other
    health care professionals\...\...\...\...\...\...\...\.....17-28

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 29-33

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

(c) Services provided by a hospital or other facility, and ambulance
    services 34-36

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

(d) Emergency services/accidents 37-39

> •Medical emergency •Ambulance

\(e\) Mental health and substance abuse
benefits\...\...\...\...\...\...\...\...\...\...\... 40-41

\(f\) Prescription drug benefits
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...42-45

\(g\) Special features
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....46-47

> • Flexible benefits option
>
> • Services for deaf and hearing impaired

-   Away From Home Care

-   Blue Quality

-   RightSteps^^

-   TakeCharge^^ Asthma Program

-   TakeCharge^^ Diabetes Program

-   TakeCharge^^ Congestive Heart Failure Program

-   Postpartum Depression Screening Program

\(h\) Dental benefits 48

\(i\) Non-FEHB benefits available to Plan members 49

Summary of benefits 72-73

+---+---+-------------------------------------+----------------+---+----+
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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 |    |
|   | * | ```{=html}                          |                | * |    |
|   | * | <!-- -->                            |                | * |    |
|   |   | ```                                 |                |   |    |
|   | * | -   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.        |                | * |    |
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+---+---+-------------------------------------+----------------+---+----+
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+---+---+-------------------------------------+----------------+---+----+
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|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| a |   |                                     |                |   |    |
| p |   |                                     |                |   |    |
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| r |   |                                     |                |   |    |
| o |   |                                     |                |   |    |
| v |   |                                     |                |   |    |
| a |   |                                     |                |   |    |
| l |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
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|   |   |                                     |                |   |    |
| f |   |                                     |                |   |    |
| r |   |                                     |                |   |    |
| o |   |                                     |                |   |    |
| m |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| u |   |                                     |                |   |    |
| s |   |                                     |                |   |    |
+---+---+-------------------------------------+----------------+---+----+

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

+---------------------------------------------+------------------------+
| ### **Diagno                                | **You pay**            |
| stic and treatment services** *(Continued)* |                        |
+---------------------------------------------+------------------------+
| # Lab, X-ray and other diagnostic tests     |                        |
+---------------------------------------------+------------------------+
| > Laboratory tests, such as:                | -   Nothing if         |
|                                             |     services are       |
| -   Blood tests                             |     received during    |
|                                             |     your office visit  |
| -   Urinalysis                              |                        |
|                                             | -   \$10 copay applies |
| -   Non-routine Pap tests                   |     to services        |
|                                             |     received at        |
| -   Pathology                               |     freestanding       |
|                                             |     facilities\        |
| -   X-rays                                  |     (Refer to Section  |
|                                             |     5(c))              |
| -   Non-routine mammograms                  |                        |
|                                             |                        |
| -   CT Scans/MRI                            |                        |
|                                             |                        |
| -   Ultrasound/Sonogram -- one routine      |                        |
|     ultrasound/sonogram for a normal        |                        |
|     pregnancy                               |                        |
|                                             |                        |
| -   Electrocardiogram and EEG               |                        |
|                                             |                        |
| > Note: Preauthorization is needed for      |                        |
| > certain outpatient diagnostic services    |                        |
| > such as MRI, MRA and PET (See page 14)    |                        |
+---------------------------------------------+------------------------+
| > Not Covered:                              | > *All Charges*        |
|                                             |                        |
| -   Ultrasound/sonogram tests for routine   |                        |
|     purposes, except one routine            |                        |
|     ultrasound/sonogram for a normal        |                        |
|     pregnancy.                              |                        |
+---------------------------------------------+------------------------+
| ##### Preventive care, adult                |                        |
+---------------------------------------------+------------------------+
| > Routine screenings, such as:              | > \$10 per office      |
| >                                           | > visit                |
| > • Total blood cholesterol -- once every   |                        |
| > three years\*                             |                        |
| >                                           |                        |
| > • Colorectal cancer screening, including  |                        |
| >                                           |                        |
| > ^\_\_^ Fecal occult blood test            |                        |
+---------------------------------------------+------------------------+
| > ^\_\_^ Sigmoidoscopy, screening -- every  |                        |
| > five years starting at age 50\*           |                        |
| >                                           |                        |
| > And other diagnostic tests as recommended |                        |
| > by the American Cancer Society Guidelines |                        |
+---------------------------------------------+------------------------+
| -   Chlamydial infection                    |                        |
|                                             |                        |
| -   Routine Prostate Specific Antigen (PSA) |                        |
|     test-- one annually for men age 40 and  |                        |
|     older\*                                 |                        |
+---------------------------------------------+------------------------+
| -   Routine Pap test -- annual\*            |                        |
|                                             |                        |
| -   Osteoporosis screening                  |                        |
+---------------------------------------------+------------------------+

> \*or more frequently if recommended by your BlueCHOICE physician.

+---------------------------------------------+------------------------+
| ##### Preventive care, adult *(Continued)*  | > **You pay**          |
+---------------------------------------------+------------------------+
| -   Routine mammogram -- once per calendar  | > \$10 per visit       |
|     year or more frequently if recommended  |                        |
|     by a physician                          |                        |
+---------------------------------------------+------------------------+
| > Routine immunizations, limited to:        | > Nothing (\$10 office |
|                                             | > visit copay applies  |
| -   Tetanus-diphtheria (Td) booster --\     | > to any other covered |
|     ages 19 and over is based on medical    | > services)            |
|     necessity                               |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Influenza vaccines                      |                        |
|                                             |                        |
| -   Pneumococcal vaccines                   |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | > *All charges.*       |
|                                             |                        |
| -   *Physical exams required for obtaining  |                        |
|     or continuing employment or insurance,  |                        |
|     attending schools or camp, or travel.*  |                        |
|                                             |                        |
| -   *Immunizations for travel or            |                        |
|     occupational reasons.*                  |                        |
+---------------------------------------------+------------------------+
| ##### Preventive care, children             |                        |
+---------------------------------------------+------------------------+
| -   Childhood immunizations recommended by  | > Nothing (\$10 office |
|     the American Academy of Pediatrics      | > visit copay applies  |
|                                             | > to any other covered |
|                                             | > services)            |
+---------------------------------------------+------------------------+
| -   Well-child care charges for routine     | > \$10 per office      |
|     examinations, immunizations and care    | > visit                |
|     (up to age 22)                          |                        |
|                                             |                        |
| -   Examinations, such as:                  |                        |
|                                             |                        |
| > ^\_\_^ Eye exams to determine the need    |                        |
| > for vision correction                     |                        |
| >                                           |                        |
| > ^\_\_^ Ear exams to determine the need    |                        |
| > for hearing correction                    |                        |
| >                                           |                        |
| > ^\_\_^ Newborn hearing screening,         |                        |
| > rescreening and initial amplification     |                        |
| >                                           |                        |
| > ^\_\_^ Examinations done on the day of    |                        |
| > immunizations                             |                        |
|                                             |                        |
| *Not covered:*                              |                        |
|                                             |                        |
| -   *Physical exams required for obtaining  |                        |
|     or continuing employment or insurance,  |                        |
|     attending schools or camp, or travel.*  |                        |
|                                             |                        |
| -   *Immunizations for travel or            |                        |
|     occupational reasons**.***              |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Maternity care                     | **You pay**            |
+---------------------------------------------+------------------------+
| > Complete maternity (obstetrical) care,    | > \$10 (for first      |
| > such as:                                  | > office visit only)   |
|                                             | >                      |
| -   Prenatal care -- includes one routine   | > Nothing              |
|     ultrasound/sonogram for a normal        | >                      |
|     pregnancy                               | > Nothing              |
|                                             |                        |
| -   Delivery                                |                        |
|                                             |                        |
| -   Postnatal care                          |                        |
|                                             |                        |
| > Note: Here are some things to keep in     |                        |
| > mind:                                     |                        |
|                                             |                        |
| -   You do not need to precertify your      |                        |
|     normal delivery; see page 14 for        |                        |
|     specific details.                       |                        |
|                                             |                        |
| -   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. If you leave in    |                        |
|     *less than* 48 hours (or 96 hours after |                        |
|     a cesarean delivery), we will cover two |                        |
|     home visits by a registered nurse       |                        |
|     provided through a network home health  |                        |
|     agency.                                 |                        |
|                                             |                        |
| -   We cover routine nursery care of the    |                        |
|     newborn child during the covered        |                        |
|     portion of the mother's maternity stay. |                        |
|     We will cover other care of an infant   |                        |
|     who requires non-routine treatment only |                        |
|     if we cover the infant under a Self and |                        |
|     Family enrollment.                      |                        |
|                                             |                        |
| -   We pay hospitalization and surgeon      |                        |
|     services (delivery) the same as for     |                        |
|     illness and injury. See Hospital        |                        |
|     benefits (Section 5(c)) and Surgery     |                        |
|     benefits (Section 5(b))*.*              |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Routine ultrasound/sonogram to         |                        |
|     determine fetal age, size or sex,       |                        |
|     except as listed above.*                |                        |
+---------------------------------------------+------------------------+
| ######## Family planning                    |                        |
+---------------------------------------------+------------------------+
| A range of voluntary family planning        | > \$10 per office      |
| services, limited to:                       | > visit                |
|                                             |                        |
| -   Voluntary sterilization (See Surgical   |                        |
|     procedures Section 5 (b))               |                        |
|                                             |                        |
| -   Surgically implanted contraceptives     |                        |
|                                             |                        |
| -   Injectable contraceptive drugs (such as |                        |
|     Depo provera)                           |                        |
|                                             |                        |
| -   Intrauterine devices (IUDs)             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Diaphragms\                             |                        |
|     \                                       |                        |
|     Note: We cover oral contraceptives      |                        |
|     under the prescription drug benefit.    |                        |
+---------------------------------------------+------------------------+
| > *Not covered: reversal of voluntary       | > *All charges.*       |
| > surgical sterilization, genetic           |                        |
| > counseling, voluntary abortions and       |                        |
| > related care**.***                        |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Infertility services               | **You pay**            |
+---------------------------------------------+------------------------+
| > Diagnosis and treatment of infertility,   | > \$10 per office      |
| > limited to:\                              | > visit                |
| > \                                         |                        |
| > ^\_\_^ in vitro fertilization\            | Nothing                |
| > \                                         |                        |
| > ^\_\_^ gamete intrafallopian tube         | We cover fertility     |
| > transfer (GIFT)\                          | drugs under the        |
| > \                                         | prescription drug      |
| > ^\_\_^ zygote intrafallopian tube         | benefit. Please refer  |
| > transfer                                  | to Section 5(f).       |
| >                                           |                        |
| > However, we will only cover these         |                        |
| > treatments if you or your spouse:         |                        |
| >                                           |                        |
| > \(1\) have not been able to become        |                        |
| > pregnant or sustain a pregnancy through   |                        |
| > reasonable, less costly and medically     |                        |
| > appropriate covered infertility           |                        |
| > treatment;                                |                        |
| >                                           |                        |
| > \(2\) have not undergone four completed   |                        |
| > oocyte retrievals (except if a live birth |                        |
| > follows a completed oocyte retrieval,     |                        |
| > then we will cover two more completed     |                        |
| > oocyte retrievals); and                   |                        |
| >                                           |                        |
| > \(3\) have the procedures performed at    |                        |
| > medical facilities that conform to the    |                        |
| > American College of Obstetrics and        |                        |
| > Gynecology guidelines or to the American  |                        |
| > Fertility Society's minimum standards for |                        |
| > in vitro fertilization.                   |                        |
| >                                           |                        |
| > Artificial insemination:                  |                        |
| >                                           |                        |
| > ^\_\_^ *intravaginal insemination (IVI)*  |                        |
| >                                           |                        |
| > ^\_\_^ *intracervical insemination (ICI)* |                        |
| >                                           |                        |
| > ^\_\_^ *intrauterine insemination (IUI)*  |                        |
| >                                           |                        |
| > Oral fertility drugs and injectable       |                        |
| > fertility drugs                           |                        |
|                                             |                        |
| **\                                         |                        |
| ***Note: Preauthorization is required for   |                        |
| fertility medication.*                      |                        |
+---------------------------------------------+------------------------+
| > *Not covered*                             | > *All charges.\       |
|                                             | > \                    |
| -   *Treatment for infertility following    | > *                    |
|     voluntary sterilization*                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Cost of donor sperm*                   |                        |
|                                             |                        |
| -   *Cost of donor egg*                     |                        |
|                                             |                        |
| -   *Any treatment not specified above*     |                        |
+---------------------------------------------+------------------------+
| > **Allergy care**                          |                        |
+---------------------------------------------+------------------------+
| -   Testing and treatment                   | > \$10 per office      |
|                                             | > visit\               |
| -   Allergy injection                       | > \                    |
|                                             | > \$3 per visit (\$10  |
|                                             | > office visit copay   |
|                                             | > applies to any other |
|                                             | > covered              |
|                                             | > services**)**        |
+---------------------------------------------+------------------------+
| -   Allergy serum                           | > Nothing              |
+---------------------------------------------+------------------------+
| > *Not covered: Provocative food testing    | > *All charges.*       |
| > and sublingual allergy desensitization*   |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Treatment therapies                | **You pay**            |
+---------------------------------------------+------------------------+
| -   Chemotherapy and radiation therapy      | Nothing\               |
|                                             | \                      |
| > Note: High-dose chemotherapy in           | \                      |
| > association with autologous bone marrow   | \                      |
| > transplants is limited to those           | \                      |
| > transplants listed under Organ/Tissue     | \$10 per visit         |
| > Transplants on page 32.                   | outpatient\            |
|                                             | \                      |
| -   Respiratory and inhalation therapy      | \$10 per visit         |
|                                             | outpatient\            |
| ```{=html}                                  | \                      |
| <!-- -->                                    | Nothing\               |
| ```                                         | \                      |
| -   Dialysis -- hemodialysis and peritoneal | Nothing                |
|     dialysis                                |                        |
|                                             | > ***\                 |
| ```{=html}                                  | > \                    |
| <!-- -->                                    | > *\                   |
| ```                                         | > \                    |
| -   Intravenous (IV)/Infusion Therapy --    | > \                    |
|     Home IV and antibiotic therapy          | > \                    |
|                                             | > **Nothing            |
| -   Benefits for medical care *associated   |                        |
|     with* phase III or IV clinical trials   |                        |
|     for cancer treatment. The clinical      |                        |
|     trial must be underwritten by the       |                        |
|     National Institutes of Health           |                        |
|     Cooperative or an equivalent entity.    |                        |
|     The clinical trial treatment (including |                        |
|     drugs, devices and procedures) itself   |                        |
|     is not covered. To receive benefits,    |                        |
|     there must not be an identical or       |                        |
|     superior non-investigational treatment  |                        |
|     available. Also, to be covered, any     |                        |
|     drugs or devices used in the clinical   |                        |
|     trial must have FDA approval for        |                        |
|     treatment of one or more conditions,    |                        |
|     but the approval does not have to be    |                        |
|     for the particular condition involved   |                        |
|     in the trial.                           |                        |
|                                             |                        |
| -   Growth hormone therapy (GHT)            |                        |
|                                             |                        |
| > Note: Before administering any GHT        |                        |
| > treatment, your BlueCHOICE physician      |                        |
| > needs to obtain authorization by          |                        |
| > submitting a written request to our       |                        |
| > Provider Services Unit. Please check with |                        |
| > your BlueCHOICE physician before          |                        |
| > receiving GHT treatment.                  |                        |
| >                                           |                        |
| > We will not cover GHT or related services |                        |
| > and supplies unless you have received     |                        |
| > prior authorization.\                     |                        |
| > \                                         |                        |
| > Growth hormone is covered as a medical    |                        |
| > benefit.                                  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:\                            | > *All charges.*       |
| > \                                         |                        |
| > *Therapy that is not listed as covered in |                        |
| > this booklet. For example, massage        |                        |
| > therapy or exercise conditioning.         |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Physical and occupational therapies**   | **You pay**            |
+---------------------------------------------+------------------------+
| -   20 visits per calendar year for         | > \$10 per office      |
|     physical therapy and chiropractic care  | > visit                |
|     combined, and                           | >                      |
|                                             | > \$10 per outpatient  |
| -   20 visits per calendar year for         | > visit                |
|     occupational therapy.                   |                        |
|                                             |                        |
| > For the services of each of the           |                        |
| > following:                                |                        |
| >                                           |                        |
| > ^\_\_^ qualified physical therapists and  |                        |
| > chiropractors, and                        |                        |
| >                                           |                        |
| > ^\_\_^ occupational therapists.           |                        |
| >                                           |                        |
| > Note: We only cover physical and          |                        |
| > occupational therapy to restore bodily    |                        |
| > function when there has been a total or   |                        |
| > partial loss of bodily function due to    |                        |
| > illness or injury.                        |                        |
|                                             |                        |
| -   Cardiac rehabilitation following, but   |                        |
|     not limited to, a heart transplant,     |                        |
|     bypass surgery or a myocardial          |                        |
|     infarction, is provided for one         |                        |
|     consecutive 12-week program per         |                        |
|     calendar year                           |                        |
|                                             |                        |
| -   Pulmonary rehabilitation for up to 14   |                        |
|     sessions within 12 months and then one  |                        |
|     session every 3 months thereafter\      |                        |
|     \                                       |                        |
|     Note: See Chiropractic care             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *long-term rehabilitative therapy*      |                        |
|                                             |                        |
| -   *exercise programs*                     |                        |
+---------------------------------------------+------------------------+
| > **Speech therapy**                        |                        |
+---------------------------------------------+------------------------+
| -   20 visits per calendar year             | > \$10 per office      |
|                                             | > visit                |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Hearing services (testing, treatment,   | **You pay**            |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| -   Routine hearing exams                   | > \$10 per office      |
|                                             | > visit                |
| -   Newborn hearing, screening, rescreening |                        |
|     and initial amplification               |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Hearing aids, testing and examinations |                        |
|     for them.*                              |                        |
+---------------------------------------------+------------------------+
| > **Vision services (testing, treatment,    |                        |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| -   Routine eye exam (one per calendar      | > \$10 per office      |
|     year)                                   | > visit                |
|                                             |                        |
| -   Eyeglasses and contact lenses are       |                        |
|     reimbursed up to \$35 per 24-month      |                        |
|     period when received from a BlueCHOICE  |                        |
|     vision care provider. In addition,      |                        |
|     reduced-cost glasses or contact lenses  |                        |
|     are available from selected             |                        |
|     providers**.**                          |                        |
+---------------------------------------------+------------------------+
| -   One pair of eyeglasses or contact       | > \$10 per office      |
|     lenses to correct an impairment         | > visit                |
|     directly caused by accidental ocular    |                        |
|     injury or intraocular surgery (such as  |                        |
|     for cataracts)                          |                        |
+---------------------------------------------+------------------------+
| -   Eye exam to determine the need for      | > \$10 per office      |
|     vision correction for children (see     | > visit                |
|     Preventive care, children)              |                        |
|                                             |                        |
| -   Annual eye refractions                  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Eye exercises and orthoptics*          |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Radial keratotomy and other refractive |                        |
|     surgery, including LASIK procedures*    |                        |
+---------------------------------------------+------------------------+
| ######## 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**     | **You pay**            |
+---------------------------------------------+------------------------+
| -   Artificial limbs and eyes; stump hose   | > Nothing\             |
|                                             | > \                    |
| -   Externally worn breast prostheses and   | > \                    |
|     surgical bras, including necessary      | > \                    |
|     replacements, following a mastectomy    | > \                    |
|                                             | > \                    |
| ```{=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.                      | > \$25 (per pair)      |
|                                             |                        |
| -   Corrective orthopedic appliances for    |                        |
|     non-dental treatment of                 |                        |
|     temporomandibular joint (TMJ) pain      |                        |
|     dysfunction syndrome.                   |                        |
|                                             |                        |
| -   Sacral nerve stimulators when medically |                        |
|     necessary to treat urge incontinence,   |                        |
|     urge frequency or urinary retention     |                        |
|     without mechanical obstruction          |                        |
|                                             |                        |
| -   Compression (anti-embolic) stockings    |                        |
|     (up to 2 pairs per calendar year); see  |                        |
|     page 26.                                |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.\       |
|                                             | > \                    |
| -   *orthopedic and corrective shoes*       | > \                    |
|                                             | > \                    |
| -   *arch supports*                         | > \                    |
|                                             | > \                    |
| -   *foot orthotics*                        | > \                    |
|                                             | > \                    |
| -   *heel pads and heel cups*               | > \                    |
|                                             | > \                    |
| -   *lumbosacral supports*                  | > \                    |
|                                             | > \                    |
| -   *orthotic devices used primarily for    | > *                    |
|     convenience, comfort or for             |                        |
|     participation in athletics*             |                        |
|                                             |                        |
| -   *corsets, trusses, support hose, and    |                        |
|     other supportive devices*               |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Durable medical equipment (DME)    | **You pay**            |
+---------------------------------------------+------------------------+
| > We cover the use of standard models of    | > \$10 to \$200        |
| > the durable medical equipment (DME) and   | >                      |
| > medical supplies listed below when        | > \$ 10\               |
| > medically necessary to treat certain      | > \$ 25\               |
| > conditions.                               | > \$ 50\               |
| >                                           | > \$ 25\               |
| > Your primary care physician or network    | > \$ 25\               |
| > specialist must give you a prescription   | > \$100\               |
| > for the equipment or supplies. You must   | > \$ 10\               |
| > obtain the equipment or supplies from a   | > \$ 10\               |
| > network DME provider.                     | > \$ 25 (per pair)\    |
| >                                           | > \$ 25\               |
| > We only provide benefits up to our        | > \$ 25\               |
| > allowed amount for supplies and for basic | > \$ 25\               |
| > models of equipment. If you want other    | > \$ 25\               |
| > than the basic model, you must pay your   | > \$ 10\               |
| > copay and any charges above the allowed   | > \$ 10\               |
| > amount for the basic equipment. We        | > \                    |
| > determine what is a basic model.          | > \$ 25\               |
| >                                           | > \$ 10\               |
| > Following is a list of covered equipment  | > \$ 50\               |
| > and medical supplies. The copay is shown  | > \$ 25\               |
| > at right.\                                | > \$ 10\               |
| > \                                         | > \                    |
| > Air flotation mattress and alternating    | > \$100\               |
| > pressure pump\                            | > \$ 25\               |
| > Apnea monitor ^(1)^\                      | > \$ 25\               |
| > Bi-directional Positive Airway Pressure   | > \$ 50\               |
| > (BIPAP) apparatus ^(1)^\                  | > \$ 25\               |
| > Bili phototherapy system ^(1)^\           | > \$ 10\               |
| > Blood glucose monitor ^(1)^\              | > \                    |
| > Bone growth stimulator (electrical)       | > \$ 25\               |
| > ^(2)^\                                    | > \$ 25\               |
| > Canes\                                    | > \$ 15\               |
| > Commode (bedside)\                        | > \                    |
| > Compression (anti-embolic) stockings (up  | > \                    |
| > to 2 pairs per calendar year)\            | > \                    |
| > Continuous Passive Motion (CPM) Devices\  | > \$ 10\               |
| > Continuous Positive Airway Pressure       | > \$ 50\               |
| > (CPAP) apparatus ^(1)\                    | > \$ 25\               |
| > ^Replacement CPAP apparatus\              | > \$ 10\               |
| > Continuous Positive Airway Pressure       | > \$ 10\               |
| > (CPAP) humidifier\                        | > \$ 10\               |
| > Crutches\                                 | > \$ 25\               |
| > Diabetic supplies and equipment, other    | > \$ 10\               |
| > than a blood glucose monitor, one month   | > \$ 25\               |
| > supply\                                   | > \$ 25\               |
| > Enteral feeding equipment\                | > \$ 25\               |
| > Enteral feeding supplies\                 | > \$ 10\               |
| > Hospital bed (electric)\                  | > \$ 50\               |
| > Hospital bed (nonelectric)\               | > \$ 25\               |
| > Incontinence cathethers and irrigation    | > \$ 10\               |
| > supplies, one month supply\               | > \                    |
| > per copayment ^(1)^\                      | > \$ 10                |
| > Insulin pump ^(2)^\                       |                        |
| > Insulin pump supplies ^(2)^\              |                        |
| > Intermittent Positive Pressure Breathing  |                        |
| > Apparatus (IPPB) ^(1)^\                   |                        |
| > Lymphedema pumps/lymphedema sleeves\      |                        |
| > Mattress overlays\                        |                        |
| > Medical and post-surgical dressings,      |                        |
| > irrigation supplies, and\                 |                        |
| > dressing tape, one month supply per       |                        |
| > copayment\                                |                        |
| > Nebulizer compressor ^(1)^\               |                        |
| > Neuromuscular Electronic Stimulator       |                        |
| > (NMES)\                                   |                        |
| > Nutritional formula and low-protein       |                        |
| > modified food products for                |                        |
| > phenylketonuria (PKU) or other inherited  |                        |
| > disease of amino and organic acids,       |                        |
| > covered for members through age 5 only,   |                        |
| > one month supply per copayment\           |                        |
| > Ostomy supplies, all types, one month     |                        |
| > supply per copayment\                     |                        |
| > Oxygen, one month supply per copayment\   |                        |
| > Patient lifts\                            |                        |
| > Peak flow meters\                         |                        |
| > Pulmoaids\                                |                        |
| > Spacers for Metered Dose Inhalers (MDI)\  |                        |
| > Sphygmomanometer for gestational          |                        |
| > hypertension\                             |                        |
| > Suction catheters, one month supply per   |                        |
| > copayment ^(1)^\                          |                        |
| > Suction equipment\                        |                        |
| > Transcutaneous Electrical Nerve           |                        |
| > Stimulator (TENS) Units\                  |                        |
| > Traction devices\                         |                        |
| > Walkers\                                  |                        |
| > Wheelchairs (electric)\                   |                        |
| > Wheelchairs (non-electric)\               |                        |
| > Wheelchair gel pads                       |                        |
| >                                           |                        |
| > The maximum benefit for a medically       |                        |
| > necessary nonstandard wheelchair is       |                        |
| > \$2,000. The regular copay for a manual   |                        |
| > or electric wheelchair applies. ^(2)\     |                        |
| > \                                         |                        |
| > ^ABI Vest, used to treat members with     |                        |
| > cystic fibrosis, is available for \$200   |                        |
| > per month.                                |                        |
| >                                           |                        |
| > ^(1)^ Includes initial provision of       |                        |
| > nonpharmaceutical medically necessary     |                        |
| > supplies.\                                |                        |
| > \                                         |                        |
| > ^(2)^ Subject to review by BlueCHOICE. To |                        |
| > obtain more information, you may contact  |                        |
| > us at 1-800-932-4480.                     |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             | >                      |
| -   Dialysis equipment (rental or purchase) | > Copay plus any       |
|                                             | > charges above the    |
| -   Equipment or supplies that are not      | > allowed amount for   |
|     listed as covered                       | > the basic equipment. |
|                                             |                        |
| -   Nonstandard models of equipment         |                        |
+---------------------------------------------+------------------------+
| ######## Home health services               | **You pay**            |
+---------------------------------------------+------------------------+
| -   Home health care ordered by a Plan      | > Nothing              |
|     physician and provided by a registered  |                        |
|     nurse (R.N.), licensed practical nurse  |                        |
|     (L.P.N.), licensed vocational nurse     |                        |
|     (L.V.N.), or home health aide. Your     |                        |
|     physician will periodically review the  |                        |
|     program for appropriateness and         |                        |
|     need**.**                               |                        |
|                                             |                        |
| -   Services include oxygen therapy,        |                        |
|     intravenous therapy and medications.    |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## 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.*                      |                        |
|                                             |                        |
| -   *Services primarily for hygiene,        |                        |
|     feeding, exercising, moving the         |                        |
|     patient, homemaking, companionship or   |                        |
|     giving oral medication.*                |                        |
|                                             |                        |
| -   *Home care primarily for personal       |                        |
|     assistance that does not include a      |                        |
|     medical component and is not            |                        |
|     diagnostic, therapeutic, or             |                        |
|     rehabilitative.*                        |                        |
+---------------------------------------------+------------------------+
| ######## Chiropractic                       |                        |
+---------------------------------------------+------------------------+
| -   20 visits per calendar year for         | > \$10 per office      |
|     chiropractic care and physical therapy  | > visit                |
|     combined                                |                        |
|                                             |                        |
| -   Manipulation of the spine and           |                        |
|     extremities                             |                        |
|                                             |                        |
| -   Adjunctive procedures such as           |                        |
|     ultrasound, electrical muscle           |                        |
|     stimulation, vibratory therapy, and     |                        |
|     cold pack application                   |                        |
|                                             |                        |
| Note: See Physical therapy                  |                        |
+---------------------------------------------+------------------------+
| > Not covered:                              | > *All charges.*       |
|                                             |                        |
| -   long-term rehabilitative therapy        |                        |
|                                             |                        |
| -   exercise programs                       |                        |
|                                             |                        |
| -   maintenance care                        |                        |
|                                             |                        |
| -   relaxation therapy                      |                        |
+---------------------------------------------+------------------------+
| ######## Alternative treatments             |                        |
+---------------------------------------------+------------------------+
| > *See Non-FEHB benefits, page 49.*         |                        |
+---------------------------------------------+------------------------+
| #### **Educational classes and programs**   |                        |
+---------------------------------------------+------------------------+
| -   Smoking Cessation                       | Please refer to Mental |
|                                             | health and substance   |
| -   Asthma and diabetes self-management     | abuse benefits in\     |
|                                             | Section 5(e); for      |
|                                             | prescription drug      |
|                                             | benefits, Section      |
|                                             | 5(f); and for non-FEHB |
|                                             | benefits, Section      |
|                                             | 5(i).\                 |
|                                             | \                      |
|                                             | Please refer to        |
|                                             | Special features,\     |
|                                             | Section 5(g).          |
+---------------------------------------------+------------------------+

+---+---+-------------------------------------+----------------+---+---+
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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 |   |
|   | * | -   Be sure to read Section 4,      |                | * |   |
|   | * |     *Your costs for covered         |                | * |   |
|   |   |     services,* for valuable         |                |   |   |
|   | * |     information about how cost      |                | * |   |
|   | * |     sharing works. Also read        |                | * |   |
|   | O |     Section 9 about coordinating    |                | O |   |
|   | * |     benefits with other coverage,   |                | * |   |
|   | * |     including with Medicare.        |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   The amounts listed below are    |                | * |   |
|   | * |     for the charges billed by a     |                | * |   |
|   | R |     physician or other health care  |                | R |   |
|   | * |     professional for your surgical  |                | * |   |
|   | * |     care. Look in Section 5(c) for  |                | * |   |
|   |   |     charges associated with the     |                |   |   |
|   | * |     facility (i.e. hospital,        |                | * |   |
|   | * |     surgical center, etc.).         |                | * |   |
|   | T |                                     |                | T |   |
|   | * | -   **YOUR PHYSICIAN MUST GET       |                | * |   |
|   | * |     PRECERTIFICATION OF SOME        |                | * |   |
|   |   |     SURGICAL PROCEDURES.** Please   |                |   |   |
|   | * |     refer to the precertification   |                | * |   |
|   | * |     information shown in Section 3  |                | * |   |
|   | A |     to be sure which services       |                | A |   |
|   | * |     require precertification and    |                | * |   |
|   | * |     identify which surgeries        |                | * |   |
|   |   |     require precertification.       |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | N |                                     |                | N |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | T |                                     |                | T |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | **You pay**    |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
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| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
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| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | > Nothing,     |   |   |
|   |   |                                     | > unless       |   |   |
| A |   |                                     | > services are |   |   |
| > |   |                                     | > received     |   |   |
|   |   |                                     | > during an    |   |   |
| c |   |                                     | > office       |   |   |
| o |   |                                     | > visit, then  |   |   |
| m |   |                                     | > the \$10     |   |   |
| p |   |                                     | > copay        |   |   |
| r |   |                                     | > applies.     |   |   |
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| . |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+

*Surgical procedures continued on next page.*

+---------------------------------------------+------------------------+
| > **Surgical procedures** *(Continued)*     | > **You pay**          |
+---------------------------------------------+------------------------+
| -   Voluntary sterilization (e.g., Tubal    | > Nothing, unless      |
|     ligation, Vasectomy)                    | > services are         |
|                                             | > received during an   |
| -   Treatment of burns                      | > office visit, then   |
|                                             | > the \$10 copay       |
| > Note: Generally, we pay for internal      | > applies.             |
| > prostheses (devices) according to where   |                        |
| > the procedure is done. For example, we    |                        |
| > pay Hospital benefits for a pacemaker and |                        |
| > Surgery benefits for insertion of the     |                        |
| > pacemaker.                                |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Reversal of voluntary sterilization*   |                        |
|                                             |                        |
| -   *Routine treatment of conditions of the |                        |
|     foot; see Foot care.*                   |                        |
+---------------------------------------------+------------------------+
| > **Reconstructive surgery**                |                        |
+---------------------------------------------+------------------------+
| -   Surgery to correct a functional defect  | > Nothing, unless      |
|                                             | > services are         |
| -   Surgery to correct a condition caused   | > received during an   |
|     by injury or illness if:                | > office visit, then   |
|                                             | > the \$10 copay       |
| > ^\_\_^ the condition produced a major     | > applies.             |
| > 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     |                        |
|     surgery following a mastectomy, such    |                        |
|     as:                                     |                        |
|                                             |                        |
| > ^\_\_^ surgery to produce a symmetrical   |                        |
| > appearance of breasts;                    |                        |
| >                                           |                        |
| > ^\_\_^ treatment of any physical          |                        |
| > complications, such as lymphedemas;       |                        |
| >                                           |                        |
| > ^\_\_^ breast prostheses and surgical     |                        |
| > bras and replacements (see Prosthetic     |                        |
| > devices)                                  |                        |
| >                                           |                        |
| > Note: If you need a mastectomy, you may   |                        |
| > choose to have the procedure performed on |                        |
| > an inpatient basis and remain in the      |                        |
| > hospital up to 48 hours after the         |                        |
| > procedure.                                |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Cosmetic surgery -- any surgical       |                        |
|     procedure (or any portion of a          |                        |
|     procedure) performed primarily to       |                        |
|     improve physical appearance through     |                        |
|     change in bodily form, except repair of |                        |
|     accidental injury*                      |                        |
|                                             |                        |
| -   *Surgeries related to sex               |                        |
|     transformation*                         |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Oral and maxillofacial surgery**        |                        |
+---------------------------------------------+------------------------+
| > Oral surgical procedures, limited to:     | > Nothing, unless      |
|                                             | > services are         |
| -   Reduction of fractures of the jaws or   | > received during an   |
|     facial bones;                           | > office visit, then   |
|                                             | > the \$10 copay       |
| ```{=html}                                  | > applies.**\          |
| <!-- -->                                    | > \                    |
| ```                                         | > \                    |
| -   Surgical correction of cleft lip, cleft | > \                    |
|     palate or severe functional             | > \                    |
|     malocclusion;                           | > \                    |
|                                             | > \                    |
| ```{=html}                                  | > \                    |
| <!-- -->                                    | > \                    |
| ```                                         | > \                    |
| -   Removal of stones from salivary ducts;  | > **                   |
|                                             | >                      |
| ```{=html}                                  | > Nothing              |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Excision of leukoplakia or              |                        |
|     malignancies;                           |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Excision of cysts and incision of       |                        |
|     abscesses when done as independent      |                        |
|     procedures;                             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Extractions of teeth that interfere     |                        |
|     with radiation therapy;                 |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Treatment of trauma resulting in        |                        |
|     injuries to the jaw, cheeks, lips,      |                        |
|     tongue, roof and floor of the mouth;    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Treatment of bony impactions;           |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Surgical correction of anatomical       |                        |
|     abnormalities for treatment of          |                        |
|     temporomandibular disease when approved |                        |
|     in advance by BlueCHOICE; and           |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Other surgical procedures that do not   |                        |
|     involve the teeth or their supporting   |                        |
|     structures.                             |                        |
|                                             |                        |
| > General anesthesia for certain dental     |                        |
| > patients, limited to:                     |                        |
|                                             |                        |
| -   Children through age 4                  |                        |
|                                             |                        |
| -   Severely disabled people; and           |                        |
|                                             |                        |
| -   People with medical or behavioral       |                        |
|     conditions that require hospitalization |                        |
|     or general anesthesia for dental care.  |                        |
|                                             |                        |
| > The general anesthesia must be provided   |                        |
| > in a network hospital, network            |                        |
| > freestanding surgery center or dentist's  |                        |
| > office. A primary care physician referral |                        |
| > is required. The dental procedures        |                        |
| > themselves are not covered.               |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges.*       |
|                                             |                        |
| -   *Oral implants and transplants*         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Procedures that involve the teeth or   |                        |
|     their supporting structures (such as    |                        |
|     the periodontal membrane, gingiva, and  |                        |
|     alveolar bone)*                         |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Organ/tissue transplants**              | > **You pay**          |
+---------------------------------------------+------------------------+
| > Limited to:                               | > Nothing              |
|                                             |                        |
| -   Cornea                                  |                        |
|                                             |                        |
| -   Heart                                   |                        |
|                                             |                        |
| -   Heart/lung                              |                        |
|                                             |                        |
| -   Kidney                                  |                        |
|                                             |                        |
| -   Kidney/pancreas                         |                        |
|                                             |                        |
| -   Liver                                   |                        |
|                                             |                        |
| -   Lung: single --double                   |                        |
|                                             |                        |
| -   Pancreas                                |                        |
|                                             |                        |
| -   Allogeneic bone marrow transplant, if   |                        |
|     the treatment is part of a National     |                        |
|     Cancer Institute (NCI) phase III or IV  |                        |
|     trial, or the treatment is available    |                        |
|     elsewhere as part of a NCI phase III or |                        |
|     IV trial. Donor screening tests and     |                        |
|     donor search expenses are also covered  |                        |
|     for allogeneic 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 |                        |
|     single or tandem 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.                  |                        |
|                                             |                        |
| -   Human Leukocyte Antigen (HLA) testing,  |                        |
|     where member is recipient.              |                        |
|                                             |                        |
| > Note: Autologous bone marrow or stem cell |                        |
| > transplants after high-dose chemotherapy  |                        |
| > to treat breast cancer, and related care, |                        |
| > must be received at St. Louis University  |                        |
| > Hospital/SLU Care.                        |                        |
| >                                           |                        |
| > National Transplant Program (NTP): We are |                        |
| > a member of the Blue Quality Center for   |                        |
| > Transplants.                              |                        |
| >                                           |                        |
| > All care for transplants must be          |                        |
| > coordinated through BlueCHOICE in         |                        |
| > writing. The physician should send a      |                        |
| > letter to the BlueCHOICE Medical Director |                        |
| > requesting precertification.              |                        |
| >                                           |                        |
| > If you live outside the St. Louis         |                        |
| > metropolitan area, we may cover up to     |                        |
| > \$10,000 in reasonable and necessary      |                        |
| > expenses for transportation, lodging and  |                        |
| > meals while you are away from home for    |                        |
| > the transplant. *This must be approved in |                        |
| > advance by Case Management**.***          |                        |
| >                                           |                        |
| > 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*         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Transplants not listed as covered*     |                        |
|                                             |                        |
| -   *Organ donation expenses unless this    |                        |
|     program is covering the organ           |                        |
|     transplantation**.***                   |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Anesthesia**                            | > **You pay**          |
+---------------------------------------------+------------------------+
| > Professional services provided in --      | > Nothing              |
|                                             |                        |
| -   Hospital (inpatient)\                   |                        |
|     \                                       |                        |
|     General anesthesia for certain dental   |                        |
|     patients, limited to:                   |                        |
|                                             |                        |
| -   Children through age 4                  |                        |
|                                             |                        |
| -   Severely disabled people; and           |                        |
|                                             |                        |
| -   People with medical or behavioral       |                        |
|     conditions that require hospitalization |                        |
|     or general anesthesia for dental care.  |                        |
|                                             |                        |
| > The general anesthesia must be provided   |                        |
| > in a network hospital, network            |                        |
| > freestanding surgery center or dentist's  |                        |
| > office. A primary care physician referral |                        |
| > is required. The dental procedures        |                        |
| > themselves are not covered.               |                        |
+---------------------------------------------+------------------------+
| > Professional services provided in --      | > Nothing\             |
|                                             | > \                    |
| -   Hospital outpatient department          | > \                    |
|                                             | > \$10 per office      |
| -   Skilled nursing facility                | > visit                |
|                                             |                        |
| -   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**,** unless it  |             | * |     |
|    | * |     is an emergency, (see Section |             | * |     |
|    |   |     5(d)).                        |             |   |     |
|    | * |                                   |             | * |     |
|    | * | -   Be sure to read Section 4,    |             | * |     |
|    | O |     *Your costs for covered       |             | O |     |
|    | * |     services,* for valuable       |             | * |     |
|    | * |     information about how cost    |             | * |     |
|    |   |     sharing works. Also read      |             |   |     |
|    | * |     Section 9 about coordinating  |             | * |     |
|    | * |     benefits with other coverage, |             | * |     |
|    | R |     including with Medicare.      |             | R |     |
|    | * |                                   |             | * |     |
|    | * | -   The amounts listed below are  |             | * |     |
|    |   |     for the charges billed by the |             |   |     |
|    | * |     facility (i.e., hospital or   |             | * |     |
|    | * |     surgical center) or ambulance |             | * |     |
|    | T |     service for your surgery or   |             | T |     |
|    | * |     care. Any costs associated    |             | * |     |
|    | * |     with the professional charge  |             | * |     |
|    |   |     (i.e., physicians, etc.) are  |             |   |     |
|    | * |     covered in Sections 5(a) or   |             | * |     |
|    | * |     (b).                          |             | * |     |
|    | A |                                   |             | A |     |
|    | * | ```{=html}                        |             | * |     |
|    | * | <!-- -->                          |             | * |     |
|    |   | ```                               |             |   |     |
|    | * | -   **YOUR PHYSICIAN MUST GET     |             | * |     |
|    | * |     PRECERTIFICATION OF HOSPITAL  |             | * |     |
|    | N |     STAYS.** Please refer to      |             | N |     |
|    | * |     Section 3 to be sure which    |             | * |     |
|    | * |     services require              |             | * |     |
|    |   |     precertification.             |             |   |     |
|    | * |                                   |             | * |     |
|    | * |                                   |             | * |     |
|    | T |                                   |             | T |     |
|    | * |                                   |             | * |     |
|    | * |                                   |             | * |     |
+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   | **You pay** |   |     |
|  * |   |                                   |             |   |     |
| *B |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| ef |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  D |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| cr |   |                                   |             |   |     |
| ip |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| ** |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| #  |   |                                   | ########    |   |     |
| ## |   |                                   |             |   |     |
| ## |   |                                   |             |   |     |
| ## |   |                                   |             |   |     |
| #  |   |                                   |             |   |     |
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| sp |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   | > Nothing   |   |     |
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| di |   |                                   |             |   |     |
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| on |   |                                   |             |   |     |
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| 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                    |                        |
|                                             |                        |
| -   Take-home items                         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   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 guest 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. We do not cover the  |                        |
| > dental procedures.                        |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Extended care bene                 | ######## You pay       |
| fits/skilled nursing care facility benefits |                        |
+---------------------------------------------+------------------------+
| > Extended care/skilled nursing facility    | > Nothing              |
| > (SNF):                                    |                        |
| >                                           |                        |
| > We cover treatment in a network skilled   |                        |
| > nursing facility for a condition that     |                        |
| > otherwise would require hospital          |                        |
| > confinement.                              |                        |
| >                                           |                        |
| > You may transfer directly from the        |                        |
| > hospital. If you do not, your primary     |                        |
| > care physician must obtain advance        |                        |
| > approval from BlueCHOICE.                 |                        |
| >                                           |                        |
| > We will cover the care only as long as it |                        |
| > is medically necessary. We will notify    |                        |
| > you if we determine SNF care is no longer |                        |
| > necessary. Then we will not cover any SNF |                        |
| > charges after the date in the notice.     |                        |
| >                                           |                        |
| > We cover the following SNF services:      |                        |
|                                             |                        |
| -   Semiprivate room and board (We will     |                        |
|     cover a private room if BlueCHOICE      |                        |
|     agrees in advance that it is medically  |                        |
|     necessary. If not, you are responsible  |                        |
|     for any difference between the private  |                        |
|     room and the semiprivate room.)         |                        |
|                                             |                        |
| -   General nursing care                    |                        |
|                                             |                        |
| -   Drugs, medications, biologicals,        |                        |
|     supplies, equipment and services        |                        |
|     ordered by the attending network        |                        |
|     physician with the primary care         |                        |
|     physician's prior authorization.        |                        |
+---------------------------------------------+------------------------+
| > Not covered: custodial care               | > *All charges*        |
+---------------------------------------------+------------------------+
| #### **Hospice care**                       | ####                   |
+---------------------------------------------+------------------------+
| > When a terminally ill member's life       | > Nothing              |
| > expectancy has reached six months or      |                        |
| > less, the member may benefit from hospice |                        |
| > care. This care provides pain control and |                        |
| > emotional support.                        |                        |
| >                                           |                        |
| > Your primary care physician must obtain   |                        |
| > advance approval from BlueCHOICE. You     |                        |
| > must go to a network hospital or receive  |                        |
| > care from a network home health agency    |                        |
| > licensed to provide hospice care. The     |                        |
| > hospice provider will write a treatment   |                        |
| > plan for your signature. BlueCHOICE and   |                        |
| > your primary care physician must          |                        |
| > coordinate your care.                     |                        |
| >                                           |                        |
| > We also cover inpatient hospice care for  |                        |
| > short-term pain control.                  |                        |
+---------------------------------------------+------------------------+
| > *Not covered: Independent nursing,        | > *All charges*        |
| > homemaker services**;** bereavement       |                        |
| > services*                                 |                        |
+---------------------------------------------+------------------------+
| ######## Ambulance                          | ########               |
+---------------------------------------------+------------------------+
| -   Local professional ambulance service    | > Nothing              |
|     when medically appropriate              |                        |
+---------------------------------------------+------------------------+

+---+---+------------------------------------------------------+---+---+
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
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|   |   |                                                      |   |   |
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| / |   |                                                      |   |   |
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| s |   |                                                      |   |   |
+---+---+------------------------------------------------------+---+---+
|   | * | > Here are some important things to keep in mind     | * | # |
|   | * | > about these benefits:                              | * | # |
|   | I |                                                      | I | # |
|   | * | -   Please remember that all benefits are subject to | * | # |
|   | * |     the definitions, limitations, and exclusions in  | * | # |
|   |   |     this brochure and are payable only when we       |   |   |
|   | * |     determine they are medically necessary.          | * |   |
|   | * |                                                      | * |   |
|   | M | -   Be sure to read Section 4, *Your costs for       | M |   |
|   | * |     covered services,* for valuable information      | * |   |
|   | * |     about how cost sharing works. Also read Section  | * |   |
|   |   |     9 about coordinating benefits with other         |   |   |
|   | * |     coverage, including with Medicare.               | * |   |
|   | * |                                                      | * |   |
|   | P | -   When you need emergency medical care outside of  | P |   |
|   | * |     the U.S., go to the nearest hospital. Call the   | * |   |
|   | * |     BlueCard Worldwide Service Center at             | * |   |
|   |   |     1-800-810-BLUE (2583), or call collect at        |   |   |
|   | * |     1-804-673-1177, if you are admitted.             | * |   |
|   | * |                                                      | * |   |
|   | O | #####                                                | O |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
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+---+---+------------------------------------------------------+---+---+
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| a |   |                                                      |   |   |
| l |   |                                                      |   |   |
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| > |   |                                                      |   |   |
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| u |   |                                                      |   |   |
| s |   |                                                      |   |   |
| e |   |                                                      |   |   |
| d |   |                                                      |   |   |
| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| f |   |                                                      |   |   |
| o |   |                                                      |   |   |
| r |   |                                                      |   |   |
| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| a |   |                                                      |   |   |
| p |   |                                                      |   |   |
| p |   |                                                      |   |   |
| o |   |                                                      |   |   |
| i |   |                                                      |   |   |
| n |   |                                                      |   |   |
| t |   |                                                      |   |   |
| m |   |                                                      |   |   |
| e |   |                                                      |   |   |
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| t |   |                                                      |   |   |
| s |   |                                                      |   |   |
| . |   |                                                      |   |   |
+---+---+------------------------------------------------------+---+---+

+-------------------------------------------------+--------------------+
| > **Benefit Description**                       | **You pay**        |
+-------------------------------------------------+--------------------+
| > **Emergency within our service area**         |                    |
+-------------------------------------------------+--------------------+
| -   Emergency care at a doctor\'s office        | > \$10 per office  |
|                                                 | > visit            |
| -   Emergency care at an urgent care center     | >                  |
|                                                 | > \$10 per office  |
| ```{=html}                                      | > visit            |
| <!-- -->                                        | >                  |
| ```                                             | > \$50 at          |
| -   Emergency care as an outpatient or          | > emergency room   |
|     inpatient at a hospital, including          | > (waived if       |
|     doctors\' services                          | > admitted)\       |
|                                                 | > \                |
| -   Hospital observation                        | > \                |
|                                                 | > \$50 (waived if  |
| > If you need follow-up care after emergency    | > admitted)        |
| > treatment, call your primary care physician.  |                    |
| > If your primary care physician cannot provide |                    |
| > the care, he or she will give you a written   |                    |
| > referral to a network specialist.\            |                    |
| > \                                             |                    |
| > If you are treated in the emergency room and  |                    |
| > then held for observation, only one copay     |                    |
| > will be charged.                              |                    |
| >                                               |                    |
| > *If you receive follow-up care without a      |                    |
| > written referral from your primary care       |                    |
| > physician, you must pay all charges**.***     |                    |
+-------------------------------------------------+--------------------+
| > *Not covered: Elective care or non-emergency  | > *All charges.*   |
| > care*                                         |                    |
+-------------------------------------------------+--------------------+
| ######## Emergency outside our service area     |                    |
+-------------------------------------------------+--------------------+
| -   Emergency care at a doctor\'s office        | > \$10 per office  |
|                                                 | > visit            |
| -   Emergency care at an urgent care center     | >                  |
|                                                 | > \$10 per office  |
| -   Emergency care as an outpatient or          | > visit            |
|     inpatient at a hospital, including          | >                  |
|     doctors\' services                          | > \$50 at          |
|                                                 | > emergency room   |
| ```{=html}                                      | > (waived if       |
| <!-- -->                                        | > admitted)\       |
| ```                                             | > \                |
| -   Hospital observation                        | > \                |
|                                                 | > \$50 (waived if  |
| > If you need follow-up care after emergency    | > admitted)        |
| > treatment, call your primary care physician.  |                    |
| > If your primary care physician cannot provide |                    |
| > the care, he or she will give you a written   |                    |
| > referral to a network specialist.\            |                    |
| > \                                             |                    |
| > If you are treated in the emergency room and  |                    |
| > then held for observation, only one copay     |                    |
| > will be charged.                              |                    |
| >                                               |                    |
| > Emergency outside our area *(continued)*      |                    |
| >                                               |                    |
| > After your condition is stabilized, you, the  |                    |
| > hospital, a family member or a friend must    |                    |
| > call us for approval of continued care.       |                    |
| >                                               |                    |
| > Benefits are available only until BlueCHOICE  |                    |
| > determines that your condition has improved   |                    |
| > enough for you to travel back to the          |                    |
| > BlueCHOICE service area.                      |                    |
| >                                               |                    |
| > *If you receive follow-up care without a      |                    |
| > written referral from your primary care       |                    |
| > physician, you must pay all charges.*         |                    |
|                                                 |                    |
| ########                                        |                    |
+-------------------------------------------------+--------------------+
| > *Not covered:*                                | > *All charges.*   |
|                                                 |                    |
| -   *Elective care or non-emergency care*       |                    |
|                                                 |                    |
| -   *Emergency care provided outside the        |                    |
|     service area if the need for care could     |                    |
|     have been foreseen before leaving the       |                    |
|     service area*                               |                    |
+-------------------------------------------------+--------------------+
| > **Ambulance**                                 | > **You pay**      |
+-------------------------------------------------+--------------------+
| > Professional ambulance and air ambulance      | > Nothing          |
| > service when medically appropriate.           |                    |
| > Transportation by air ambulance must be       |                    |
| > approved in advance by BlueCHOICE**.**        |                    |
| >                                               |                    |
| > See Section 5(c) for non-emergency service.   |                    |
+-------------------------------------------------+--------------------+

+---+---+-----------------------------------------+----------------+---+---+
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| S |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| c |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| o |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| 5 |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| ( |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| ) |   |                                         |                |   |   |
| . |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| M |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| l |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| h |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| l |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| h |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| d |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| u |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| c |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| u |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| f |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+
|   | * | Cost-sharing and limitations for Plan   |                | * |   |
|   | * | mental health and substance abuse       |                | * |   |
|   | I | benefits will be no greater than for    |                | I |   |
|   | * | similar benefits for other illnesses    |                | * |   |
|   | * | and conditions.                         |                | * |   |
|   |   |                                         |                |   |   |
|   | * | **Here are some important things to     |                | * |   |
|   | * | keep in mind about these benefits:**    |                | * |   |
|   | M |                                         |                | M |   |
|   | * | > • Please remember that all benefits   |                | * |   |
|   | * | > are subject to the definitions,       |                | * |   |
|   |   | > limitations, and exclusions in this   |                |   |   |
|   | * | > brochure and are payable only when we |                | * |   |
|   | * | > determine they are medically          |                | * |   |
|   | P | > necessary.                            |                | P |   |
|   | * | >                                       |                | * |   |
|   | * | > • Be sure to read Section 4, *Your    |                | * |   |
|   |   | > costs for covered services,* for      |                |   |   |
|   | * | > valuable information about how cost   |                | * |   |
|   | * | > sharing works. Also read Section 9    |                | * |   |
|   | O | > about coordinating benefits with      |                | O |   |
|   | * | > other coverage, including with        |                | * |   |
|   | * | > Medicare.                             |                | * |   |
|   |   |                                         |                |   |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   | R |                                         |                | R |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   |   |                                         |                |   |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   | T |                                         |                | T |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   |   |                                         |                |   |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
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|   | * |                                         |                | * |   |
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+---+---+-----------------------------------------+----------------+---+---+
| > |   |                                         | **You pay**    |   |   |
|   |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
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+---+---+-----------------------------------------+----------------+---+---+
| # |   |                                         | ###            |   |   |
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+---+---+-----------------------------------------+----------------+---+---+
| - |   |                                         | > \$10 per     |   |   |
|   |   |                                         | > office visit |   |   |
|   |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
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| . |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+

> *Mental health and substance abuse benefits - Continued on next page*

+----------------------------------------------+-----------------------+
| ### **Mental health a                        | ### **You pay**       |
| nd substance abuse benefits** *(Continued)*  |                       |
+----------------------------------------------+-----------------------+
| -   Diagnostic tests                         | > \$10 per office     |
|                                              | > visit or test       |
+----------------------------------------------+-----------------------+
| -   Individual and group therapy for the     | > Nothing             |
|     treatment of\                            |                       |
|     smoking cessation                        |                       |
+----------------------------------------------+-----------------------+
| -   Services provided by a hospital or other | > Nothing on          |
|     facility                                 | > inpatient basis;\   |
|                                              | > \$10 per visit for  |
| -   Services that have been preauthorized    | > outpatient          |
|     for alternative care settings such as    |                       |
|     partial hospitalization, half-way house, |                       |
|     residential treatment, full-day          |                       |
|     hospitalization, facility based          |                       |
|     intensive outpatient treatment           |                       |
+----------------------------------------------+-----------------------+
| > **Preauthorization** If you think you have |                       |
| > a mental health or substance abuse         |                       |
| > problem, we encourage you to see your      |                       |
| > primary care physician. If you do not wish |                       |
| > to go through your primary care physician, |                       |
| > you may choose to receive care from        |                       |
| > another network provider without a         |                       |
| > referral.\                                 |                       |
| > \                                          |                       |
| > Inpatient, intensive outpatient, partial   |                       |
| > hospitalization, residential treatment and |                       |
| > certain outpatient treatment for mental    |                       |
| > health and substance abuse require         |                       |
| > precertification. Your network provider is |                       |
| > responsible for contacting us to obtain    |                       |
| > precertification.\                         |                       |
| > \                                          |                       |
| > Outpatient benefits include up to 2 visits |                       |
| > per calendar year to diagnose or assess a  |                       |
| > mental health condition, in or out of      |                       |
| > network, without authorization.            |                       |
+----------------------------------------------+-----------------------+

+-----+---+--------------------------------------------------+---+----+
| #   |   |                                                  |   |    |
| ### |   |                                                  |   |    |
| ### |   |                                                  |   |    |
|  Se |   |                                                  |   |    |
| cti |   |                                                  |   |    |
| on  |   |                                                  |   |    |
| 5 ( |   |                                                  |   |    |
| f). |   |                                                  |   |    |
|  Pr |   |                                                  |   |    |
| esc |   |                                                  |   |    |
| rip |   |                                                  |   |    |
| tio |   |                                                  |   |    |
| n d |   |                                                  |   |    |
| rug |   |                                                  |   |    |
|  be |   |                                                  |   |    |
| nef |   |                                                  |   |    |
| its |   |                                                  |   |    |
+-----+---+--------------------------------------------------+---+----+
|     | * | **Here are some important things to keep in mind | * |    |
|     | * | about these benefits:**                          | * |    |
|     | I |                                                  | I |    |
|     | * | -   We cover prescribed drugs and medications,   | * |    |
|     | * |     as described in the chart beginning on the   | * |    |
|     |   |     next page.                                   |   |    |
|     | * |                                                  | * |    |
|     | * | -   All benefits are subject to the definitions, | * |    |
|     | M |     limitations and exclusions in this brochure  | M |    |
|     | * |     and are payable only when we determine they  | * |    |
|     | * |     are medically necessary.                     | * |    |
|     |   |                                                  |   |    |
|     | * | -   Some prescription drugs are covered only if  | * |    |
|     | * |     your physician obtains prior authorization   | * |    |
|     | P |     from us. In addition, coverage for some      | P |    |
|     | * |     drugs is provided in limited quantities.     | * |    |
|     | * |                                                  | * |    |
|     |   | ```{=html}                                       |   |    |
|     | * | <!-- -->                                         | * |    |
|     | * | ```                                              | * |    |
|     | O | -   Be sure to read Section 4, *Your costs for   | O |    |
|     | * |     covered services,* for valuable information  | * |    |
|     | * |     about how cost sharing works. Also read      | * |    |
|     |   |     Section 9 about coordinating benefits with   |   |    |
|     | * |     other coverage, including with Medicare.     | * |    |
|     | * |                                                  | * |    |
|     | R |                                                  | R |    |
|     | * |                                                  | * |    |
|     | * |                                                  | * |    |
|     |   |                                                  |   |    |
|     | * |                                                  | * |    |
|     | * |                                                  | * |    |
|     | T |                                                  | T |    |
|     | * |                                                  | * |    |
|     | * |                                                  | * |    |
|     |   |                                                  |   |    |
|     | * |                                                  | * |    |
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|     | n |                                                  |   |    |
|     |   |                                                  |   |    |
|     |   |                                                  |   |    |
|     |   |                                                  |   |    |
|     |   |                                                  |   |    |
|     | 7 |                                                  |   |    |
|     | . |                                                  |   |    |
+-----+---+--------------------------------------------------+---+----+

*Prescription drug benefits begin on the next page.*

+---------------------------------------------+------------------------+
| > **Benefit Description**                   | **You pay**            |
+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      |                        |
+---------------------------------------------+------------------------+
| > We cover the following medications and    | > Retail (up to a      |
| > supplies prescribed by a Plan physician   | > 30-day supply)\      |
| > and obtained from a Plan pharmacy or      | > \$7 generic\         |
| > through our mail order and online         | > \$12 preferred       |
| > program:                                  | > brand\               |
|                                             | > \$25 nonpreferred    |
| -   Drugs and medicines that by Federal law | > brand                |
|     of the United States require a          | >                      |
|     physician's prescription for their      | > Mail order and       |
|     purchase, except those listed as *Not   | > online (up to a      |
|     covered*.                               | > 90-day supply)\      |
|                                             | > \$14 generic\        |
| -   Drugs that under state law are          | > \$24 preferred       |
|     dispensed only with a written           | > brand\               |
|     prescription from a physician or other  | > \$50 nonpreferred    |
|     lawful provider.                        | > brand                |
|                                             | >                      |
| -   Insulin                                 | > Note: If there is no |
|                                             | > generic equivalent   |
| -   Disposable needles and syringes for the | > available, you will  |
|     administration of covered medications,  | > still have to pay    |
|     including insulin                       | > the brand-name       |
|                                             | > copay.               |
| -   Drugs for sexual dysfunction (See       |                        |
|     Limited Drug Benefits below)            |                        |
|                                             |                        |
| -   FDA-approved prescription drugs and     |                        |
|     devices for birth control               |                        |
|                                             |                        |
| -   Diabetic test strips, lancets           |                        |
|                                             |                        |
| -   FDA-approved medications for the        |                        |
|     treatment of tobacco use                |                        |
|                                             |                        |
| > **Please note:**                          |                        |
|                                             |                        |
| -   Most prescriptions are limited to a     |                        |
|     30-day supply each time the             |                        |
|     prescription is filled.                 |                        |
|                                             |                        |
| -   Refills your doctor authorizes are      |                        |
|     covered for up to 12 months from the    |                        |
|     original prescription date. Then a new  |                        |
|     prescription is required.               |                        |
|                                             |                        |
| -   Some prescription drugs are covered     |                        |
|     only if your physician obtains prior    |                        |
|     authorization from us. In addition,     |                        |
|     coverage for some drugs is provided in  |                        |
|     limited quantities.                     |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Intravenous fluids and medication for   |                        |
|     home use are provided under home health |                        |
|     services at no charge; and some         |                        |
|     injectable drugs are covered under      |                        |
|     Medical and Surgical Benefits.          |                        |
|                                             |                        |
| > **Limited Drug Benefits**                 |                        |
| >                                           |                        |
| > Prescription benefits for the treatment   |                        |
| > of sexual dysfunction will only be        |                        |
| > available with prior authorization where  |                        |
| > sexual dysfunction is secondary to a      |                        |
| > medical condition and the medical history |                        |
| > and work-up is documented. You must       |                        |
| > receive prior authorization before        |                        |
| > receiving any prescription for the        |                        |
| > treatment of sexual dysfunction. If       |                        |
| > approved, four prescribed treatments per  |                        |
| > month will be available and subject to    |                        |
| > the nonpreferred brand-name copayment.    |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      | > **You pay**          |
| > *(continued)*                             |                        |
+---------------------------------------------+------------------------+
| GenericSelect^SM^ Drugs covered are:        | The first prescription |
|                                             | is filled free at a    |
| -   **Fluoxetine\*** - for the common FDA   | network pharmacy.      |
|     indications for depression\             | Subsequent refills can |
|     *Equivalent Brand Name Drug*: Prozac\   | be obtained at the     |
|     *Other Brand Name Drugs with Similar    | generic copay.         |
|     FDA Indications:* Zoloft\*, Paxil\*,    |                        |
|     Celexa\*                                |                        |
|                                             |                        |
| -   **Lovastatin\*** - for the common FDA   |                        |
|     indications for High Cholesterol\       |                        |
|     *Equivalent Brand Name Drug*: Mevacor\  |                        |
|     *Other Brand Name Drugs with Similar    |                        |
|     FDA Indications:* Lipitor\*,            |                        |
|     Pravachol\*, Zocor, Lescol              |                        |
|                                             |                        |
| -   **Ranitidine Tablets\*** - for the      |                        |
|     common FDA indications for Acid Reflux\ |                        |
|     *Equivalent Brand Name Drug*: Zantac    |                        |
|     Tablets\                                |                        |
|     *Other Brand Name Drugs with Similar    |                        |
|     FDA Indications:* Prevacid\*,           |                        |
|     AcipHex\*, Nexium, Protonix, Prilosec   |                        |
|                                             |                        |
| -   **Lisinopril**\* - for the common FDA   |                        |
|     indications for High Blood Pressure\    |                        |
|     *Equivalent Brand Name Drug*: Zestril / |                        |
|     Prinivil\                               |                        |
|     *Other Brand Name Drugs with Similar    |                        |
|     FDA Indications:* Diovan\*, Cozaar\*,   |                        |
|     Avapro, Atacand, Norvasc\*              |                        |
|                                             |                        |
| -   **Atenolol**\* - for the common FDA     |                        |
|     indications for High Blood Pressure\    |                        |
|     *Equivalent Brand Name Drug*: Tenormin  |                        |
|                                             |                        |
| -   **Metoprolol**\* - for the common FDA   |                        |
|     indications for High Blood Pressure\    |                        |
|     *Equivalent Brand Name Drug*: Lopressor |                        |
|                                             |                        |
| -   **Hydrochlorothiazide**\* - for the     |                        |
|     common FDA indications for High Blood   |                        |
|     Pressure\                               |                        |
|     *Equivalent Brand Name Drug*: Hygroton  |                        |
|                                             |                        |
| -   **Chlorthalidone**\* - for the common   |                        |
|     FDA indications for High Blood          |                        |
|     Pressure\                               |                        |
|     *Equivalent Brand Name Drug*: Oretic    |                        |
|                                             |                        |
| -   **Metformin**\* - for the common FDA    |                        |
|     indications for Diabetes\               |                        |
|     *Equivalent Brand Name Drug*:           |                        |
|     Glucophage\                             |                        |
|     *Other Brand Name Drugs with Similar    |                        |
|     FDA Indications:* Actos\*, Avandia\*    |                        |
|                                             |                        |
| -   **Ibuprofen**\* - for the common FDA    |                        |
|     indications for Arthritis Pain\         |                        |
|     *Equivalent Brand Name Drug*: Motrin\   |                        |
|     *Other Brand Name Drugs with Similar    |                        |
|     FDA Indications:* Celebrex\*^†^,        |                        |
|     Vioxx\*^†^, Bextra                      |                        |
|                                             |                        |
| -   **Naproxen**\* - for the common FDA     |                        |
|     indications for Arthritis Pain\         |                        |
|     *Equivalent Brand Name Drug*: Naprosyn\ |                        |
|     *Other Brand Name Drugs with Similar    |                        |
|     FDA Indications:* Celebrex\*^†^,        |                        |
|     Vioxx\*^†^, Bextra                      |                        |
|                                             |                        |
| \*Formulary (preferred brand) drug          |                        |
|                                             |                        |
| † Requires Prior Authorization              |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      | > **You pay**          |
| > *(continued)*                             |                        |
+---------------------------------------------+------------------------+
| > Here are some things to keep in mind      |                        |
| > about our prescription drug program:      |                        |
|                                             |                        |
| -   A generic equivalent will be dispensed  |                        |
|     if it is available, unless your         |                        |
|     physician specifically requires a name  |                        |
|     brand. If you receive a name-brand drug |                        |
|     when a Federally approved generic drug  |                        |
|     is available, *whether or not your      |                        |
|     physician has specified Dispense as     |                        |
|     Written* for the name-brand drug, you   |                        |
|     have to pay the difference in cost      |                        |
|     between the name-brand drug and the     |                        |
|     generic, unless your physician has      |                        |
|     obtained prior authorization for the    |                        |
|     brand-name drug.                        |                        |
|                                             |                        |
| -   We have an incentive-based, three-tier  |                        |
|     formulary. If your physician believes a |                        |
|     name-brand product is necessary or      |                        |
|     there is no generic available, your     |                        |
|     physician may prescribe a name-brand    |                        |
|     drug from a formulary list. This list   |                        |
|     of name-brand drugs is a preferred list |                        |
|     of drugs that we selected to meet       |                        |
|     patient needs at a lower cost. We       |                        |
|     update our formulary throughout the     |                        |
|     year. To obtain the most current        |                        |
|     information, please check our Web site  |                        |
|     listed below. To order a copy of our    |                        |
|     Preferred Drug List, please call Client |                        |
|     Services at 1-800-932-4480 or visit our |                        |
|     Web site at                             |                        |
|                                             |                        |
|   [www.bcbsmo.com](http://www.bcbsmo.com/). |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All Charges*        |
|                                             |                        |
| -   *Drugs for which there is a             |                        |
|     nonprescription equivalent available*   |                        |
|                                             |                        |
| -   *Drugs obtained at a non-Plan pharmacy  |                        |
|     (except out-of-area emergencies)*       |                        |
|                                             |                        |
| -   *Vitamins and nutritional substances    |                        |
|     that can be purchased without a         |                        |
|     prescription*                           |                        |
|                                             |                        |
| -   *Medical equipment, devices and         |                        |
|     supplies such as dressings and          |                        |
|     antiseptics*                            |                        |
|                                             |                        |
| -   *Drugs for cosmetic purposes*           |                        |
|                                             |                        |
| -   *Drugs to enhance athletic performance* |                        |
|                                             |                        |
| -   *Test agents and devices*               |                        |
|                                             |                        |
| -   *Appetite suppressants and other drugs  |                        |
|     for weight loss*                        |                        |
|                                             |                        |
| -   *Nonprescription medicines*             |                        |
|                                             |                        |
| -   *Replacement drugs due to loss or       |                        |
|     theft*                                  |                        |
|                                             |                        |
| -   *Travel (except for emergencies)*       |                        |
|                                             |                        |
| -   *Special packaging for drugs in nursing |                        |
|     homes*                                  |                        |
+---------------------------------------------+------------------------+

+----------------------+-----------------------------------------------+
| > Section 5 (g).     |                                               |
| > Special features   |                                               |
+======================+===============================================+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| > **Flexible         | Under the flexible benefits option, we        |
| > Benefits Option**  | determine the most effective way to provide   |
|                      | services.                                     |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| > **Services for     | > For the hearing impaired (TDD), call        |
| > deaf and hearing   | > 1-800-822-1215.                             |
| > impaired**         |                                               |
+----------------------+-----------------------------------------------+
| > **Away From Home   | > Through our BlueCard program, BlueCHOICE   |
| > Care\              | > offers its members medical care in          |
| > **                 | > emergency and urgent situations when        |
|                      | > traveling outside the service area.\        |
|                      | > \                                           |
|                      | > Also, members who are traveling for an      |
|                      | > extended time or who are on an extended     |
|                      | > work assignment in another city may be      |
|                      | > eligible to apply for a Guest Membership in |
|                      | > a local Blue Cross and Blue Shield HMO. The |
|                      | > Guest Membership also temporarily covers    |
|                      | > dependent children who are away at school   |
|                      | > or living in another city. For more         |
|                      | > information, see Section 1, page 10, or     |
|                      | > members can call Customer Service at the    |
|                      | > number listed on the back of their ID card. |
+----------------------+-----------------------------------------------+
| > **Blue Quality**   | > National Transplant Program (NTP): We are a |
|                      | > member of the Blue Quality Centers for      |
|                      | > Transplants.                                |
+----------------------+-----------------------------------------------+
| > **RightSteps^^\   | > This is a voluntary program that strives to |
| > **                 | > help mothers-to-be avoid potential problems |
|                      | > during pregnancy. Pregnant women who choose |
|                      | > to participate are asked to complete a      |
|                      | > questionnaire within 20 weeks of becoming   |
|                      | > pregnant. An obstetrical registered nurse   |
|                      | > will then contact the member periodically   |
|                      | > to provide information on pregnancy and     |
|                      | > childbirth. We encourage the member to have |
|                      | > early, regular prenatal care and to pay     |
|                      | > attention to her lifestyle behaviors.       |
|                      | > Mothers-to-be who participate in the        |
|                      | > program will also receive a nationally      |
|                      | > recognized book on pregnancy, childbirth    |
|                      | > and infant care; up to a \$40 reimbursement |
|                      | > for the cost of a childbirth or parenting   |
|                      | > class; and a gift from us after the baby    |
|                      | > arrives.                                    |
+----------------------+-----------------------------------------------+
| > **TakeCharge^^    | > Our goal is to help our members who have    |
| > Asthma Program**   | > asthma manage their disease more            |
|                      | > successfully. Working with the patient's    |
|                      | > physician, we provide case management       |
|                      | > services to severe asthmatics through       |
|                      | > frequent phone calls, individual care       |
|                      | > plans, home health visits (as approved by   |
|                      | > the patient's doctor), durable medical      |
|                      | > equipment benefits and asthma educational   |
|                      | > material. Adults and children with mild or  |
|                      | > moderate asthma receive asthma educational  |
|                      | > materials as requested.                     |
+----------------------+-----------------------------------------------+
| > **TakeCharge^^    | > This comprehensive care and disease         |
| > Diabetes Program** | > management program is designed to support   |
|                      | > the health care needs of people with        |
|                      | > diabetes. The program is a complimentary,   |
|                      | > value-added service offered to members with |
|                      | > diabetes to reinforce the diabetes          |
|                      | > treatment plan that has been designed by    |
|                      | > each member's physician. The member's       |
|                      | > doctor and other members of the diabetes    |
|                      | > management team also receive information    |
|                      | > about the program. This program provides    |
|                      | > newsletters, reminder cards and other       |
|                      | > important educational health information to |
|                      | > members with diabetes throughout the year.  |
+----------------------+-----------------------------------------------+
| > **TakeCharge^^    | > Members with congestive heart failure who   |
| > Congestive Heart   | > enroll in the program will receive          |
| > Failure Program**  | > information on how to manage their          |
|                      | > condition. A team of health coaches         |
|                      | > routinely follows members at high risk.     |
|                      | > Those at low risk will receive preventive   |
|                      | > health reminder mailings and educational    |
|                      | > newsletters.                                |
+----------------------+-----------------------------------------------+
| > **Postpartum       | > The purpose of the program is to help       |
| > Depression         | > members and their physicians in the early   |
| > Screening          | > identification of postpartum depression so  |
| > Program**          | > that the member can get appropriate         |
|                      | > referral and treatment. We send each member |
|                      | > a copy of a postpartum depression brochure  |
|                      | > after delivery, along with the Edinburgh    |
|                      | > Depression Scale and a return envelope.     |
+----------------------+-----------------------------------------------+
| Note: Special        |                                               |
| programs such as     |                                               |
| *RightSteps,        |                                               |
| TakeCharge Asthma   |                                               |
| Program, TakeCharge |                                               |
| Diabetes Program,,   |                                               |
| TakeCharge          |                                               |
| Congestive Heart     |                                               |
| Failure Program, and |                                               |
| the* *Postpartum     |                                               |
| Depression Screening |                                               |
| Program* are special |                                               |
| programs that are    |                                               |
| available to members |                                               |
| who have primary     |                                               |
| health coverage      |                                               |
| through BlueCHOICE.  |                                               |
+----------------------+-----------------------------------------------+

+-----------------------------------------------------------------------+
| > Section 5 (h). Dental benefits                                      |
+=======================================================================+
| ### **No Dental Benefits**                                            |
+-----------------------------------------------------------------------+

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

The benefits on this page are not part of the FEHB contract or premium,
**and you cannot file an FEHB disputed claim about them**. Fees you pay
for these services do not count toward the FEHB out-of-pocket maximum.
Your medical program copay does not apply to these services. You must
pay for the services or supplies when you receive them.

**Wellness and Education Programs**

**Eat Smart:** Learn to eat right and control your weight. You'll get
\$75 if you achieve your weight loss goal through a participating
facility.

**Breathe Easy:** Smoking cessation classes offered in cooperation with
local health care providers teach you some helpful tips for kicking the
habit. Earn \$50 for regular class attendance and for quitting smoking.

**Physical Fitness:** If you are 18 or older, we will reimburse you 25%
(up to \$100) for a single membership and 50% of annual dues (up to
\$200) for a family membership at the health club of your choice.

**Discounted Services**

**Hearing Aids:** Free hearing evaluations and savings on hearing aids
are available through Hometown Hearing and Audiology providers
(314-962-1200) and Southwestern Hearing Aid Centers' providers
(1-800-272-1101).

**Vision Care:** BlueCHOICE members may receive discounts on eye exams,
lenses and frames by showing their ID card at a participating vision
center. Members also can receive discounts off the regular retail price
for all eye care accessories, including contact lens solutions and
non-prescription sunglasses. Members can obtain discounted eye wear and
eye care services through Crown Optical (1-800-475-6320) and Unity
Health Eye Care network (314-729-4610), and discounts on contact lenses
from TruVision (1-866-487-2020).

Savings on LASIK surgery are available to members through Crown Optical.
For more information, contact Crown at 1-800-232-4526. TruVision also
offers savings to members for LASIK surgery. Additional information can
be obtained by calling 1-866-487-2020.

Note: Members can no longer obtain discounts through Access Eye Care or
Accent Hearing networks.

**Alternative Health Programs through American Specialty Health
Networks:** BlueCHOICE provides access to an alternative health care
discount program through American Specialty Health Networks (ASHN).
BlueCHOICE members can pay discounted fees when they see chiropractors,
acupuncturists and massage therapists in ASHN's credentialed network.
Members receive ASHN's toll-free telephone number to request provider
directories and program brochures when they enroll.

In addition, members can access ASHN's national network of fitness clubs
at the clubs' lowest membership rates. Additionally, members can try the
fitness facilities at no charge for one full week.

Additional discounts are available for everything from educational
videos to herbal supplements ordered through the Internet. Just go to
**[www.bcbsmo.com]{.underline}** for additional information.

**Dental Services**

For an additional premium, you may choose dental coverage with one of
our *DentaBlue* plans, *DentaBlue Individual*, for individuals and
families, or *DentaBlue Senior*, for individuals age 65 and older.
*DentaBlue* uses a select network of local dentists and, in addition,
provides access to a nationwide network of approximately 33,000
dentists. This means that you will be able to receive the higher network
level of benefits should you need dental care when outside the Missouri
service area. Members are also free to receive care from non-network
dentists. The level of network and non-network benefits depends on the
plan you select. As a *DentaBlue* member, you will get the added
advantage of the OrthoBlue orthodontic discount program. For more
information, call 1-888-800-7830.

*Note: We may receive payments from the providers of these discount
programs to cover administrative and related costs associated with
offering the programs and services to members. We do not select or
recommend providers for the discount programs and do not recommend or
prescribe the services or treatments provided. We encourage members to
consult with their physician about any of these services or products.*

+-----------------------------------------------------------------------+
| > 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.**
>
> 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 the 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;

-   Investigational or Experimental Care, except reasonable and
    medically necessary drugs, devices, medical treatments, procedures
    or other technology included as part of a Phase III or IV clinical
    trial undertaken to treat cancer. The clinical trial must be
    underwritten by a National Institute of Health Cooperative or an
    equivalent entity. Covered items do not include: the investigational
    item or service itself; items and services used only for data
    collection, not for clinical management of the patient; or items and
    services customarily provided by research sponsors at no charge.

-   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, drugs, or supplies you receive from immediate relatives or
    household members, such as spouse, parent, child, brother or sister,
    by blood, marriage or adoption.

-   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.

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

**Medical and hospital 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
1-800-932-4480.

> *How to file a claim:*

-   You can obtain claim forms by calling Client Services at
    1-800-932-4480. The back of the claim form has complete filing
    instructions.

```{=html}
<!-- -->
```
-   You can use the same claim form to file a claim for all your health
    care benefits, except for prescription drugs.

-   You may submit claims for more than one person in the same envelope.
    *However, you must submit a separate claim form for each person.*
    Attach each person's bill to the correct form.

-   Complete the claim form fully and accurately. You must check "yes"
    or "no" for each question. If you do not answer a question, we may
    have to return your claim to you. This is also true if you do not
    provide additional information required.

-   When you write in your identification number on the claim form, be
    sure to include the first three digits.

-   We can only accept itemized bills. Each bill must show: the name of
    the patient; the name and address of the provider of care; a
    description of each service and the date provided; a diagnosis; and
    the charge for each service.

-   Canceled checks and nonitemized bills that show only "balance due"
    or "for professional services rendered" are not sufficient.

-   Include all bills for covered services not previously submitted.

-   If you have paid the provider, mark each bill "paid."

-   In some cases, we will pay you directly for covered services. In
    other cases, we will pay the provider.

-   Please keep copies of the completed claim form and itemized bills.

-   Send your claims to the address shown on the form.

    **Prescription drugs** Major chains and independent pharmacies
    belong to your pharmacy network. At these pharmacies, if you show
    your BlueCHOICE ID card, you should only be responsible for paying
    your share of the cost. The pharmacy should file your claim, and we
    will pay the pharmacy directly*.\
    \
    ***At a Non-Network Pharmacy:** If you go to a non-network pharmacy
    in an urgent or emergency situation outside the BlueCHOICE service
    area, you are responsible for paying for your prescription at the
    time of service and then filing a claim. Your program will not
    provide benefits if you use a non-network pharmacy within the
    BlueCHOICE service area.\
    \
    You can obtain a Prescription Drug Claim Form by calling Client
    Services at 1-800-932-4480.\
    \
    You can file up to three prescriptions on each form. *Please do not
    use a regular health benefits claim form to file your prescription
    drug claim.* If you do, your claim may be denied.

```{=html}
<!-- -->
```
-   Please fill out a separate claim form for each person and pharmacy.

-   Be sure to provide all the information requested for each
    prescription. You may need to have the pharmacy complete the form or
    get the information from the pharmacy.

-   Then you or the pharmacist should fill out the pharmacy's name,
    address and National Association of Board of Pharmacy (NABP) number.

-   On the completed form, *tape* your *original* itemized prescription
    drug receipt(s). Please do not send cash register receipts, canceled
    checks, bottle labels, copies of the original prescription drug
    receipts, or your own itemization of charges.

-   The receipt(s) must show: the prescription number, the patient's
    name, the name of the drug, the quantity and unit dose, and the
    strength of the drug.

-   Sign the claim form. Then mail it and your receipt(s) to the address
    shown on the form.

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

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

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

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

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

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | > \(a\) Write to us within six months from the date of our       |
| * | > decision; and\                                                 |
| * | > (b) Send your request to us at: BlueCHOICE Grievance Unit\     |
|   | > P.O. Box 66828\                                                |
|   | > St. Louis, MO 63166-6828\                                      |
|   | > (c) Include a statement about why you believe our initial      |
|   | > decision was wrong, based on specific benefit provisions in    |
|   | > this brochure; and\                                            |
|   | > (d) Include copies of documents that support your claim, such  |
|   | > as physicians' letters, operative reports, bills,\             |
|   | > medical records, and explanation of benefits (EOB) forms.      |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:\       |
| * | \                                                                |
| 2 | (a) Pay the claim (or, if applicable, arrange for the health     |
| * | care provider to give you the care); or\                         |
| * | (b) Write to you and maintain our denial \-- go to step 4; or\   |
|   | (c) Ask you or your provider for more information. If we ask     |
|   | your provider, we will send you a copy of our request \-- go to  |
|   | step 3.                                                          |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.\                                            |
| * | \                                                                |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.\      |
|   | \                                                                |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us \-- if we did not       |
|   |     answer that request in some way within 30 days; or           |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: United States Office of Personnel Management,   |
|   | Insurance Services Program, Health Insurance Group 2, 1900 E     |
|   | Street, NW, Washington, DC 20415-3620.                           |
+---+------------------------------------------------------------------+
|   | 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;            |
|   |                                                                  |
|   | -   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.           |
+---+------------------------------------------------------------------+
|   | The Disputed Claims process *(Continued)*                        |
|   |                                                                  |
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must include a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | If you do not agree with OPM's decision, your only recourse is   |
|   | to sue. If you decide to sue, you must file the suit against OPM |
|   | in Federal court by December 31 of the third year after the year |
|   | in which you received the disputed services, drugs or supplies   |
|   | or from the year in which you were denied precertification or    |
|   | prior approval. This is the only deadline that may not be        |
|   | extended.                                                        |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support its 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 1-800-932-4480 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 it can give your claim expedited treatment too, or

```{=html}
<!-- -->
```
-   **You may call the OPM's Health Insurance Group 2 at 202-606-3818
    between 8 a.m. and 5 p.m. Eastern time.**

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

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

> 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. All programs together will not pay more than 100%
of allowable expenses. The allowable expense is the maximum amount that
a plan will pay for covered services. We will not pay more than our
allowance.

Medicare is a Health Insurance Program for:

-   People 65 years of age and older.

```{=html}
<!-- -->
```
-   Some people with disabilities, under 65 years of age.

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

> The decision to enroll in Medicare is yours. We 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 in the

**(Part A or Part B)** 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 by your Plan PCP and you
will still be responsible for the Plan's copayments.*

**•Filing a claim** *When this Plan is primary* and you have a claim for
covered services that you must file yourself, please follow the claim
filing instruction in Section 7.

Once you receive an Explanation of Benefits (EOB) from us, then file a
claim for your Medicare benefits. *(For information on filing a Medicare
claim, contact your Social Security office.) When Original Medicare is
primary* you must submit your claims to Medicare first. The federal
government requires most health care providers and suppliers to file
your Medicare claims for you. So in most cases, you shouldn't need to
file a claim to obtain your Medicare benefits.

Also, in most cases, *you* shouldn't need to file to receive the
benefits of *this* program. If the services or supplies are covered by
Medicare, the Medicare carrier will usually forward your medical claim
to us. Then we will provide the benefits of this program automatically
in most cases.

You should *not* submit a claim for benefits of this program if your
Medicare Summary Notice (MSN) states, in part: "This information is
being sent to your private insurer." This note means that the Medicare
carrier is submitting your claim to us. Then we can provide the benefits
of this program. If this note is on your MSN, please do *not* submit a
claim to us. Also, please let your providers of care know that they
should *not* submit your claim to us. When we receive duplicate claims,
this increases costs.

Your MSN may not indicate that your claim has been referred to
supplemental claims processing. In that case, you should file your own
claim.

•**To file your own claim** To file, send us a copy of your MSN. Include
a completed claim form and copies of your itemized bills. Send the
information to the address shown on the claim form.

You should also file a claim if you receive services or supplies that
are not covered by Medicare but are covered by this program. Send a
completed claim form and copies of your itemized bills to us.

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

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

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

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

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

•**Medicare + 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 + Choice plan, the following options are
available to you:

**This Plan and another plan's Medicare + Choice plan:** You may enroll
in another plan's Medicare + Choice plan and also remain enrolled in our
FEHB plan. We will still provide benefits when your Medicare + Choice
plan is primary, even out of the Medicare + Choice plan's network and/or
service area (if you use our Plan providers), but **you will still be
responsible for** copayments**.** 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 & CHAMPVA** TRICARE is the health care program for eligible
dependents of military persons and retirees of the military. TRICARE
includes the CHAMPUS program. CHAMPVA provides health coverage to
disabled Veterans and their dependents. If both 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 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. If you need more information, contact us for our
subrogation procedures.

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

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

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

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

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

**Custodial care** Services that do not seek to cure, but are provided
primarily for the convenience of the patient or his or her family, the
maintenance of the patient, or to assist the patient in meeting his or
her activities of daily living, rather than primarily for therapeutic
value in the treatment of a Condition. Custodial care includes, but is
not limited to, help in walking, bathing, dressing, eating, preparation
of special diets, supervision over self-administration of medications
not requiring constant attention of trained medical personnel, or acting
as a companion or sitter. Custodial care that lasts 90 days or more is
sometimes known as Long term care.

*Note: BlueCHOICE will have the sole discretion to determine whether
care is Custodial care. BlueCHOICE may consult with professional peer
review committees or other appropriate sources for recommendations.*

**Experimental or\
investigational services** A drug, device or biological product is
experimental or investigational if the drug, device, or biological
product cannot be lawfully marketed without approval of the U.S. Food
and Drug Administration (FDA) and approval for marketing has not been
given at the time it is furnished. Approval means all forms of
acceptance by the FDA.

An FDA-approved drug, device or biological product (for use other than
its intended purpose and labeled indications), or medical treatment or
procedure is experimental or investigational if

1\) reliable evidence shows that it is the subject of ongoing phase I,
II or III clinical trials or under study to determine its maximum
tolerated dose, its toxicity, its safety, or

2\) reliable evidence shows that the consensus of opinion among experts
regarding the drug, device, or biological product or medical treatment
or procedure is that further studies or clinical trials are necessary to
determine its maximum tolerated dose, its toxicity, its safety, its
efficacy, or its efficacy as compared with the standard means of
treatment or diagnosis.

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

FDA-approved drugs, devices, or biological products used for their
intended purpose and labeled indication and those that have received FDA
approval subject to postmarketing approval clinical trials, and devices
classified by the FDA as "Category B Non-experimental/Investigational
Devices" are not considered experimental or investigational.

**Group health coverage** A health benefit plan that is offered to
employees through their place of employment or to the membership of a
sponsoring organization such as a union or association.

**Medical necessity** We only cover care that is medically necessary.
But we do not cover all medically necessary care. Even if the type of
care is covered in general, the care is not covered if we determine it
was not medically necessary in a specific case. BlueCHOICE must agree
that care was medically necessary.

However, in some cases, you will not have to pay for care that was not
medically necessary. In these cases, the provider is responsible. You do
not need to pay if *all* of the following are true:

-   You obtained the proper referral for the care.

-   BlueCHOICE did not notify you in advance that the care was not
    medically necessary.

-   The services would have been covered if they were medically
    necessary.

> To be medically necessary, care must be provided to diagnose or treat
> a condition. Also, the type and level of care must be necessary and
> appropriate. We use current standards of medical practice to decide
> necessity and appropriateness. The type and level of care must not be
> more than what is necessary.\
> \
> For example, surgery may not be medically necessary for your condition
> if your provider has not tried more conservative treatment. Also,
> inpatient care is not medically necessary if appropriate care is
> available on an outpatient basis.

**Plan allowance** The maximum amount we will pay for covered services.

**Us/We** Us and we refer to BlueCHOICE.

**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,

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

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

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

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

**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

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

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

**•Spouse equity** 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 Web site,
[www.opm.gov/insure](http://www.opm.gov/insure).

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

**of coverage (TCC)** longer qualify as a family member, you may be
eligible for Temporary Continuation of Coverage (TCC). For example, you
can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your 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 conversion
policy if:

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

> • You decided not to receive coverage under TCC or the spouse equity
> law; or
>
> • You are not eligible for coverage under TCC or the spouse equity
> law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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-   **Enroll during Open Season** You **must make an election** to
    enroll in an FSA during the FEHB Open Season. Even if you enrolled
    during the initial Open Season for 2003, you must make a new
    election to continue participating in 2004. Enrollment is easy!

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-   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

**contribute to my FSA?** the tax benefits of an FSA, the IRS places
strict guidelines on them. You need to estimate how much you want to
allocate to an FSA because current IRS regulations require you forfeit
any funds remaining in your account(s) at the end of the FSA plan year.
This is referred to as the "use-it-or-lose-it" rule. You will have until
April 29, 2004 to submit claims for your eligible expenses incurred
during 2003 if you enrolled in FSAFEDS when it was initially offered.
You will have until April 30, 2005 to submit claims for your eligible
expenses incurred from January 1 through December 31, 2004 if you elect
FSAFEDS during this Open Season.

> The **FSAFEDS Calculator** at
> [www.fsafeds.com](http://www.fsafeds.com/) will help you plan your FSA
> allocations and provide an estimate of your tax savings based on your
> individual situation.
>
> Every FEHB health plan includes cost sharing features, such as
> deductibles you must meet before the Plan provides benefits,
> coinsurance or copayments that you pay when you and the Plan share
> costs, and medical services and supplies that are not covered by the
> Plan and for which you must pay. These out-of-pocket costs are
> summarized on page 72 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: office-visit
> copay, emergency room copay and prescription drug copay.

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.
>
> Probably not. While there is an administrative fee of \$4.00 per month
> for an
>
> FSA 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**llergy tests 21

Alternative treatment 49

Allogenetic (donor) bone marrow transplant 32

Ambulance 34, 36, 39

Anesthesia 29, 31, 33, 35

Autologous bone marrow transplant 22, 32

**B**lood and blood plasma 35

**C**asts 29, 35

Catastrophic protection 15, 73

Changes for 2004 10

Chemotherapy 22, 32

Childbirth 46

Chiropractic 23, 28

Cholesterol tests 18

Claims 12, 16, 51, 53, 54, 56, 54, 63, 67

Coinsurance 15

Colorectal cancer screening 18

Congenital anomalies 29, 30

Contraceptive devices and drugs 20

Coordination of benefits 55

Covered charges 15

Covered providers 9, 41

Crutches 26

**D**eductible 15

Definitions 60, 61

Dental care 48, 49

Diagnostic services 17, 18, 35, 41

Disputed claims review 53, 54

Donor expenses (transplants) 32

Dressings 35

Durable medical equipment (DME) 26, 27, 45

**E**ducational classes and programs 49

Effective date of enrollment 12, 60, 63

Emergency 8, 10, 14, 34, 37, 38, 39

Experimental or investigational 50, 60, 61

Eyeglasses 24

**F**amily planning 20

Fecal occult blood test 18\
Fraud 5, 6

**G**eneral Exclusions 50

**H**earing services 24

Home health services 27

Hospice care 36

Hospital 34, 35, 36, 37

**I**mmunizations 19

Infertility 21

In-hospital physician care 17

Inpatient hospital benefits 34, 35

Insulin 42, 43

**L**aboratory and pathological services 18, 35

**M**agnetic Resonance Imagings (MRIs) 18

Mail order prescription drugs 42, 43

Mammograms 17

Maternity benefits 19, 34

Medicaid 59

Medically necessary 13, 50, 61

Medicare 11, 55, 56, 57, 58

Mental conditions/substance abuse benefits 11, 13, 40, 41

**N**ewborn care 19, 20, 24

Non-FEHB benefits 49

Nurse

Licensed Practical Nurse 27

Registered Nurse 20, 27, 46

Nursery charges 20

**O**bstetrical care 20

Occupational therapy 23

Ocular injury 24

Office visits 17

Oral and maxillofacial surgery 31

Orthopedic devices 25

Ostomy and catheter supplies 26

Out-of-pocket expenses 15

Outpatient facility care 35

Oxygen 26, 27, 35

**P**ap test 18

Physical examination 18, 19

Physical therapy 23

Precertification 14, 37, 41

Preventive care, adult 11, 18, 19

Preventive care, children 19

Prescription drugs 42, 43, 44, 45, 52

Prior approval 14

Prostate cancer screening 18

Prosthetic devices 25

Psychologist 40

**R**adiation therapy 22

Renal dialysis 22

Room and board 34, 36

**S**econd surgical opinion 17

Skilled nursing facility care 33, 36

Smoking cessation 28, 41, 49

Speech therapy 23

Splints 35

Sterilization procedures 20, 21, 30

Subrogation 59

Substance abuse 11, 13, 40, 41

Surgery 29

-   Anesthesia 29, 33, 35

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-   Oral 31

-   Outpatient 35

-   Reconstructive 30

    Syringes 43

    **T**emporary continuation of coverage 63, 64, 65

    Transplants 32, 46

    Treatment therapies 22

    **V**ision services 24

    **W**ell child care 19

    Wheelchairs 27

    Workers' compensation 57, 59

**X**-rays 18, 35

  -----------------------------------------------------------------------
  **Summary of benefits for BlueCHOICE -- 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.

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-   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: \$10        |   |
| -   Diagnostic and treatment services     |                      | 1 |
|     provided in the office                |                      | 7 |
+-------------------------------------------+----------------------+---+
| Services provided by a hospital:          | > Nothing            | > |
|                                           | >                    |   |
| -   Inpatient                             | > Nothing            | 3 |
|                                           |                      | 4 |
| -   Outpatient                            |                      | > |
|                                           |                      | > |
|                                           |                      |   |
|                                           |                      | 3 |
|                                           |                      | 5 |
+-------------------------------------------+----------------------+---+
| Emergency benefits:                       | > \$ 50 per          | > |
|                                           | > emergency room     |   |
| -   In-area                               | > visit              | 3 |
|                                           | >                    | 8 |
| -   Out-of-area                           | > \$ 50 per          | \ |
|                                           | > emergency room     | > |
|                                           | > visit              |   |
|                                           |                      | \ |
|                                           |                      | > |
|                                           |                      |   |
|                                           |                      | 3 |
|                                           |                      | 8 |
+-------------------------------------------+----------------------+---+
| > Mental health and substance abuse       | > Regular cost       | > |
| > treatment                               | > sharing            |   |
|                                           |                      | 4 |
|                                           |                      | 0 |
+-------------------------------------------+----------------------+---+
| Prescription drugs\                       | > \$7 generic\       | > |
| \                                         | > \$12 preferred     |   |
| \                                         | > brand name\        | 4 |
| \                                         | > \$25 nonpreferred  | 2 |
| \                                         | > brand name\        |   |
| Mail order                                | > \                  |   |
|                                           | > \                  |   |
|                                           | > \$14 generic\      |   |
|                                           | > \$24 preferred     |   |
|                                           | > brand name\        |   |
|                                           | > \$50 nonpreferred  |   |
|                                           | > brand name         |   |
+-------------------------------------------+----------------------+---+
| Vision Care                               | > Routine eye exam   | > |
|                                           | > (one per calendar  |   |
|                                           | > year); \$10 per    | 2 |
|                                           | > office visit.      | 4 |
|                                           | > Eyeglasses and     |   |
|                                           | > contact lenses are |   |
|                                           | > reimbursed up to   |   |
|                                           | > \$35 per 24-month  |   |
|                                           | > period when        |   |
|                                           | > received from a    |   |
|                                           | > BlueCHOICE vision  |   |
|                                           | > care provider. In  |   |
|                                           | > addition,          |   |
|                                           | > reduced-cost       |   |
|                                           | > glasses or contact |   |
|                                           | > lenses are         |   |
|                                           | > available from     |   |
|                                           | > selected           |   |
|                                           | > providers.         |   |
+-------------------------------------------+----------------------+---+

+-------------------------------------------+----------------------+---+
| Special features:                         |                      | > |
|                                           |                      |   |
| -   Flexible Benefits Option              |                      | 4 |
|                                           |                      | 6 |
| -   Services for deaf and hearing         |                      |   |
|     impaired                              |                      |   |
|                                           |                      |   |
| -   Away From Home Care                   |                      |   |
|                                           |                      |   |
| -   Blue Quality                          |                      |   |
|                                           |                      |   |
| -   RightSteps^^                         |                      |   |
|                                           |                      |   |
| -   TakeCharge^^ Asthma Program          |                      |   |
|                                           |                      |   |
| -   TakeCharge^^ Diabetes Program        |                      |   |
|                                           |                      |   |
| -   TakeCharge^^ Congestive Heart        |                      |   |
|     Failure Program                       |                      |   |
|                                           |                      |   |
| -   Postpartum Depression Screening       |                      |   |
|     Program                               |                      |   |
+-------------------------------------------+----------------------+---+
| Protection against catastrophic costs     | After you pay 100%   | > |
|                                           | of your annual       |   |
| (your catastrophic protection             | premium in           | 1 |
| out-of-pocket maximum)                    | copayments for one   | 5 |
|                                           | family member (per   |   |
|                                           | person), or 100% of  |   |
|                                           | your annual premium  |   |
|                                           | for two or more      |   |
|                                           | family members (self |   |
|                                           | and family), you do  |   |
|                                           | not have to make any |   |
|                                           | further payments for |   |
|                                           | certain services for |   |
|                                           | the rest of the      |   |
|                                           | year. Some costs do  |   |
|                                           | not count toward     |   |
|                                           | this protection.     |   |
+-------------------------------------------+----------------------+---+

**2004 Rate Information for**

**BlueCHOICE**

**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** |
+--------------+-----+-------+-------+-------+-------+-------+-------+

  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------
  **Self Only**   **9G1**   **\$115.26**   **\$38.42**   **\$249.73**   **\$83.24**    **\$136.39**   **\$17.29**

  **Self and      **9G2**   **\$249.55**   **\$83.18**   **\$540.69**   **\$180.23**   **\$295.30**   **\$37.43**
  Family**                                                                                            
  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------