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Dear Federal Employees Health Benefits Program Participant:

Welcome to the 2005 Open Season! By continuing to introduce pro-consumer
health care ideas, the Office of Personnel Management (OPM) team has
given you greater, cost effective choices. This year several national
and local health plans are offering new options, strengthening the
Federal Employees Health Benefits (FEHB) Program and highlighting once
again its unique and distinctive market-oriented features. I remain firm
in my belief that you, when fully informed as a Federal subscriber, are
in the best position to make the decisions that meet your needs and
those of your family. Plan brochures provide information to help
subscribers make these fully informed decisions. Please take the time to
review the plan's benefits, particularly Section 2, which explains plan
changes.

Exciting new features this year give you additional opportunities to
save and better manage your hard-earned dollars. For 2005, I am very
pleased and enthusiastic about the new High Deductible Health Plans
(HDHP) with a Health Savings Account (HSA) or Health Reimbursement
Arrangement (HRA) component. This combination of health plan and savings
vehicle provides a new opportunity to save and better manage your money.
If an HDHP/HSA is not for you and you are not retired, I encourage you
to consider a Flexible Spending Account (FSA) for health care. FSAs
allow you to reduce your out-of-pocket health care costs by 20 to more
than 40 percent by paying for certain health care expenses with tax-free
dollars, instead of after-tax dollars.

Since prevention remains a major factor in the cost of health care, last
year OPM launched the *HealthierFeds* campaign. Through this effort we
are encouraging Federal team members to take greater responsibility for
living a healthier lifestyle. The positive effect of a healthier life
style brings dividends for you and reduces the demands and costs within
the health care system. This campaign embraces four key "actions" that
can lead to a healthy America: be physically active every day, eat a
nutritious diet, seek out preventative screenings, and make healthy
lifestyle choices. Be sure to visit *HealthierFeds* at
[www.healthierfeds.opm.gov](http://www.healthierfeds.opm.gov/) for more
details on this important initiative. I also encourage you to visit the
Department of Health and Human Services Web site on Wellness and Safety,
[www.hhs.gov/safety/index.shtml](http://www.hhs.gov/safety/index.shtml),
which complements and broadens healthier lifestyle resources. The site
provides extensive information from health care experts and
organizations to support your personal interest in staying healthy.

The FEHB Program offers the Federal team the widest array of
cost-effective health care options and the information needed to make
the best choice for you and your family. You will find comprehensive
health plan information in this brochure, in the 2005 Guide to FEHB
Plans, and on the OPM Web site at
[www.opm.gov/insure](http://www.opm.gov/insure). I hope you find these
resources useful, and thank you once again for your service to the
nation.

> Sincerely,
>
> Kay Coles James
>
> Director

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

**Privacy Practices**

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice,
look at [www.opm.gov/insure](http://www.opm.gov/insure) on the Web. You
may also call 202-606-0745 and ask for OPM's FEHB Program privacy
official for this purpose.

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

Privacy Complaints

Unites States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

Table of Contents

Introduction [4](#introduction)

Plain Language [4](#plain-language)

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

Preventing medical mistakes [6](#preventing-medical-mistakes)

Section 1. Facts about this plan [8](#section-1.-facts-about-this-plan)

Facts about this Plan's High Option
[8](#facts-about-this-plans-high-option)

Facts about this Plan's HDHP option
[8](#facts-about-this-plans-hdhp-option)

We have network providers [8](#we-have-network-providers)

How we pay providers [9](#how-we-pay-providers)

Your Rights [9](#your-rights)

Service Area [9](#service-area)

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

Program-wide changes [10](#program-wide-changes)

Changes to this Plan [10](#changes-to-this-plan)

Section 3. How you get care [11](#section-3.-how-you-get-care)

Identification cards [11](#identification-cards)

Where you get covered care [11](#where-you-get-covered-care)

Plan providers [11](#plan-providers)

Plan facilities [11](#plan-facilities)

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

Primary care [11](#primary-care)

Specialty care [12](#specialty-care)

Hospital care [12](#hospital-care)

Circumstances beyond our control [13](#circumstances-beyond-our-control)

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

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

Copayments [15](#copayments)

Deductible [15](#deductible)

Coinsurance [15](#coinsurance)

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

Differences between our allowance and the bill
[16](#differences-between-our-allowance-and-the-bill)

Section 5.1 HMO Benefits -- OVERVIEW
[17](#section-5.1-hmo-benefits-overview)

Section 5.1(a) Medical services and supplies provided by physicians and
other health care professionals
[20](#section-5.1a-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)

Section 5.1(b) Surgical and anesthesia services provided by physicians
and other health care professionals
[30](#section-5.1b-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)

Section 5.1(c) Services provided by a hospital or other facility, and
ambulance services
[35](#section-5.1c-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

Section 5.1(d) Emergency services/accidents
[38](#section-5.1d-emergency-servicesaccidents)

Section 5.1(e) Mental health and substance abuse benefits
[40](#section-5.1e-mental-health-and-substance-abuse-benefits)

Section 5.1(f) Prescription drug benefits
[41](#section-5.1f-prescription-drug-benefits)

Section 5.1(g) Special features [44](#section-5.1g-special-features)

-   
-   
-   
-   
-   
-   

Flexible benefits option [44](#flexible-benefits-option)Services for
deaf and hearing impaired
[44](#services-for-deaf-and-hearing-impaired)Joint replacement
[44](#joint-replacement)High risk pregnancies
[44](#high-risk-pregnancies)Centers of excellence
[44](#centers-of-excellence)Members Choice [44](#members-choice)Section
5.1(h) Dental benefits [45](#section-5.1h-dental-benefits)

Section 5.2 HDHP Benefits - OVERVIEW
[46](#section-5.2-hdhp-benefits---overview)

General features of an HDHP [46](#general-features-of-an-hdhp)

HDHP Summary [46](#hdhp-summary)

Section 5.2(a) Preventive care [50](#section-5.2a-preventive-care)

Section 5.2(b) High Deductible Medical Coverage subject to the
deductible
[52](#section-5.2b-high-deductible-medical-coverage-subject-to-the-deductible)

Section 5.2(c) Medical services and supplies provided by physicians and
other health care professionals
[54](#section-5.2c-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)

Section 5.2(d) Surgical and anesthesia services provided by physicians
and other health care professionals
[62](#section-5.2d-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)

Section 5.2(e) Services provided by a hospital or other facility, and
ambulance services
[66](#section-5.2e-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

Section 5.2(f) Emergency services/accidents
[69](#section-5.2f-emergency-servicesaccidents)

Section 5.2(g) Mental health and substance abuse benefits
[71](#section-5.2g-mental-health-and-substance-abuse-benefits)

Section 5.2(h) Prescription drug benefits
[73](#section-5.2h-prescription-drug-benefits)

Section 5.2(i) Special features [75](#section-5.2i-special-features)

-   
-   
-   
-   
-   
-   

Flexible benefits option [75](#flexible-benefits-option-1)Services for
deaf and hearing impaired
[75](#services-for-deaf-and-hearing-impaired-1)Joint replacement
[75](#joint-replacement-1)High risk pregnancies
[75](#high-risk-pregnancies-1)Centers of excellence
[75](#centers-of-excellence-1)Members Choice
[75](#members-choice-1)Section 5.2(j) Dental benefits
[76](#section-5.2j-dental-benefits)

Section 5.2(k) Savings -- HSAs and HRAs
[77](#section-5.2k-savings-hsas-and-hras)

-   
-   
-   
-   
-   
-   
-   
-   
-   
-   
-   

Administrator [77](#administrator)Fees [77](#fees)Eligibility
[77](#eligibility)Funding [78](#funding)Contributions/credits
[78](#contributionscredits)Access funds
[79](#access-funds)Distributions/withdrawals
[80](#distributionswithdrawals)Availability of funds
[81](#availability-of-funds)Account owner [81](#account-owner)Portable
[81](#portable)Annual rollover [81](#annual-rollover)Section 5.2(l)
Catastrophic protection for out-of-pocket expenses
[84](#section-5.2l-catastrophic-protection-for-out-of-pocket-expenses)

Section 5.2(m) Health education resources and account management tools
[85](#section-5.2m-health-education-resources-and-account-management-tools)

-   
-   
-   
-   
-   

Special features [85](#special-features)Health education resources
[85](#health-education-resources)Account management tools
[85](#account-management-tools)Consumer choice information
[86](#consumer-choice-information)Care support
[86](#care-support)Section 5.3 Non-FEHB benefits available to Plan
members [87](#section-5.3-non-fehb-benefits-available-to-plan-members)

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

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

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

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

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

What is Medicare? [92](#what-is-medicare)

Should I enroll in Medicare? [92](#should-i-enroll-in-medicare)

The Original Medicare Plan (Part A or Part B)
[93](#the-original-medicare-plan-part-a-or-part-b)

Medicare Advantage [95](#medicare-advantage)

TRICARE and CHAMPVA [95](#tricare-and-champva)

Workers' Compensation [95](#workers-compensation)

Medicaid [96](#medicaid)

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

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

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

Section 11. FEHB Facts [98](#section-11.-fehb-facts)

Coverage information [98](#coverage-information)

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

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

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

Children's Equity Act [99](#childrens-equity-act)

When benefits and premiums start [99](#when-benefits-and-premiums-start)

When you retire [99](#when-you-retire)

When you lose benefits [99](#when-you-lose-benefits)

When FEHB coverage ends [99](#when-fehb-coverage-ends)

Spouse equity coverage [100](#spouse-equity-coverage)

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

Converting to individual coverage
[100](#converting-to-individual-coverage)

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

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

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

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

Index [107](#index)

Summary of HMO benefits for Group Health Plan *-* 2005 108

Summary of HDHP benefits for Group Health Plan *-* 2005
[109](#summary-of-hdhp-benefits-for-group-health-plan---2005)

2005 Rate Information for Group Health Plan 111

# Introduction

This brochure describes the benefits of Group Health Plan under our
contract (CS 1930) with the United States Office of Personnel
Management, as authorized by the Federal Employees Health Benefits law.
The address for Group Health Plan administrative offices is:

Group Health Plan

111 Corporate Office Drive, Suite 400

Earth City, MO 63045

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

If you are enrolled in this Plan, you are entitled to the benefits
described in this brochure. If you are enrolled in Self and Family
coverage, each eligible family member is also entitled to these
benefits. You do not have a right to benefits that were available before
January 1, 2005, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2005, and changes are summarized on
page 10. Rates are shown at the end of this brochure.

# Plain Language

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

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

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

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

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

# Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

    If the provider does not resolve the matter, call us at 800-755-3901
    and explain the situation.

    If we do not resolve the issue:

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

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

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

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

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

# Preventing medical mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

4.  **Talk to your doctor about which hospital is best for your health
    needs.**

-   Ask your doctor about which hospital has the best care and results
    for your condition if you have more than one hospital to choose from
    to get the health care you need.

-   Be sure you understand the instructions you get about follow-up care
    when you leave the hospital.

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

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

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

-   Ask your surgeon:

> Exactly what will you be doing?
>
> About how long will it take?
>
> What will happen after surgery?
>
> How can I expect to feel during recovery?

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

Want more information on patient safety?

-   [www.ahrq.gov/consumer/pathqpack.htm](http://www.ahrq.gov/consumer/pathqpack.htm)l.
    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 plan

##### 

### Facts about this Plan's High Option 

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

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

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

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

### Facts about this Plan's HDHP option

This Plan is an Individual Practice Plan offering a Health Savings
Account (HSA) or Health Reimbursement Arrangement (HRA) component. An
HDHP is a new health plan product that provides health care coverage and
a tax advantaged way to help you build savings for future medical needs.
An HDHP with an HSA or HRA is designed to give greater flexibility and
discretion over how you use your health care benefits. As an informed
consumer, you decide how to utilize your plan coverage with a high
deductible and out-of-pocket expenses limited by catastrophic
protection. And you decide how to spend the dollars in your HSA or HRA.
You may consider:

-   Using the most cost effective provider

-   Actively pursuing a healthier lifestyle and utilizing your
    preventive care benefit

-   Becoming an informed health care consumer so you can be more
    involved in the treatment of any medical condition or chronic
    illness.

The type and extent of covered services, and the amount we allow, may be
different from other plans. Read our brochure carefully to understand
the benefits and features of this HDHP. Internal Revenue Service (IRS)
rules govern the administration of all HDHPs. The IRS Web site at
[[http://www.ustreas.gov/offices/public-affairs/hsa/faq1.html]{.underline}](http://www.ustreas.gov/offices/public-affairs/hsa/faq1.html)
has additional information about HDHPs.

### We have network providers

GHP offers services through a network of providers. When you use our
network providers, you will receive covered services at reduced cost.
Group Health Plan is solely responsible for the selection of network
providers in your area. Contact us for the names of network providers
and to verify their continued participation. You can also go to our Web
page, which you can reach through the FEHB Web site,
[www.opm.gov/insure](http://www.opm.gov/insure). Contact Group Health
Plan to request a network provider directory.

In-network benefits apply only when you use a network provider. In order
to receive network benefits for hospitalization, both the physician and
the hospital must be participating Plan providers. Provider networks may
be more extensive in some areas than others. We cannot guarantee the
availability of every specialty in all areas.

### How we pay providers

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

### Your Rights

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

Group Health Plan is in compliance with the state requirements of
Missouri and Illinois. In addition, Coventry, our parent company, has
had a comprehensive system in place to identify and prevent medical
errors and to ensure that all providers credentialed are competent.
Through the Quality Improvement Program, medical errors and other
adverse events are monitored to identify patterns of preventable events
and events related to individual network providers. Patterns or
individual cases are investigated and action is taken to make
improvements.

If you want more information about us, call 800-755-3901, or write to
111 Corporate Office Drive, Suite 400, Earth City, MO 63045. You may
also contact us by fax at 314-506-1959 or visit our Web site at
[www.ghp.com](http://www.ghp.com/).

### Service Area

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

St. Louis City, St. Louis County, and the Missouri counties of Crawford,
Franklin, Gasconade, Jefferson, Lincoln, St. Charles, Ste. Genevieve and
Warren.

The Illinois counties of Bond, Calhoun, Christian, Clinton, Cole,
Franklin, Jersey, Johnson, Macoupin, Madison, Menard, Monroe,
Montgomery, Morgan, Saline, Sangamon, St. Clair and Williamson.

If you receive care outside our service area, we will pay only for
emergency care benefits. We will not pay for any other health care
services out of our service area unless the services have prior plan
approval.

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

# Section 2. How we change for 2005

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

### Program-wide changes

-   In Section 9, we revised the **Medicare Primary Payer Chart** and
    updated the language regarding Medicare Advantage plans (formerly
    called Medicare + Choice plans).

-   In Section 12, we revised the language regarding the Flexible
    Spending Account Program - *FSAFEDS* and the Federal Long Term Care
    Insurance Program.

### Changes to this Plan

-   Your share of the non-Postal premium will decrease by 2% for Self
    Only or 2% for Self and Family.

-   We offer a High Deductible Health Plan (HDHP) option for the first
    time under the Federal Employees Health Benefits Program during the
    2005 Open Season.

# Section 3. How you get care

+--------------------+-------------------------------------------------+
| ### Id             | We will send you an identification (ID) card    |
| entification cards | when you enroll. You should carry your ID card  |
|                    | with you at all times. You must show it         |
|                    | whenever you receive services from a Plan       |
|                    | provider, or fill a prescription at a Plan      |
|                    | pharmacy. Until you receive your ID card, use   |
|                    | your copy of the Health Benefits Election Form, |
|                    | SF-2809, your health benefits enrollment        |
|                    | confirmation (for annuitants), or your Employee |
|                    | Express confirmation letter.                    |
+--------------------+-------------------------------------------------+
|                    | If you do not receive your ID card within 15    |
|                    | days after the effective date of your           |
|                    | enrollment, or if you need replacement cards,   |
|                    | call us at 800-755-3901 or write to us at 111   |
|                    | Corporate Office Drive, Suite 400, Earth City,  |
|                    | MO 63045. You may also request replacement      |
|                    | cards through our Web site at                   |
|                    | [www.ghp.com](http://www.ghp.com/).             |
+--------------------+-------------------------------------------------+
| ### Where yo       | For the HMO plan, you get care from "Plan       |
| u get covered care | providers" and "Plan facilities" and you will   |
|                    | not have to file claims. Within the HDHP plan,  |
|                    | you may choose to receive care from any         |
|                    | provider or facility within the service area.   |
+--------------------+-------------------------------------------------+
| #                  | Plan providers are physicians and other health  |
| ### Plan providers | care professionals in our service area that we  |
|                    | contract with to provide covered services to    |
|                    | our members. We credential Plan providers       |
|                    | according to national standards. All providers  |
|                    | must go through our credentialing process. The  |
|                    | elements verified include state license, DEA    |
|                    | certificate to administer drugs, board          |
|                    | certification, work history, clinical           |
|                    | privileges at the admitting hospital,           |
|                    | education, training and malpractice insurance   |
|                    | coverage. In addition, the provider's history   |
|                    | of federal or state sanctions and malpractice   |
|                    | claims are investigated using state and federal |
|                    | sources. These are all verified by going to the |
|                    | original source. All credentials are verified   |
|                    | using the primary source.                       |
|                    |                                                 |
|                    | We list Plan providers in the provider          |
|                    | directory, which we update periodically. The    |
|                    | list is also on our Web site.                   |
+--------------------+-------------------------------------------------+
| ##                 | Plan facilities are hospitals and other         |
| ## Plan facilities | facilities in our service area that we contract |
|                    | with to provide covered services to our         |
|                    | members. We list these in the provider          |
|                    | directory, which we update periodically. The    |
|                    | list is also on our Web site.                   |
+--------------------+-------------------------------------------------+
| ###                | Sensicare is GHP's Open Access HMO product.     |
| What you must do t | Open Access means that you are not required to  |
| o get covered care | choose a primary care physician or obtain a     |
|                    | referral to see specialists. You will receive   |
|                    | HMO benefits when you see a participating       |
|                    | physician for health services. You or your      |
|                    | covered dependents may use any participating    |
|                    | internal medicine physician, family practice    |
|                    | physician, general practice physician,          |
|                    | pediatrician, OB/GYN or specialists             |
|                    | participating in the network for your care.     |
|                    |                                                 |
|                    | Within the HDHP option, in order to utilize the |
|                    | highest available benefit, you would need to    |
|                    | follow the same outline as for the HMO. A       |
|                    | physician referral is not necessary to utilize  |
|                    | the out-of-network benefit for covered          |
|                    | services; however, any services requiring prior |
|                    | authorization would still need to be            |
|                    | pre-authorized through GHP's Medical Management |
|                    | Department. When utilizing the out-of-network   |
|                    | benefit, it is the member's responsibility to   |
|                    | obtain prior authorization.                     |
+--------------------+-------------------------------------------------+
| #### Primary care  | We urge members to establish a relationship     |
|                    | with a participating physician. Through regular |
|                    | office visits, the physician becomes the        |
|                    | member's health care advisor and advocate.      |
|                    | Frequently, members choose a physician          |
|                    | specializing in internal medicine, family       |
|                    | practice or pediatrics.                         |
+--------------------+-------------------------------------------------+

+--------------------+-------------------------------------------------+
| ####  {#sect       | The provider directory lists primary care       |
| ion-1 .unnumbered} | physicians (family/general practitioners,       |
|                    | pediatricians, internists and OB/GYNs) and      |
|                    | specialists with their locations, phone number  |
|                    | and notes whether or not the physician is       |
|                    | accepting new patients. Directories are         |
|                    | available by calling 800-755-3901 or by         |
|                    | visiting our Web site at                        |
|                    | [www.ghp.com](http://www.ghp.com/).             |
+--------------------+-------------------------------------------------+
| #                  | A specialist is a Medical Doctor (MD), Doctor   |
| ### Specialty care | of Osteopathy (DO) or other health care         |
|                    | professional who is an expert in a specific     |
|                    | branch of medicine such as orthopedics,         |
|                    | neurology, surgery, cardiology, endocrinology,  |
|                    | etc. Group Health Plan members who have the     |
|                    | Sensicare product may see a participating       |
|                    | specialist at any time without a referral. The  |
|                    | participating physician is responsible for      |
|                    | obtaining prior authorization from Group Health |
|                    | Plan for treatment from a chiropractor or a     |
|                    | physician specializing in pain management or    |
|                    | infertility services. If your health care       |
|                    | provider believes these services are            |
|                    | appropriate, he or she will obtain an           |
|                    | authorization for you.                          |
|                    |                                                 |
|                    | Within the HDHP option, members may see a       |
|                    | participating or non-participating specialist   |
|                    | without a referral. Prior authorization is the  |
|                    | member's responsibility for all out-of-network  |
|                    | services.                                       |
|                    |                                                 |
|                    | Here are some other things you should know      |
|                    | about specialty care within the HMO option:     |
|                    |                                                 |
|                    | -   If your current specialist does not         |
|                    |     participate with GHP, you must receive      |
|                    |     treatment from a specialist who does.       |
|                    |     Generally, we will not pay for you to see   |
|                    |     another specialist.                         |
|                    |                                                 |
|                    | -   If you are seeing a specialist and your     |
|                    |     specialist leaves the Plan, call your       |
|                    |     participating health care advisor who can   |
|                    |     help arrange for you to see another         |
|                    |     specialist.                                 |
|                    |                                                 |
|                    | -   If you have a chronic or disabling          |
|                    |     condition and lose access to your           |
|                    |     specialist because we:                      |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   Terminate our contract with your specialist |
|                    |     for other than cause; or                    |
|                    |                                                 |
|                    | -   Drop out of the Federal Employees Health    |
|                    |     Benefits (FEHB) Program and you enroll in   |
|                    |     another FEHB program Plan; or               |
|                    |                                                 |
|                    | -   Reduce our service area and you enroll in   |
|                    |     another FEHB Plan,                          |
|                    |                                                 |
|                    | you may be able to continue seeing your         |
|                    | specialist for up to 90 days after you receive  |
|                    | notice of the change. Contact us, or if we drop |
|                    | out of the Program, contact your new plan.      |
|                    |                                                 |
|                    | If you are in the second or third trimester of  |
|                    | pregnancy and you lose access to your           |
|                    | specialist based on the above circumstances,    |
|                    | you can continue to see your specialist until   |
|                    | the end of your postpartum care, even if it is  |
|                    | beyond the 90 days.                             |
+--------------------+-------------------------------------------------+
| #### Hospital care | Your Plan primary care physician or specialist  |
|                    | will make necessary hospital arrangements and   |
|                    | supervise your care. This includes admission to |
|                    | a skilled nursing or other type of facility.    |
|                    |                                                 |
|                    | If you are in the hospital when your enrollment |
|                    | in our Plan begins, call our customer service   |
|                    | department immediately at 800-755-3901. 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 92nd day after you become a member of   |
|                    |     this Plan, whichever happens first.         |
|                    |                                                 |
|                    | These provisions apply only to the benefits of  |
|                    | the hospitalized person. If your plan           |
|                    | terminates participation in the FEHB Program in |
|                    | whole or in part, or if OPM orders an           |
|                    | enrollment change, this continuation of         |
|                    | coverage provision does not apply. In such      |
|                    | case, the hospitalized family member's benefits |
|                    | under the new plan begin on the effective date  |
|                    | of enrollment.                                  |
+--------------------+-------------------------------------------------+
| ### Circumstances  | Under certain extraordinary circumstances, such |
| beyond our control | as natural disasters, we may have to delay your |
|                    | services or we may be unable to provide them.   |
|                    | In that case, we will make all reasonable       |
|                    | efforts to provide you with the necessary care. |
+--------------------+-------------------------------------------------+
| ### S              | Your physician has authority to refer you for   |
| ervices requiring  | most services. For certain services, however,   |
| our prior approval | approval must obtained from us. Before giving   |
|                    | approval, we consider if the service is         |
|                    | covered, medically necessary, and follows       |
|                    | generally accepted medical practice.            |
|                    |                                                 |
|                    | For the HMO plan, it is the responsibility of   |
|                    | the participating physician to obtain any       |
|                    | necessary authorizations from the Plan before   |
|                    | rendering certain procedures or making          |
|                    | arrangements for hospitalization.               |
|                    |                                                 |
|                    | For the HDHP plan, if the member stays within   |
|                    | GHP's network, it is the primary care           |
|                    | physician's responsibility to obtain any        |
|                    | necessary prior authorizations. Should the      |
|                    | member choose to seek services outside the      |
|                    | network, it is the member's responsibility to   |
|                    | make sure that any necessary prior              |
|                    | authorizations are obtained.                    |
|                    |                                                 |
|                    | We call this review and approval process        |
|                    | precertification. Precertification must be      |
|                    | obtained for services such as, but not limited  |
|                    | to inpatient admissions, skilled nursing or     |
|                    | rehabilitation admissions, transplants,         |
|                    | outpatient surgeries, dialysis, certain         |
|                    | outpatient diagnostics, cardiac rehabilitation, |
|                    | pulmonary rehabilitation, ancillary services,   |
|                    | pain management, infertility services,          |
|                    | maternity, self-injectable drugs, botox,        |
|                    | visudyne, chiropractic manipulations, speech    |
|                    | therapy, and observation hospital stays. The    |
|                    | Prior Authorization Department is available     |
|                    | weekdays from 8:00 a.m. to 5:00 p.m. central    |
|                    | standard time at 800-546-4603.                  |
+--------------------+-------------------------------------------------+
| ###                | Prior authorization is required for, but not    |
|                    | limited to the following health services:       |
|                    |                                                 |
|                    | -   All hospital admissions including           |
|                    |     observations                                |
|                    |                                                 |
|                    | -   All admissions to skilled nursing           |
|                    |     facilities or inpatient specialty care      |
|                    |     programs such as rehabilitation; hospice;   |
|                    |     mental health and substance abuse           |
|                    |                                                 |
|                    | -   All surgical procedures at a hospital,      |
|                    |     outpatient, or surgical center              |
|                    |                                                 |
|                    | -   Mental health and substance abuse           |
|                    |     (outpatient services)                       |
|                    |                                                 |
|                    | -   Pain management injections including        |
|                    |     epidural, facet, and trigger point          |
|                    |     injections                                  |
|                    |                                                 |
|                    | -   Transplants                                 |
|                    |                                                 |
|                    | -   Rehabilitation/therapy including cardiac,   |
|                    |     occupational, physical, pulmonary, speech   |
|                    |                                                 |
|                    | -   Outpatient diagnostics/services including   |
|                    |     bone mineral density (all types), PET       |
|                    |     scans, MRI/MRA, radio frequency ablation,   |
|                    |     all cardiac stress imaging, stress          |
|                    |     echocardiogram, cardiac nuclear scans,      |
|                    |     cardiac catheterizations, hysteroscopy      |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   \*All pregnancy related services including  |
|                    |     but not limited to global obstetrical care, |
|                    |     perinatologist visits, ultrasounds (more    |
|                    |     than three)                                 |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   Infertility services                        |
|                    |                                                 |
|                    | -   \*Chiropractic services                     |
|                    |                                                 |
|                    | -   Chemotherapy (off label use only)           |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   Lesion removal in office or facility        |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   Sclerotherapy                               |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   Home health care                            |
|                    |                                                 |
|                    | -   Home hospice care                           |
|                    |                                                 |
|                    | -   In-home infusion therapy                    |
|                    |                                                 |
|                    | -   Durable medical equipment; prosthetic       |
|                    |     devices; orthotics                          |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   Orthopedic devices over \$200 dispensed     |
|                    |     from the office                             |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   Non-emergency ambulance transfers           |
|                    |                                                 |
|                    | -   Injectable medications                      |
|                    |                                                 |
|                    | \* Only notification is required                |
+--------------------+-------------------------------------------------+

# Section 4. Your costs for covered services

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

+------------------+------------+-----------------+-------------------+
| ### Copayments   | A          |                 |                   |
|                  | copayment  |                 |                   |
|                  | is a fixed |                 |                   |
|                  | amount of  |                 |                   |
|                  | money you  |                 |                   |
|                  | pay to the |                 |                   |
|                  | provider,  |                 |                   |
|                  | facility,  |                 |                   |
|                  | pharmacy,  |                 |                   |
|                  | etc., when |                 |                   |
|                  | you        |                 |                   |
|                  | receive    |                 |                   |
|                  | services.  |                 |                   |
|                  |            |                 |                   |
|                  | Example:   |                 |                   |
|                  | When you   |                 |                   |
|                  | see your   |                 |                   |
|                  | primary    |                 |                   |
|                  | care       |                 |                   |
|                  | physician  |                 |                   |
|                  | in the HMO |                 |                   |
|                  | plan, you  |                 |                   |
|                  | pay a      |                 |                   |
|                  | copayment  |                 |                   |
|                  | of \$10    |                 |                   |
|                  | per office |                 |                   |
|                  | visit and  |                 |                   |
|                  | when you   |                 |                   |
|                  | go in the  |                 |                   |
|                  | hospital,  |                 |                   |
|                  | you pay    |                 |                   |
|                  | \$100 per  |                 |                   |
|                  | admission. |                 |                   |
+------------------+------------+-----------------+-------------------+
| ### Deductible   | A          |                 |                   |
|                  | deductible |                 |                   |
|                  | is a fixed |                 |                   |
|                  | amount of  |                 |                   |
|                  | covered    |                 |                   |
|                  | expenses   |                 |                   |
|                  | you must   |                 |                   |
|                  | incur for  |                 |                   |
|                  | certain    |                 |                   |
|                  | covered    |                 |                   |
|                  | services   |                 |                   |
|                  | and        |                 |                   |
|                  | supplies   |                 |                   |
|                  | before we  |                 |                   |
|                  | start      |                 |                   |
|                  | paying     |                 |                   |
|                  | benefits   |                 |                   |
|                  | for them.  |                 |                   |
|                  | We do not  |                 |                   |
|                  | have a     |                 |                   |
|                  | deductible |                 |                   |
|                  | for the    |                 |                   |
|                  | HMO        |                 |                   |
|                  | option*.*  |                 |                   |
|                  | The annual |                 |                   |
|                  | deductible |                 |                   |
|                  | for the    |                 |                   |
|                  | HDHP       |                 |                   |
|                  | option is  |                 |                   |
|                  | \$1,500    |                 |                   |
|                  | Self Only  |                 |                   |
|                  | or \$2,500 |                 |                   |
|                  | Self and   |                 |                   |
|                  | Family for |                 |                   |
|                  | in-network |                 |                   |
|                  | services   |                 |                   |
|                  | and        |                 |                   |
|                  | \$3,000    |                 |                   |
|                  | Self Only  |                 |                   |
|                  | or \$5,000 |                 |                   |
|                  | Self and   |                 |                   |
|                  | Family for |                 |                   |
|                  | out-       |                 |                   |
|                  | of-network |                 |                   |
|                  | services.  |                 |                   |
|                  | Copayments |                 |                   |
|                  | do not     |                 |                   |
|                  | count      |                 |                   |
|                  | toward any |                 |                   |
|                  | d          |                 |                   |
|                  | eductible. |                 |                   |
|                  |            |                 |                   |
|                  | [Note: If  |                 |                   |
|                  | you change |                 |                   |
|                  | plans      |                 |                   |
|                  | during     |                 |                   |
|                  | Open       |                 |                   |
|                  | Season,    |                 |                   |
|                  | you do not |                 |                   |
|                  | have to    |                 |                   |
|                  | start a    |                 |                   |
|                  | new        |                 |                   |
|                  | deductible |                 |                   |
|                  | under your |                 |                   |
|                  | old plan   |                 |                   |
|                  | between    |                 |                   |
|                  | January 1  |                 |                   |
|                  | and the    |                 |                   |
|                  | effective  |                 |                   |
|                  | date of    |                 |                   |
|                  | your new   |                 |                   |
|                  | plan. If   |                 |                   |
|                  | you change |                 |                   |
|                  | plans at   |                 |                   |
|                  | another    |                 |                   |
|                  | time       |                 |                   |
|                  | during the |                 |                   |
|                  | year, you  |                 |                   |
|                  | must begin |                 |                   |
|                  | a new      |                 |                   |
|                  | deductible |                 |                   |
|                  | under your |                 |                   |
|                  | new        |                 |                   |
|                  | pla        |                 |                   |
|                  | n.]{.mark} |                 |                   |
|                  |            |                 |                   |
|                  | [And, if   |                 |                   |
|                  | you change |                 |                   |
|                  | options in |                 |                   |
|                  | this Plan  |                 |                   |
|                  | during the |                 |                   |
|                  | year, we   |                 |                   |
|                  | will       |                 |                   |
|                  | credit the |                 |                   |
|                  | amount of  |                 |                   |
|                  | covered    |                 |                   |
|                  | expenses   |                 |                   |
|                  | already    |                 |                   |
|                  | applied    |                 |                   |
|                  | toward the |                 |                   |
|                  | deductible |                 |                   |
|                  | of your    |                 |                   |
|                  | old option |                 |                   |
|                  | to the     |                 |                   |
|                  | deductible |                 |                   |
|                  | of your    |                 |                   |
|                  | new        |                 |                   |
|                  | optio      |                 |                   |
|                  | n.]{.mark} |                 |                   |
+------------------+------------+-----------------+-------------------+
| ### Coinsurance  | C          |                 |                   |
|                  | oinsurance |                 |                   |
|                  | is the     |                 |                   |
|                  | percentage |                 |                   |
|                  | of our     |                 |                   |
|                  | allowance  |                 |                   |
|                  | that you   |                 |                   |
|                  | must pay   |                 |                   |
|                  | for your   |                 |                   |
|                  | care.      |                 |                   |
|                  | C          |                 |                   |
|                  | oinsurance |                 |                   |
|                  | doesn't    |                 |                   |
|                  | begin      |                 |                   |
|                  | until you  |                 |                   |
|                  | meet your  |                 |                   |
|                  | d          |                 |                   |
|                  | eductible, |                 |                   |
|                  | where      |                 |                   |
|                  | a          |                 |                   |
|                  | pplicable. |                 |                   |
|                  |            |                 |                   |
|                  | Example:   |                 |                   |
|                  | In our HMO |                 |                   |
|                  | plan, you  |                 |                   |
|                  | pay 20% of |                 |                   |
|                  | our        |                 |                   |
|                  | allowance  |                 |                   |
|                  | for        |                 |                   |
|                  | durable    |                 |                   |
|                  | medical    |                 |                   |
|                  | equipment. |                 |                   |
+------------------+------------+-----------------+-------------------+
| ### You          | For the    |                 |                   |
| r catastrophic p | HMO plan,  |                 |                   |
| rotection out-of | after your |                 |                   |
| -pocket maximum  | copayments |                 |                   |
|                  | and        |                 |                   |
|                  | c          |                 |                   |
|                  | oinsurance |                 |                   |
|                  | total      |                 |                   |
|                  | \$1,000    |                 |                   |
|                  | per person |                 |                   |
|                  | or \$2,000 |                 |                   |
|                  | per family |                 |                   |
|                  | enrollment |                 |                   |
|                  | in any     |                 |                   |
|                  | calendar   |                 |                   |
|                  | year, you  |                 |                   |
|                  | do not     |                 |                   |
|                  | have to    |                 |                   |
|                  | pay any    |                 |                   |
|                  | more for   |                 |                   |
|                  | covered    |                 |                   |
|                  | services.  |                 |                   |
|                  | However,   |                 |                   |
|                  | copayments |                 |                   |
|                  | for the    |                 |                   |
|                  | following  |                 |                   |
|                  | services   |                 |                   |
|                  | do not     |                 |                   |
|                  | count      |                 |                   |
|                  | toward     |                 |                   |
|                  | your       |                 |                   |
|                  | ca         |                 |                   |
|                  | tastrophic |                 |                   |
|                  | protection |                 |                   |
|                  | out        |                 |                   |
|                  | -of-pocket |                 |                   |
|                  | maximum,   |                 |                   |
|                  | and you    |                 |                   |
|                  | must       |                 |                   |
|                  | continue   |                 |                   |
|                  | to pay     |                 |                   |
|                  | copayments |                 |                   |
|                  | for these  |                 |                   |
|                  | services:  |                 |                   |
|                  |            |                 |                   |
|                  | -   Pr     |                 |                   |
|                  | escription |                 |                   |
|                  |     Drugs  |                 |                   |
|                  |            |                 |                   |
|                  | Be sure to |                 |                   |
|                  | keep       |                 |                   |
|                  | accurate   |                 |                   |
|                  | records of |                 |                   |
|                  | your       |                 |                   |
|                  | copayments |                 |                   |
|                  | since you  |                 |                   |
|                  | are        |                 |                   |
|                  | r          |                 |                   |
|                  | esponsible |                 |                   |
|                  | for        |                 |                   |
|                  | informing  |                 |                   |
|                  | us when    |                 |                   |
|                  | you reach  |                 |                   |
|                  | the        |                 |                   |
|                  | maximum.   |                 |                   |
|                  |            |                 |                   |
|                  | For the    |                 |                   |
|                  | HDHP plan, |                 |                   |
|                  | you are    |                 |                   |
|                  | protected  |                 |                   |
|                  | by an      |                 |                   |
|                  | annual     |                 |                   |
|                  | ca         |                 |                   |
|                  | tastrophic |                 |                   |
|                  | maximum on |                 |                   |
|                  | out        |                 |                   |
|                  | -of-pocket |                 |                   |
|                  | expenses   |                 |                   |
|                  | for        |                 |                   |
|                  | covered    |                 |                   |
|                  | services.  |                 |                   |
|                  | After your |                 |                   |
|                  | co         |                 |                   |
|                  | insurance, |                 |                   |
|                  | copayments |                 |                   |
|                  | and        |                 |                   |
|                  | d          |                 |                   |
|                  | eductibles |                 |                   |
|                  | total      |                 |                   |
|                  | \$5,000    |                 |                   |
|                  | per person |                 |                   |
|                  | or         |                 |                   |
|                  | \$10,000   |                 |                   |
|                  | per family |                 |                   |
|                  | enrollment |                 |                   |
|                  | in-network |                 |                   |
|                  | and        |                 |                   |
|                  | \$10,000   |                 |                   |
|                  | per person |                 |                   |
|                  | or         |                 |                   |
|                  | \$20,000   |                 |                   |
|                  | per family |                 |                   |
|                  | out-       |                 |                   |
|                  | of-network |                 |                   |
|                  | in any     |                 |                   |
|                  | calendar   |                 |                   |
|                  | year, you  |                 |                   |
|                  | do not     |                 |                   |
|                  | have to    |                 |                   |
|                  | pay any    |                 |                   |
|                  | more for   |                 |                   |
|                  | covered    |                 |                   |
|                  | services   |                 |                   |
|                  | from       |                 |                   |
|                  | network    |                 |                   |
|                  | providers. |                 |                   |
|                  | However,   |                 |                   |
|                  | certain    |                 |                   |
|                  | expenses   |                 |                   |
|                  | do not     |                 |                   |
|                  | count      |                 |                   |
|                  | toward     |                 |                   |
|                  | your       |                 |                   |
|                  | out        |                 |                   |
|                  | -of-pocket |                 |                   |
|                  | maximum    |                 |                   |
|                  | and you    |                 |                   |
|                  | must       |                 |                   |
|                  | continue   |                 |                   |
|                  | to pay     |                 |                   |
|                  | these      |                 |                   |
|                  | expenses   |                 |                   |
|                  | once you   |                 |                   |
|                  | reach your |                 |                   |
|                  | out        |                 |                   |
|                  | -of-pocket |                 |                   |
|                  | maximum    |                 |                   |
|                  | (such as   |                 |                   |
|                  | expenses   |                 |                   |
|                  | in excess  |                 |                   |
|                  | of the     |                 |                   |
|                  | Plan's     |                 |                   |
|                  | benefit    |                 |                   |
|                  | maximum,   |                 |                   |
|                  | or if you  |                 |                   |
|                  | use        |                 |                   |
|                  | out-       |                 |                   |
|                  | of-network |                 |                   |
|                  | providers, |                 |                   |
|                  | amounts in |                 |                   |
|                  | excess of  |                 |                   |
|                  | the Plan   |                 |                   |
|                  | a          |                 |                   |
|                  | llowance). |                 |                   |
|                  | Refer to   |                 |                   |
|                  | Section    |                 |                   |
|                  | 5.2(b)     |                 |                   |
|                  | *High      |                 |                   |
|                  | Deductible |                 |                   |
|                  | Health     |                 |                   |
|                  | Plan*, and |                 |                   |
|                  | Section    |                 |                   |
|                  | 5.2(l)     |                 |                   |
|                  | *Ca        |                 |                   |
|                  | tastrophic |                 |                   |
|                  | protection |                 |                   |
|                  | for        |                 |                   |
|                  | out        |                 |                   |
|                  | -of-pocket |                 |                   |
|                  | expenses*  |                 |                   |
|                  | for more   |                 |                   |
|                  | details.   |                 |                   |
+------------------+------------+-----------------+-------------------+
| ##               | -   **     |                 |                   |
| # Differences be | In-network |                 |                   |
| tween our allowa |     p      |                 |                   |
| nce and the bill | roviders** |                 |                   |
|                  |     agree  |                 |                   |
|                  |     to     |                 |                   |
|                  |     limit  |                 |                   |
|                  |     what   |                 |                   |
|                  |     they   |                 |                   |
|                  |     will   |                 |                   |
|                  |     bill   |                 |                   |
|                  |     you.   |                 |                   |
|                  |            |                 |                   |
|                  |    Because |                 |                   |
|                  |     of     |                 |                   |
|                  |     that,  |                 |                   |
|                  |     when   |                 |                   |
|                  |     you    |                 |                   |
|                  |     use a  |                 |                   |
|                  |            |                 |                   |
|                  |    network |                 |                   |
|                  |            |                 |                   |
|                  |  provider, |                 |                   |
|                  |     your   |                 |                   |
|                  |     share  |                 |                   |
|                  |     of     |                 |                   |
|                  |            |                 |                   |
|                  |    covered |                 |                   |
|                  |            |                 |                   |
|                  |    charges |                 |                   |
|                  |            |                 |                   |
|                  |   consists |                 |                   |
|                  |     only   |                 |                   |
|                  |     of     |                 |                   |
|                  |     your   |                 |                   |
|                  |            |                 |                   |
|                  | deductible |                 |                   |
|                  |     and    |                 |                   |
|                  |     c      |                 |                   |
|                  | oinsurance |                 |                   |
|                  |     or     |                 |                   |
|                  |            |                 |                   |
|                  | copayment. |                 |                   |
|                  |     Here   |                 |                   |
|                  |     is an  |                 |                   |
|                  |            |                 |                   |
|                  |    example |                 |                   |
|                  |     about  |                 |                   |
|                  |     co     |                 |                   |
|                  | insurance: |                 |                   |
|                  |     You    |                 |                   |
|                  |     see a  |                 |                   |
|                  |            |                 |                   |
|                  |    network |                 |                   |
|                  |            |                 |                   |
|                  |  physician |                 |                   |
|                  |     who    |                 |                   |
|                  |            |                 |                   |
|                  |    charges |                 |                   |
|                  |     \$150, |                 |                   |
|                  |     but    |                 |                   |
|                  |     our    |                 |                   |
|                  |            |                 |                   |
|                  |  allowance |                 |                   |
|                  |     is     |                 |                   |
|                  |     \$100. |                 |                   |
|                  |     If you |                 |                   |
|                  |     have   |                 |                   |
|                  |     met    |                 |                   |
|                  |     your   |                 |                   |
|                  |     d      |                 |                   |
|                  | eductible, |                 |                   |
|                  |     you    |                 |                   |
|                  |     are    |                 |                   |
|                  |     only   |                 |                   |
|                  |     r      |                 |                   |
|                  | esponsible |                 |                   |
|                  |     for    |                 |                   |
|                  |     your   |                 |                   |
|                  |     co     |                 |                   |
|                  | insurance. |                 |                   |
|                  |     That   |                 |                   |
|                  |     is,    |                 |                   |
|                  |     you    |                 |                   |
|                  |     pay    |                 |                   |
|                  |     just   |                 |                   |
|                  |     -- 10% |                 |                   |
|                  |     of our |                 |                   |
|                  |     \$100  |                 |                   |
|                  |            |                 |                   |
|                  |  allowance |                 |                   |
|                  |            |                 |                   |
|                  |    (\$10). |                 |                   |
|                  |            |                 |                   |
|                  |    Because |                 |                   |
|                  |     of the |                 |                   |
|                  |            |                 |                   |
|                  | agreement, |                 |                   |
|                  |     your   |                 |                   |
|                  |            |                 |                   |
|                  |    network |                 |                   |
|                  |            |                 |                   |
|                  |  physician |                 |                   |
|                  |     will   |                 |                   |
|                  |     not    |                 |                   |
|                  |     bill   |                 |                   |
|                  |     you    |                 |                   |
|                  |     for    |                 |                   |
|                  |     the    |                 |                   |
|                  |     \$50   |                 |                   |
|                  |            |                 |                   |
|                  | difference |                 |                   |
|                  |            |                 |                   |
|                  |    between |                 |                   |
|                  |     our    |                 |                   |
|                  |            |                 |                   |
|                  |  allowance |                 |                   |
|                  |     and    |                 |                   |
|                  |     his    |                 |                   |
|                  |     bill.  |                 |                   |
|                  |            |                 |                   |
|                  | -   **Out- |                 |                   |
|                  | of-network |                 |                   |
|                  |     pr     |                 |                   |
|                  | oviders**, |                 |                   |
|                  |     on the |                 |                   |
|                  |     other  |                 |                   |
|                  |     hand,  |                 |                   |
|                  |     have   |                 |                   |
|                  |     no     |                 |                   |
|                  |            |                 |                   |
|                  |  agreement |                 |                   |
|                  |     to     |                 |                   |
|                  |     limit  |                 |                   |
|                  |     what   |                 |                   |
|                  |     they   |                 |                   |
|                  |     will   |                 |                   |
|                  |     bill   |                 |                   |
|                  |     you.   |                 |                   |
|                  |     When   |                 |                   |
|                  |     you    |                 |                   |
|                  |     use an |                 |                   |
|                  |     out-   |                 |                   |
|                  | of-network |                 |                   |
|                  |            |                 |                   |
|                  |  provider, |                 |                   |
|                  |     you    |                 |                   |
|                  |     will   |                 |                   |
|                  |     pay    |                 |                   |
|                  |     your   |                 |                   |
|                  |            |                 |                   |
|                  | deductible |                 |                   |
|                  |     and    |                 |                   |
|                  |     c      |                 |                   |
|                  | oinsurance |                 |                   |
|                  |     --     |                 |                   |
|                  |            |                 |                   |
|                  |   **plus** |                 |                   |
|                  |     any    |                 |                   |
|                  |            |                 |                   |
|                  | difference |                 |                   |
|                  |            |                 |                   |
|                  |    between |                 |                   |
|                  |     our    |                 |                   |
|                  |            |                 |                   |
|                  |  allowance |                 |                   |
|                  |     and    |                 |                   |
|                  |            |                 |                   |
|                  |    charges |                 |                   |
|                  |     on the |                 |                   |
|                  |     bill.  |                 |                   |
|                  |     Here   |                 |                   |
|                  |     is an  |                 |                   |
|                  |            |                 |                   |
|                  |   example: |                 |                   |
|                  |     You    |                 |                   |
|                  |     see an |                 |                   |
|                  |     out-   |                 |                   |
|                  | of-network |                 |                   |
|                  |            |                 |                   |
|                  |  physician |                 |                   |
|                  |     who    |                 |                   |
|                  |            |                 |                   |
|                  |    charges |                 |                   |
|                  |     \$150  |                 |                   |
|                  |     and    |                 |                   |
|                  |     our    |                 |                   |
|                  |            |                 |                   |
|                  |  allowance |                 |                   |
|                  |     is     |                 |                   |
|                  |     again  |                 |                   |
|                  |     \$100. |                 |                   |
|                  |            |                 |                   |
|                  |    Because |                 |                   |
|                  |     you've |                 |                   |
|                  |     met    |                 |                   |
|                  |     your   |                 |                   |
|                  |     d      |                 |                   |
|                  | eductible, |                 |                   |
|                  |     you    |                 |                   |
|                  |     are    |                 |                   |
|                  |     r      |                 |                   |
|                  | esponsible |                 |                   |
|                  |     for    |                 |                   |
|                  |     your   |                 |                   |
|                  |     co     |                 |                   |
|                  | insurance, |                 |                   |
|                  |     so you |                 |                   |
|                  |     pay    |                 |                   |
|                  |     30% of |                 |                   |
|                  |     our    |                 |                   |
|                  |     \$100  |                 |                   |
|                  |            |                 |                   |
|                  |  allowance |                 |                   |
|                  |            |                 |                   |
|                  |    (\$30). |                 |                   |
|                  |     Plus,  |                 |                   |
|                  |            |                 |                   |
|                  |    because |                 |                   |
|                  |     there  |                 |                   |
|                  |     is no  |                 |                   |
|                  |            |                 |                   |
|                  |  agreement |                 |                   |
|                  |            |                 |                   |
|                  |    between |                 |                   |
|                  |     the    |                 |                   |
|                  |     out-   |                 |                   |
|                  | of-network |                 |                   |
|                  |            |                 |                   |
|                  |  physician |                 |                   |
|                  |     and    |                 |                   |
|                  |     us, he |                 |                   |
|                  |     can    |                 |                   |
|                  |     bill   |                 |                   |
|                  |     you    |                 |                   |
|                  |     for    |                 |                   |
|                  |     the    |                 |                   |
|                  |     \$50   |                 |                   |
|                  |            |                 |                   |
|                  | difference |                 |                   |
|                  |            |                 |                   |
|                  |    between |                 |                   |
|                  |     our    |                 |                   |
|                  |            |                 |                   |
|                  |  allowance |                 |                   |
|                  |     and    |                 |                   |
|                  |     his    |                 |                   |
|                  |     bill.  |                 |                   |
|                  |            |                 |                   |
|                  | The        |                 |                   |
|                  | following  |                 |                   |
|                  | table      |                 |                   |
|                  | i          |                 |                   |
|                  | llustrates |                 |                   |
|                  | the        |                 |                   |
|                  | examples   |                 |                   |
|                  | of how     |                 |                   |
|                  | much you   |                 |                   |
|                  | have to    |                 |                   |
|                  | pay        |                 |                   |
|                  | out        |                 |                   |
|                  | -of-pocket |                 |                   |
|                  | for        |                 |                   |
|                  | services   |                 |                   |
|                  | from an    |                 |                   |
|                  | in-network |                 |                   |
|                  | physician  |                 |                   |
|                  | vs. an     |                 |                   |
|                  | out-       |                 |                   |
|                  | of-network |                 |                   |
|                  | physician. |                 |                   |
|                  | The table  |                 |                   |
|                  | uses our   |                 |                   |
|                  | example of |                 |                   |
|                  | a service  |                 |                   |
|                  | for which  |                 |                   |
|                  | the        |                 |                   |
|                  | physician  |                 |                   |
|                  | charges    |                 |                   |
|                  | \$150 and  |                 |                   |
|                  | our        |                 |                   |
|                  | allowance  |                 |                   |
|                  | is \$100.  |                 |                   |
|                  | The table  |                 |                   |
|                  | shows the  |                 |                   |
|                  | amount you |                 |                   |
|                  | pay if you |                 |                   |
|                  | have met   |                 |                   |
|                  | your       |                 |                   |
|                  | calendar   |                 |                   |
|                  | year       |                 |                   |
|                  | d          |                 |                   |
|                  | eductible. |                 |                   |
+------------------+------------+-----------------+-------------------+
|                  | *          | **In-network    | **Out-of-network  |
|                  | *EXAMPLE** | physician**     | physician**       |
+------------------+------------+-----------------+-------------------+
|                  | P          | \$150           | \$150             |
|                  | hysician's |                 |                   |
|                  | charge     |                 |                   |
+------------------+------------+-----------------+-------------------+
|                  | Our        | We set it at:   | We set it at: 100 |
|                  | allowance  | 100             |                   |
+------------------+------------+-----------------+-------------------+
|                  | We pay     | 90% of our      | 70% of our        |
|                  |            | allowance: 90   | allowance: 70     |
+------------------+------------+-----------------+-------------------+
|                  | You owe:   | 10% of our      | 30% of our        |
|                  | C          | allowance: 10   | allowance: 30     |
|                  | oinsurance |                 |                   |
+------------------+------------+-----------------+-------------------+
|                  | +          | No: 0           | Yes: 50           |
|                  | Difference |                 |                   |
|                  | up to      |                 |                   |
|                  | charge?    |                 |                   |
+------------------+------------+-----------------+-------------------+
|                  | **TOTAL    | \$10            | \$80              |
|                  | YOU PAY**  |                 |                   |
+------------------+------------+-----------------+-------------------+
|                  |            |                 |                   |
+------------------+------------+-----------------+-------------------+

# Section 5.1 HMO Benefits -- OVERVIEW

\
*(See page 10 for how our benefits changed this year and page 108 and
109 for benefits summaries.)*

*Note: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
800-755-3901 or at our Web site at [www.ghp.com](http://www.ghp.com/)*.

Section 5.1(a) Medical services and supplies provided by physicians and
other health care professionals
[20](#section-5.1a-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)

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

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

Preventive care, adult [21](#preventive-care-adult)

Preventive care, children [22](#preventive-care-children)

Maternity care [22](#maternity-care)

Family planning [23](#family-planning)

Infertility services [23](#infertility-services)

Allergy care [24](#allergy-care)

Treatment therapies [24](#treatment-therapies)

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

Speech therapy [25](#speech-therapy)

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

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

Foot care [26](#foot-care)

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

Durable medical equipment (DME) [27](#durable-medical-equipment-dme)

Home health services [27](#home-health-services)

Chiropractic [28](#chiropractic)

Alternative treatments [28](#alternative-treatments)

Educational classes and programs [28](#educational-classes-and-programs)

Section 5.1(b) Surgical and anesthesia services provided by physicians
and other health care professionals
[30](#section-5.1b-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)

Surgical procedures [30](#surgical-procedures)

Reconstructive surgery [31](#reconstructive-surgery)

Oral and maxillofacial surgery [32](#oral-and-maxillofacial-surgery)

Organ/tissue transplants [33](#organtissue-transplants)

Anesthesia [34](#anesthesia)

Section 5.1(c) Services provided by a hospital or other facility, and
ambulance services
[35](#section-5.1c-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

Inpatient hospital [35](#inpatient-hospital)

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

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

Hospice care [37](#hospice-care)

Ambulance [37](#ambulance)

Section 5.1(d) Emergency services/accidents
[38](#section-5.1d-emergency-servicesaccidents)

Emergency within our service area [38](#__RefHeading___Toc84929111)

Emergency outside our service area [39](#__RefHeading___Toc84929112)

Ambulance [39](#__RefHeading___Toc84929113)

Section 5.1(e) Mental health and substance abuse benefits
[40](#section-5.1e-mental-health-and-substance-abuse-benefits)

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

Section 5.1(f) Prescription drug benefits
[41](#section-5.1f-prescription-drug-benefits)

Covered medications and supplies [42](#covered-medications-and-supplies)

Section 5.1(g) Special features [44](#section-5.1g-special-features)

Flexible benefits option [44](#flexible-benefits-option)

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

Joint replacement [44](#joint-replacement)

High risk pregnancies [44](#high-risk-pregnancies)

Centers of excellence [44](#centers-of-excellence)

Members Choice [44](#members-choice)

Section 5.1(h) Dental benefits [45](#section-5.1h-dental-benefits)

Accidental injury benefit [45](#accidental-injury-benefit)

Summary of HMO benefits for Group Health Plan *-* 2005 108

2005 Rate Information for Group Health Plan 111

Section 5.2 HDHP Benefits - OVERVIEW
[46](#section-5.2-hdhp-benefits---overview)

Section 5.2(a) Preventive care [50](#section-5.2a-preventive-care)

Preventive care, adult [50](#preventive-care-adult-1)

Preventive care, children [50](#preventive-care-children-1)

Section 5.2(b) High Deductible Medical Coverage subject to the
deductible
[52](#section-5.2b-high-deductible-medical-coverage-subject-to-the-deductible)

Deductible before Medical Coverage begins
[52](#deductible-before-medical-coverage-begins)

Section 5.2(c) Medical services and supplies provided by physicians and
other health care professionals
[54](#section-5.2c-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)

Diagnostic and treatment services
[54](#diagnostic-and-treatment-services-1)

Lab, X-ray and other diagnostic tests
[54](#lab-x-ray-and-other-diagnostic-tests-1)

Maternity care [54](#maternity-care-1)

Family planning [55](#family-planning-1)

Infertility services [55](#infertility-services-1)

Allergy care [56](#allergy-care-1)

Treatment therapies [56](#treatment-therapies-1)

Physical and occupational therapies
[57](#physical-and-occupational-therapies-1)

Speech therapy [57](#speech-therapy-1)

Pulmonary and cardiac rehabilitation
[57](#pulmonary-and-cardiac-rehabilitation)

Hearing services (testing, treatment and supplies)
[58](#hearing-services-testing-treatment-and-supplies-1)

Vision services [58](#vision-services)

Foot care [58](#foot-care-1)

Orthopedic and prosthetic devices
[59](#orthopedic-and-prosthetic-devices-1)

Durable medical equipment (DME) [59](#durable-medical-equipment-dme-1)

Home health services [60](#home-health-services-1)

Chiropractic [60](#chiropractic-1)

Alternative treatments [60](#alternative-treatments-1)

Educational classes and programs
[60](#educational-classes-and-programs-1)

Section 5.2(d) Surgical and anesthesia services provided by physicians
and other health care professionals
[62](#section-5.2d-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)

Surgical procedures [62](#surgical-procedures-1)

Reconstructive surgery [63](#reconstructive-surgery-1)

Oral and maxillofacial surgery [63](#oral-and-maxillofacial-surgery-1)

Organ/tissue transplants [64](#organtissue-transplants-1)

Anesthesia [65](#anesthesia-1)

Section 5.2(e) Services provided by a hospital or other facility, and
ambulance services
[66](#section-5.2e-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

Inpatient hospital [66](#inpatient-hospital-1)

Outpatient hospital or ambulatory surgical center
[67](#outpatient-hospital-or-ambulatory-surgical-center-1)

Extended care /skilled nursing facility (SNF) benefits
[67](#extended-careskilled-nursing-facility-snf-benefits)

Hospice care [68](#hospice-care-1)

Ambulance [68](#ambulance-1)

Section 5.2(f) Emergency services/accidents
[69](#section-5.2f-emergency-servicesaccidents)

Emergency within our service area
[69](#emergency-within-our-service-area)

Emergency outside our service area
[70](#emergency-outside-our-service-area)

Ambulance [70](#ambulance-2)

Section 5.2(g) Mental health and substance abuse benefits
[71](#section-5.2g-mental-health-and-substance-abuse-benefits)

In-network benefits [71](#in-network-benefits)

Out of network benefits [72](#out-of-network-benefits)

Section 5.2(h) Prescription drug benefits
[73](#section-5.2h-prescription-drug-benefits)

Covered medications and supplies
[74](#covered-medications-and-supplies-1)

Section 5.2(i) Special features [75](#section-5.2i-special-features)

Flexible benefits option [75](#flexible-benefits-option-1)

Services for deaf and hearing impaired
[75](#services-for-deaf-and-hearing-impaired-1)

Joint replacement [75](#joint-replacement-1)

High risk pregnancies [75](#high-risk-pregnancies-1)

Centers of excellence [75](#centers-of-excellence-1)

Members Choice [75](#members-choice-1)

Section 5.2(j) Dental benefits [76](#section-5.2j-dental-benefits)

Accidental injury benefit [76](#accidental-injury-benefit-1)

Section 5.2(k) Savings -- HSAs and HRAs
[77](#section-5.2k-savings-hsas-and-hras)

Section 5.2(l) Catastrophic protection for out-of-pocket expenses
[84](#section-5.2l-catastrophic-protection-for-out-of-pocket-expenses)

Section 5.2(m) Health education resources and account management tools
[85](#section-5.2m-health-education-resources-and-account-management-tools)

Summary of HDHP benefits for Group Health Plan *-* 2005
[109](#summary-of-hdhp-benefits-for-group-health-plan---2005)

2005 Rate Information for Group Health Plan 111

## Section 5.1(a) Medical services and supplies provided by physicians and other health care professionals

+---+---+-------------------------------------+---------------------+---+---+
|   | * | **Here are some important things    |                     | * |   |
|   | * | you should keep in mind about these |                     | * |   |
|   | I | benefits:**                         |                     | I |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Be sure to read Section 4,      |                     | * |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | P |     services*, for valuable         |                     | P |   |
|   | * |     information about how cost      |                     | * |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   |   |     Section 9 about coordinating    |                     |   |   |
|   | * |     benefits with other coverage,   |                     | * |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | O |                                     |                     | O |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | R |                                     |                     | R |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | N |                                     |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
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| s |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
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| p |   |                                     |                     |   |   |
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| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
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| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$10 per visit to a |   |   |
| r |   |                                     | primary care        |   |   |
| o |   |                                     | physician           |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     | \$20 per visit to a |   |   |
| s |   |                                     | specialist          |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | Nothing             |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$10 per visit to a |   |   |
| r |   |                                     | primary care        |   |   |
| o |   |                                     | physician           |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     | \$20 per visit to a |   |   |
| s |   |                                     | specialist          |   |   |
| s |   |                                     |                     |   |   |
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| l |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$10 by a primary   |   |   |
| r |   |                                     | care physician      |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     | \$20 by a           |   |   |
| e |   |                                     | specialist          |   |   |
| s |   |                                     |                     |   |   |
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| T |   |                                     | Nothing if you      |   |   |
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| t |   |                                     | your office visit;  |   |   |
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| o |   |                                     | primary care        |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| R |   |                                     | \$10 per visit to a |   |   |
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| u |   |                                     | physician           |   |   |
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+---+---+-------------------------------------+---------------------+---+---+

*Preventive care, adult - continued on next page*

+------------------------------------------+---------------------------+
| ###                                      | You pay                   |
| ### Preventive care, adult *(continued)* |                           |
+------------------------------------------+---------------------------+
| Routine immunizations, limited to:       | \$10 per visit to a       |
|                                          | primary care physician    |
| -   Tetanus-diphtheria (Td) booster --   |                           |
|     once every 10 years, ages19 and over | \$20 per visit to a       |
|     (except as provided for under        | specialist                |
|     Childhood immunizations)             |                           |
|                                          |                           |
| -   Influenza vaccine, annually          |                           |
|                                          |                           |
| -   Pneumococcal vaccine, age 65 and     |                           |
|     older                                |                           |
+------------------------------------------+---------------------------+
| *Not covered: Physical exams required    | *All charges.*            |
| for obtaining or continuing employment   |                           |
| or insurance, attending schools or camp, |                           |
| or travel.*                              |                           |
+------------------------------------------+---------------------------+
| ###### Preventive care, children         |                           |
+------------------------------------------+---------------------------+
| -   Childhood immunizations recommended  | Nothing                   |
|     by the American Academy of           |                           |
|     Pediatrics                           |                           |
+------------------------------------------+---------------------------+
| -   Well-child care charges for routine  | \$10 per visit to a       |
|     examinations, immunizations and care | primary care physician    |
|     (up to age 22)                       |                           |
|                                          | \$20 per visit to a       |
| -   Examinations, such as:               | specialist                |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Eye exams through age 17 to          |                           |
|     determine the need for vision        |                           |
|     correction                           |                           |
|                                          |                           |
| -   Ear exams through age 17 to          |                           |
|     determine the need for hearing       |                           |
|     correction                           |                           |
|                                          |                           |
| -   Examinations done on the day of      |                           |
|     immunizations (up to age 22)         |                           |
+------------------------------------------+---------------------------+
| ###### Maternity care                    |                           |
+------------------------------------------+---------------------------+
| Complete maternity (obstetrical) care,   | \$10 per office visit for |
| such as:                                 | initial visit only;       |
|                                          | covered at 100%           |
| -   Prenatal care                        | thereafter                |
|                                          |                           |
| -   Delivery                             |                           |
|                                          |                           |
| -   Postnatal care                       |                           |
|                                          |                           |
| Note: Here are some things to keep in    |                           |
| mind:                                    |                           |
|                                          |                           |
| -   You do not need to precertify your   |                           |
|     normal delivery; see page 13 for     |                           |
|     other circumstances, such as         |                           |
|     extended stays for you or your baby. |                           |
|                                          |                           |
| -   You may remain in the hospital up to |                           |
|     48 hours after a regular delivery    |                           |
|     and 96 hours after a cesarean        |                           |
|     delivery. We will extend your        |                           |
|     inpatient stay if medically          |                           |
|     necessary.                           |                           |
+------------------------------------------+---------------------------+

*Maternity care - continued on next page*

+------------------------------------------+---------------------------+
| ###### Maternity care *(continued)*      | You pay                   |
+------------------------------------------+---------------------------+
| -   We cover routine nursery care of the | \$10 per office visit for |
|     newborn child during the covered     | initial visit only;       |
|     portion of the mother's maternity    | covered at 100%           |
|     stay. We will cover other care of an | thereafter                |
|     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 5.1c) and Surgery  |                           |
|     benefits (Section 5.1b).             |                           |
+------------------------------------------+---------------------------+
| *Not covered: Routine sonograms to       | *All charges.*            |
| determine fetal age, size or sex.*       |                           |
+------------------------------------------+---------------------------+
| ###### Family planning                   |                           |
+------------------------------------------+---------------------------+
| A range of voluntary family planning     | \$10 per visit to a       |
| services, limited to:                    | primary care physician    |
|                                          |                           |
| -   Voluntary sterilization (See         | \$20 per visit to a       |
|     Surgical procedures Section 5.1(b))  | specialist                |
|                                          |                           |
| -   Surgically implanted contraceptives  |                           |
|                                          |                           |
| -   Injectable contraceptive drugs (such |                           |
|     as Depo provera)                     |                           |
|                                          |                           |
| -   Intrauterine devices (IUDs)          |                           |
|                                          |                           |
| -   Diaphragms                           |                           |
|                                          |                           |
| Note: We cover oral contraceptives under |                           |
| the prescription drug benefit. Prior     |                           |
| authorization required.                  |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   Reversal of voluntary surgical       |                           |
|     sterilization                        |                           |
|                                          |                           |
| -   Genetic counseling                   |                           |
+------------------------------------------+---------------------------+
| ###### Infertility services              |                           |
+------------------------------------------+---------------------------+
| Diagnosis and treatment of infertility   | \$10 per visit to a       |
| such as:                                 | primary care physician    |
|                                          |                           |
| -   Artificial insemination:             | \$20 per visit to a       |
|                                          | specialist                |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *intravaginal insemination (IVI)*    |                           |
|                                          |                           |
| -   *intracervical insemination (ICI)*   |                           |
|                                          |                           |
| -   *intrauterine insemination (IUI)*    |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Fertility drugs                      |                           |
|                                          |                           |
| Note: We cover injectable fertility      |                           |
| drugs under medical benefits and oral    |                           |
| fertility drugs under the prescription   |                           |
| drug benefit.                            |                           |
+------------------------------------------+---------------------------+
|                                          | *Infertility services -   |
|                                          | continued on next page*   |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| #                                        | You pay                   |
| ##### Infertility services *(continued)* |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Assisted reproductive technology    |                           |
|     (ART) procedures, such as:*          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *in vitro fertilization*             |                           |
|                                          |                           |
| -   *embryo transfer, gamete             |                           |
|     intra-fallopian transfer (GIFT) and  |                           |
|     zygote intra-fallopian transfer      |                           |
|     (ZIFT)*                              |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Services and supplies related to    |                           |
|     ART procedures*                      |                           |
|                                          |                           |
| -   *Cost of donor sperm*                |                           |
|                                          |                           |
| -   *Cost of donor egg*                  |                           |
+------------------------------------------+---------------------------+
| ###### Allergy care                      |                           |
+------------------------------------------+---------------------------+
| -   Testing and treatment                | \$10 per visit to a       |
|                                          | primary care physician    |
| -   Allergy injections                   |                           |
|                                          | \$20 per visit to a       |
|                                          | specialist                |
+------------------------------------------+---------------------------+
| -   Allergy serum                        | Nothing                   |
+------------------------------------------+---------------------------+
| *Not covered: Provocative food testing   | *All charges.*            |
| and sublingual allergy desensitization*  |                           |
+------------------------------------------+---------------------------+
| ###### Treatment therapies               |                           |
+------------------------------------------+---------------------------+
| -   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    |                           |
| Transplants on page 32.                  |                           |
|                                          |                           |
| -   Respiratory and inhalation therapy   |                           |
|                                          |                           |
| -   Dialysis -- hemodialysis and         |                           |
|     peritoneal dialysis                  |                           |
|                                          |                           |
| -   Intravenous (IV)/Infusion Therapy -- |                           |
|     Home IV and antibiotic therapy       |                           |
|                                          |                           |
| -   Growth hormone therapy (GHT)         |                           |
|                                          |                           |
| Note: Growth hormone is covered under    |                           |
| the prescription drug benefit.           |                           |
|                                          |                           |
| Note: -- We only cover GHT when we       |                           |
| preauthorize the treatment. Call         |                           |
| 800-546-4603 for preauthorization. We    |                           |
| will ask you to submit information that  |                           |
| establishes that the GHT is medically    |                           |
| necessary. Ask us to authorize GHT       |                           |
| before you begin treatment; otherwise,   |                           |
| we will only cover GHT services from the |                           |
| date you submit the information. If you  |                           |
| do not ask or if we determine GHT is not |                           |
| medically necessary, we will not cover   |                           |
| the GHT or related services and          |                           |
| supplies. See *Services requiring our    |                           |
| prior approval* in Section 3.            |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###                                      | You pay                   |
| ### Physical and occupational therapies  |                           |
+------------------------------------------+---------------------------+
| 60 visits for the services of each of    | 20% coinsurance for       |
| the following:                           | therapies done in the     |
|                                          | office or outpatient      |
| -   qualified physical therapists and    | basis                     |
|                                          |                           |
| -   occupational therapists              |                           |
|                                          |                           |
| Note: We only cover therapy to restore   |                           |
| bodily function when there has been a    |                           |
| total or partial loss of bodily function |                           |
| due to illness or injury and if          |                           |
| significant improvement can be expected  |                           |
| within two consecutive months.           |                           |
|                                          |                           |
| -   Cardiac rehabilitation following a   |                           |
|     heart transplant, bypass surgery or  |                           |
|     a myocardial infarction is provided  |                           |
|     for up to 36 sessions                |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Long-term rehabilitative therapy*   |                           |
|                                          |                           |
| -   *Exercise programs*                  |                           |
+------------------------------------------+---------------------------+
| ###### Speech therapy                    |                           |
+------------------------------------------+---------------------------+
| 20 visits or two consecutive months,     | 20% coinsurance for       |
| whichever is greater, per condition per  | therapies done in office  |
| year                                     | or outpatient basis       |
+------------------------------------------+---------------------------+
| *Not covered: Speech therapy services    | *All charges.*            |
| that are not medically necessary*        |                           |
+------------------------------------------+---------------------------+
| ###### Hearing ser                       |                           |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| -   First hearing aid and testing only   | \$10 per visit to a       |
|     when necessitated by accidental      | primary care physician    |
|     injury                               |                           |
|                                          | \$20 per visit to a       |
| -   Hearing testing for children through | specialist                |
|     age 17 (see *Preventive care,        |                           |
|     children)*                           |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *All other hearing testing*          |                           |
|                                          |                           |
| -   *Hearing aids, testing and           |                           |
|     examinations for them*               |                           |
+------------------------------------------+---------------------------+
| ###### Vision ser                        |                           |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| -   One pair of eyeglasses or contact    | Nothing                   |
|     lenses to correct an impairment      |                           |
|     directly caused by accidental ocular |                           |
|     injury or intraocular surgery (such  |                           |
|     as for cataracts)                    |                           |
+------------------------------------------+---------------------------+
| -   Eye exam to determine the need for   | \$10 per visit to a       |
|     vision correction for children       | primary care physician    |
|     through age 17 (see Preventive care, |                           |
|     children)                            | \$20 per visit to a       |
|                                          | specialist                |
+------------------------------------------+---------------------------+
| *Vision services (testing, treatment,    |                           |
| and supplies) - continued on next page*  |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Vision services (testing          | You pay                   |
| , treatment, and supplies) *(continued)* |                           |
+------------------------------------------+---------------------------+
| -   Annual eye exam                      | \$20 per visit to a       |
|                                          | specialist                |
| -   Annual eye refraction                |                           |
|                                          |                           |
|     Note: See *Preventive care,          |                           |
|     children* for eye exams for          |                           |
|     children.                            |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Eyeglasses or contact lenses and    |                           |
|     after age 17, examinations for them* |                           |
|                                          |                           |
| -   *Eye exercises and orthoptics*       |                           |
|                                          |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
+------------------------------------------+---------------------------+
| ###### Foot care                         |                           |
+------------------------------------------+---------------------------+
| Routine foot care when you are under     | \$10 per visit to a       |
| active treatment for a metabolic or      | primary care physician    |
| peripheral vascular disease, such as     |                           |
| diabetes.                                | \$20 per visit to a       |
|                                          | specialist                |
| Note: See Orthopedic and prosthetic      |                           |
| devices for information on podiatric     |                           |
| shoe inserts.                            |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Cutting, trimming or removal of     |                           |
|     corns, calluses, or the free edge of |                           |
|     toenails, and similar routine        |                           |
|     treatment of conditions of the foot, |                           |
|     except as stated above*              |                           |
|                                          |                           |
| -   *Treatment of weak, strained or flat |                           |
|     feet or bunions or spurs; and of any |                           |
|     instability, imbalance or            |                           |
|     subluxation of the foot (unless the  |                           |
|     treatment is by open cutting         |                           |
|     surgery)*                            |                           |
+------------------------------------------+---------------------------+
| #                                        |                           |
| ##### Orthopedic and prosthetic devices  |                           |
+------------------------------------------+---------------------------+
| -   Artificial limbs and eyes; stump     | \$10 per visit to a       |
|     hose                                 | primary care physician    |
|                                          |                           |
| -   Externally worn breast prostheses    | \$20 per visit to a       |
|     and surgical bras, including         | specialist                |
|     necessary replacements following a   |                           |
|     mastectomy                           | 20% coinsurance for       |
|                                          | orthotic or prosthetic    |
| -   Internal prosthetic devices, such as | device                    |
|     artificial joints, pacemakers,       |                           |
|     cochlear implants, and surgically    | Note: Office visit copay  |
|     implanted breast implant following   | is in addition to the 20% |
|     mastectomy. Note: See 5.1(b) for     | coinsurance for the       |
|     coverage of the surgery to insert    | device whether billed     |
|     the device.                          | separately or together.   |
|                                          |                           |
| -   Corrective orthopedic appliances for |                           |
|     non-dental treatment of              |                           |
|     temporomandibular joint (TMJ) pain   |                           |
|     dysfunction syndrome.                |                           |
+------------------------------------------+---------------------------+
| *Orthopedic and prosthetic devices -     |                           |
| continued on next page*                  |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Orthope                           | You pay                   |
| dic and prosthetic devices *(continued)* |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Orthopedic, diabetic and corrective |                           |
|     shoes*                               |                           |
|                                          |                           |
| -   *Arch supports*                      |                           |
|                                          |                           |
| -   *Foot orthotics*                     |                           |
|                                          |                           |
| -   *Heel pads and heel cups*            |                           |
|                                          |                           |
| -   *Lumbosacral supports*               |                           |
|                                          |                           |
| -   *Corsets, trusses, elastic           |                           |
|     stockings, support hose, and other   |                           |
|     supportive devices*                  |                           |
|                                          |                           |
| -   *Prosthetic replacements*            |                           |
|                                          |                           |
| -   *Testicular implants*                |                           |
+------------------------------------------+---------------------------+
| ###### Durable medical equipment (DME)   |                           |
+------------------------------------------+---------------------------+
| Rental or purchase, at our option,       | 20% coinsurance           |
| including repair and adjustment, of      |                           |
| durable medical equipment prescribed by  |                           |
| your Plan physician, such as oxygen and  |                           |
| dialysis equipment. Under this benefit,  |                           |
| we also cover:                           |                           |
|                                          |                           |
| -   Hospital beds;                       |                           |
|                                          |                           |
| -   Wheelchairs;                         |                           |
|                                          |                           |
| -   Crutches;                            |                           |
|                                          |                           |
| -   Walkers;                             |                           |
|                                          |                           |
| -   Blood glucose monitors; and          |                           |
|                                          |                           |
| -   Insulin pumps.                       |                           |
|                                          |                           |
| Note: Your physician will arrange        |                           |
| coverage for durable medical equipment   |                           |
| with GHP and a Plan provider.            |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Motorized wheelchairs*              |                           |
|                                          |                           |
| -   *Non-durable medical supplies such   |                           |
|     as c-pap masks, foley catheters,     |                           |
|     dressings and leg bags*              |                           |
|                                          |                           |
| -   *Repair or replacement of purchased  |                           |
|     equipment*                           |                           |
+------------------------------------------+---------------------------+
| ###### Home health services              |                           |
+------------------------------------------+---------------------------+
| -   Home health care ordered by a Plan   | 20% coinsurance           |
|     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.                         |                           |
|                                          |                           |
| -   Services include oxygen therapy,     |                           |
|     intravenous therapy and medications. |                           |
+------------------------------------------+---------------------------+
| *Home health services - continued on     |                           |
| next page*                               |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| #                                        | You pay                   |
| ##### Home health services *(continued)* |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Nursing care requested by, or for   |                           |
|     the convenience of, the patient or   |                           |
|     the patient's family*                |                           |
|                                          |                           |
| -   *Home care primarily for personal    |                           |
|     assistance that does not include a   |                           |
|     medical component and is not         |                           |
|     diagnostic, therapeutic, or          |                           |
|     rehabilitative*                      |                           |
+------------------------------------------+---------------------------+
| ###### Chiropractic                      |                           |
+------------------------------------------+---------------------------+
| -   Up to 26 visits; treatment plan is   | \$10 per visit to a       |
|     required.                            | primary care physician    |
|                                          |                           |
|                                          | \$20 per visit to a       |
|                                          | specialist                |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Adjunctive procedures such as       |                           |
|     ultrasound, electrical muscle        |                           |
|     stimulation, vibratory therapy, and  |                           |
|     cold pack application.*              |                           |
+------------------------------------------+---------------------------+
| ###### Alternative treatments            |                           |
+------------------------------------------+---------------------------+
| -   Biofeedback when all other           | \$10 per visit to a       |
|     conservative measures have been      | primary care physician    |
|     exhausted                            |                           |
|                                          | \$20 per visit to a       |
|                                          | specialist                |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Naturopathic services*              |                           |
|                                          |                           |
| -   *Hypnotherapy*                       |                           |
|                                          |                           |
| -   *Acupuncture*                        |                           |
+------------------------------------------+---------------------------+
| ###### Educational classes and programs  |                           |
+------------------------------------------+---------------------------+
| Coverage is limited to:                  | Nothing                   |
|                                          |                           |
| -   Diabetes self management - Living    |                           |
|     with Diabetes is an education-based  |                           |
|     program supervised by a Certified    |                           |
|     Diabetes Educator. The program is    |                           |
|     coordinated through GHP's Complex    |                           |
|     Case Management Department and is    |                           |
|     directed at members who have         |                           |
|     diabetes. The program includes       |                           |
|     educational materials, quarterly     |                           |
|     newsletters, self-care guidelines,   |                           |
|     periodic health postcard reminders   |                           |
|     (for foot exams, retinal eye exams,  |                           |
|     cholesterol testing and long-term    |                           |
|     blood sugar tests), and referrals to |                           |
|     group and individual educational     |                           |
|     programs/support groups provided by  |                           |
|     hospitals and home health agencies.  |                           |
+------------------------------------------+---------------------------+
| *Educational classes and programs -      |                           |
| continued on next page*                  |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Educat                            | You pay                   |
| ional classes and programs *(continued)* |                           |
+------------------------------------------+---------------------------+
| -   Healthy Basics for Healthy Babies -  | Nothing                   |
|     To help promote a healthy pregnancy, |                           |
|     GHP has developed a Healthy Basics   |                           |
|     for a Healthy Baby Program for its   |                           |
|     expectant members. Healthy Basics    |                           |
|     encourages prenatal care and a       |                           |
|     healthy lifestyle, provides          |                           |
|     educational material, and identifies |                           |
|     pregnancies that may be of greater   |                           |
|     than average risk. Healthy Basics is |                           |
|     a free enhancement to the regular    |                           |
|     obstetrical care mothers receive     |                           |
|     during pregnancy. Expectant members  |                           |
|     are enrolled in Healthy Basics when  |                           |
|     GHP is notified of the pregnancy.    |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| *Weight loss program*                    |                           |
+------------------------------------------+---------------------------+

## **Section** 5.1(b) Surgical and anesthesia services provided by physicians and other health care professionals

+---+---+------------------------------------+--------------------+---+---+
|   | * | **Here are some important things   |                    | * |   |
|   | * | you should keep in mind about      |                    | * |   |
|   | I | these benefits:**                  |                    | I |   |
|   | * |                                    |                    | * |   |
|   | * | -   Please remember that all       |                    | * |   |
|   |   |     benefits are subject to the    |                    |   |   |
|   | * |     definitions, limitations, and  |                    | * |   |
|   | * |     exclusions in this brochure    |                    | * |   |
|   | M |     and are payable only when we   |                    | M |   |
|   | * |     determine they are medically   |                    | * |   |
|   | * |     necessary.                     |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   Plan physicians must provide   |                    | * |   |
|   | * |     or arrange your care.          |                    | * |   |
|   | 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 5.1(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 |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
+---+---+------------------------------------+--------------------+---+---+
| B |   |                                    | You pay            |   |   |
| e |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| f |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| D |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| s |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| p |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| o |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| S |   |                                    |                    |   |   |
| u |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| g |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
| a |   |                                    |                    |   |   |
| l |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| p |   |                                    |                    |   |   |
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| o |   |                                    |                    |   |   |
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| d |   |                                    |                    |   |   |
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| r |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| s |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| A |   |                                    | \$10 per visit to  |   |   |
| c |   |                                    | a primary care     |   |   |
| o |   |                                    | physician          |   |   |
| m |   |                                    |                    |   |   |
| p |   |                                    | \$20 per visit to  |   |   |
| r |   |                                    | a specialist       |   |   |
| e |   |                                    |                    |   |   |
| h |   |                                    | \$50 for           |   |   |
| e |   |                                    | outpatient surgery |   |   |
| n |   |                                    |                    |   |   |
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| ) |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+

*Surgical procedures - continued on next page*

+------------------------------------------+---------------------------+
| Surgical procedures *(continued)*        | You pay                   |
+------------------------------------------+---------------------------+
| -   Surgical treatment of morbid obesity | \$10 per visit to a       |
|     \-- a condition in which an          | primary care physician    |
|     individual weighs 100 pounds or 100% |                           |
|     over his or her normal weight        | \$20 per visit to a       |
|     according to current underwriting    | specialist                |
|     standards; eligible members must be  |                           |
|     age 18 or over.                      | \$50 for outpatient       |
|                                          | surgery                   |
| -   Insertion of internal prosthetic     |                           |
|     devices. See 5.1(a) -- Orthopedic    | \$100 for inpatient       |
|     and prosthetic devices for device    | services                  |
|     coverage information.                |                           |
|                                          |                           |
| -   Voluntary sterilization (e.g., Tubal |                           |
|     ligation, Vasectomy)                 |                           |
|                                          |                           |
| -   Treatment of burns                   |                           |
|                                          |                           |
| Note: Generally, we pay for internal     |                           |
| prostheses (devices) according to where  |                           |
| the procedure is done.                   |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Reversal of voluntary               |                           |
|     sterilization*                       |                           |
|                                          |                           |
| -   *Routine treatment of conditions of  |                           |
|     the foot; see Foot care*             |                           |
|                                          |                           |
| -   *Replacement of penile prosthesis*   |                           |
+------------------------------------------+---------------------------+
| ###### Reconstructive surgery            |                           |
+------------------------------------------+---------------------------+
| -   Surgery to correct a functional      | \$10 per visit to a       |
|     defect                               | primary care physician    |
|                                          |                           |
| -   Surgery to correct a condition       | \$20 per visit to a       |
|     caused by injury or illness if:      | specialist                |
|                                          |                           |
| ```{=html}                               | \$50 for outpatient       |
| <!-- -->                                 | surgery                   |
| ```                                      |                           |
| -   *the condition produced a major      | \$100 for inpatient       |
|     effect on the member's appearance    | surgery                   |
|     and*                                 |                           |
|                                          |                           |
| -   *the condition can reasonably be     |                           |
|     expected to be corrected by such     |                           |
|     surgery*                             |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Surgery to correct a condition that  |                           |
|     existed at or from birth and is a    |                           |
|     significant deviation from the       |                           |
|     common form or norm. Examples of     |                           |
|     congenital anomalies are: protruding |                           |
|     ear deformities; cleft lip; cleft    |                           |
|     palate; birth marks; webbed fingers; |                           |
|     and webbed toes.                     |                           |
|                                          |                           |
| -   All stages of breast reconstruction  |                           |
|     surgery following a mastectomy, such |                           |
|     as:                                  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *surgery to produce a symmetrical    |                           |
|     appearance of breasts;*              |                           |
|                                          |                           |
| -   *treatment of any physical           |                           |
|     complications, such as lymphedemas;* |                           |
|                                          |                           |
| -   *breast prostheses and surgical bras |                           |
|     and replacements (see Prosthetic     |                           |
|     devices)*                            |                           |
|                                          |                           |
| Note: If you need a mastectomy, you may  |                           |
| choose to have the procedure performed   |                           |
| on an inpatient basis and remain in the  |                           |
| hospital up to 48 hours after the        |                           |
| procedure.                               |                           |
+------------------------------------------+---------------------------+
| ######                                   | *Reconstructive surgery   |
|                                          | -- continued on next      |
|                                          | page*                     |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###                                      | You pay                   |
| ### Reconstructive surgery *(continued)* |                           |
+------------------------------------------+---------------------------+
| *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*                      |                           |
|                                          |                           |
| -   *Scar revision*                      |                           |
+------------------------------------------+---------------------------+
| ###### Oral and maxillofacial surgery    |                           |
+------------------------------------------+---------------------------+
| Oral surgical procedures, limited to:    | \$10 per visit to a       |
|                                          | primary care physician    |
| -   Reduction of fractures of the jaws   |                           |
|     or facial bones;                     | \$20 per visit to a       |
|                                          | specialist                |
| -   Surgical correction of cleft lip,    |                           |
|     cleft palate or severe functional    | \$50 for outpatient       |
|     malocclusion;                        | surgery                   |
|                                          |                           |
| -   Removal of stones from salivary      | \$100 for inpatient       |
|     ducts;                               | surgery                   |
|                                          |                           |
| -   Excision of leukoplakia or           |                           |
|     malignancies;                        |                           |
|                                          |                           |
| -   Excision of cysts and incision of    |                           |
|     abscesses when done as independent   |                           |
|     procedures; and                      |                           |
|                                          |                           |
| -   Other surgical procedures that do    |                           |
|     not involve the teeth or their       |                           |
|     supporting structures.               |                           |
|                                          |                           |
| -   Non-dental treatment of              |                           |
|     Temporomandibular (TMJ) joint pain   |                           |
|     dysfunction syndrome                 |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Oral implants and transplants*      |                           |
|                                          |                           |
| -   *Procedures that involve the teeth   |                           |
|     or their supporting structures (such |                           |
|     as the periodontal membrane,         |                           |
|     gingiva, and alveolar bone)*         |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Dental care involved in treatment   |                           |
|     of TMJ*                              |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Organ/tissue transplants          | You pay                   |
+------------------------------------------+---------------------------+
| Limited to:                              | Nothing                   |
|                                          |                           |
| -   Cornea                               |                           |
|                                          |                           |
| -   Heart                                |                           |
|                                          |                           |
| -   Heart/lung                           |                           |
|                                          |                           |
| -   Kidney                               |                           |
|                                          |                           |
| -   Kidney/Pancreas                      |                           |
|                                          |                           |
| -   Liver                                |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Lung: Single -- Double               |                           |
|                                          |                           |
| -   Pancreas                             |                           |
|                                          |                           |
| -   Allogeneic (donor) bone marrow       |                           |
|     transplants                          |                           |
|                                          |                           |
| -   Autologous bone marrow transplants   |                           |
|     (autologous stem cell and peripheral |                           |
|     stem cell support) for the following |                           |
|     conditions: acute lymphocytic or     |                           |
|     non-lymphocytic leukemia; advanced   |                           |
|     Hodgkin's lymphoma; advanced         |                           |
|     non-Hodgkin's lymphoma; advanced     |                           |
|     neuroblastoma; breast cancer;        |                           |
|     multiple myeloma; epithelial ovarian |                           |
|     cancer; and testicular, mediastinal, |                           |
|     retroperitoneal and ovarian germ     |                           |
|     cell tumors                          |                           |
|                                          |                           |
| -   Intestinal transplants (small        |                           |
|     intestine) and the small intestine   |                           |
|     with the liver or small intestine    |                           |
|     with multiple organs such as the     |                           |
|     liver, stomach, and pancreas         |                           |
|                                          |                           |
| Limited Benefits -- Treatment for breast |                           |
| cancer, multiple myeloma, and epithelial |                           |
| ovarian cancer may be provided in a      |                           |
| National Cancer Institute -- or National |                           |
| Institutes of Health-approved clinical   |                           |
| trial at a Plan-designated center of     |                           |
| excellence and if approved by the Plan's |                           |
| medical director in accordance with the  |                           |
| Plan's protocols.                        |                           |
|                                          |                           |
| -   Note: We cover related medical and   |                           |
|     hospital expenses of the donor when  |                           |
|     we cover the recipient.              |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Donor screening tests and donor     |                           |
|     search expenses, except those        |                           |
|     performed for the actual donor*      |                           |
|                                          |                           |
| -   *Implants of artificial organs*      |                           |
|                                          |                           |
| -   *Transplants not listed as covered*  |                           |
|                                          |                           |
| -   *Non-human organs*                   |                           |
|                                          |                           |
| -   *Hair transplants*                   |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Anesthesia                        | You pay                   |
+------------------------------------------+---------------------------+
| Professional services provided in --     | Nothing                   |
|                                          |                           |
| -   Hospital (inpatient)                 |                           |
|                                          |                           |
| -   Hospital outpatient department       |                           |
|                                          |                           |
| -   Skilled nursing facility             |                           |
|                                          |                           |
| -   Ambulatory surgical center           |                           |
|                                          |                           |
| -   Office                               |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Note: Anesthesia for dental          |                           |
|     procedure is not a covered benefit.  |                           |
+------------------------------------------+---------------------------+

## **Section** 5.1(c) Services provided by a hospital or other facility, and ambulance services 

+---+---+-------------------------------------+---------------------+---+---+
|   | * | **Here are some important things    |                     | * |   |
|   | * | you should keep in mind about these |                     | * |   |
|   | I | benefits:**                         |                     | I |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Plan physicians must provide or |                     | * |   |
|   | * |     arrange your care and you must  |                     | * |   |
|   | P |     be hospitalized in a Plan       |                     | P |   |
|   | * |     facility.                       |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | -   We have no calendar year        |                     |   |   |
|   | * |     deductible.                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | O | -   Be sure to read Section 4,      |                     | O |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | * |     services* for valuable          |                     | * |   |
|   |   |     information about how cost      |                     |   |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   | * |     Section 9 about coordinating    |                     | * |   |
|   | R |     benefits with other coverage,   |                     | R |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | -   The amounts listed below are    |                     |   |   |
|   | * |     for the charges billed by the   |                     | * |   |
|   | * |     facility (i.e., hospital or     |                     | * |   |
|   | T |     surgical center) or ambulance   |                     | T |   |
|   | * |     service for your surgery or     |                     | * |   |
|   | * |     care. Any costs associated with |                     | * |   |
|   |   |     the professional charge (i.e.,  |                     |   |   |
|   | * |     physicians, etc.) are in        |                     | * |   |
|   | * |     Sections 5.1(a) or (b).         |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * | -   **YOUR PHYSICIAN MUST GET       |                     | * |   |
|   | * |     PRECERTIFICATION OF HOSPITAL    |                     | * |   |
|   |   |     STAYS.** Please refer to        |                     |   |   |
|   | * |     Section 3 to be sure which      |                     | * |   |
|   | * |     services require                |                     | * |   |
|   | N |     precertification.               |                     | N |   |
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|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | 20% coinsurance     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| I |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | 20% coinsurance     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| L |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
| w |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

## Section 5.1(d) Emergency services/accidents

+---+---+-------------------------------------+---------------------+---+---+
| # | * | **Here are some important things to |                     | * |   |
| # | * | keep in mind about these            |                     | * |   |
| # | I | benefits:**                         |                     | I |   |
| # | * |                                     |                     | * |   |
| # | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   We have no calendar year        |                     | * |   |
|   | * |     deductible.                     |                     | * |   |
|   | P |                                     |                     | P |   |
|   | * | -   Be sure to read Section 4,      |                     | * |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   |   |     services,* for valuable         |                     |   |   |
|   | * |     information about how cost      |                     | * |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   | O |     Section 9 about coordinating    |                     | O |   |
|   | * |     benefits with other coverage,   |                     | * |   |
|   | * |     including with Medicare.        |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | #####                               |                     | * |   |
|   | * |                                     |                     | * |   |
|   | R |                                     |                     | R |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | N |                                     |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
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| * |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$10 per visit to a |   |   |
|   |   |                                     | primary care        |   |   |
|   |   |                                     | physician           |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     | \$20 per visit to a |   |   |
| m |   |                                     | specialist          |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$75 per visit      |   |   |
|   |   |                                     | (waived if          |   |   |
|   |   |                                     | admitted) emergency |   |   |
|   |   |                                     | room                |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     | \$100 copay per     |   |   |
| e |   |                                     | admission for       |   |   |
| r |   |                                     | inpatient services  |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$75 per visit      |   |   |
|   |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
| N |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
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| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| E |   |                                     | You pay             |   |   |
| m |   |                                     |                     |   |   |
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| _ |   |                                     |                     |   |   |
| _ |   |                                     |                     |   |   |
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| 2 |   |                                     |                     |   |   |
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| 1 |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$10 per visit to a |   |   |
|   |   |                                     | primary care        |   |   |
|   |   |                                     | physician           |   |   |
|   |   |                                     |                     |   |   |
| E |   |                                     | \$20 per visit to a |   |   |
| m |   |                                     | specialist          |   |   |
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| c |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$75 per visit      |   |   |
|   |   |                                     | (waived if          |   |   |
|   |   |                                     | admitted) emergency |   |   |
|   |   |                                     | room                |   |   |
| E |   |                                     |                     |   |   |
| m |   |                                     | \$100 copay per     |   |   |
| e |   |                                     | admission for       |   |   |
| r |   |                                     | inpatient services  |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$75 per visit      |   |   |
|   |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
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| u |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
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| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

## **Section** 5.1(e) Mental health and substance abuse benefits

+---+---+-----------------------------------+----------------------+---+---+
|   | * | When you get our approval for     |                      | * |   |
|   | * | services and follow a treatment   |                      | * |   |
|   | I | plan we approve, cost-sharing and |                      | I |   |
|   | * | limitations for Plan mental       |                      | * |   |
|   | * | health and substance abuse        |                      | * |   |
|   |   | benefits will be no greater than  |                      |   |   |
|   | * | for similar benefits for other    |                      | * |   |
|   | * | illnesses and conditions.         |                      | * |   |
|   | M |                                   |                      | M |   |
|   | * | **Here are some important things  |                      | * |   |
|   | * | to keep in mind about these       |                      | * |   |
|   |   | benefits:**                       |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * | -   Please remember that all      |                      | * |   |
|   | P |     benefits are subject to the   |                      | P |   |
|   | * |     definitions, limitations, and |                      | * |   |
|   | * |     exclusions in this brochure   |                      | * |   |
|   |   |     and are payable only when we  |                      |   |   |
|   | * |     determine they are medically  |                      | * |   |
|   | * |     necessary.                    |                      | * |   |
|   | O |                                   |                      | O |   |
|   | * | -   Be sure to read Section 4,    |                      | * |   |
|   | * |     *Your costs for covered       |                      | * |   |
|   |   |     services*, for valuable       |                      |   |   |
|   | * |     information about how cost    |                      | * |   |
|   | * |     sharing works. Also read      |                      | * |   |
|   | R |     Section 9 about coordinating  |                      | R |   |
|   | * |     benefits with other coverage, |                      | * |   |
|   | * |     including with Medicare.      |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * | -   **YOU MUST GET                |                      | * |   |
|   | * |     PREAUTHORIZATION OF THESE     |                      | * |   |
|   | T |     SERVICES.** See the           |                      | T |   |
|   | * |     instructions after the        |                      | * |   |
|   | * |     benefits description below.   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | A |                                   |                      | A |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | N |                                   |                      | N |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | T |                                   |                      | T |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
+---+---+-----------------------------------+----------------------+---+---+
| B |   |                                   | You pay              |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| f |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| D |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| c |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| M |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| h |   |                                   |                      |   |   |
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| a |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
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|   |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| d |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
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| b |   |                                   |                      |   |   |
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| c |   |                                   |                      |   |   |
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|   |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| b |   |                                   |                      |   |   |
| u |   |                                   |                      |   |   |
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|   |   |                                   |                      |   |   |
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| n |   |                                   |                      |   |   |
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| f |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| A |   |                                   | Your cost sharing    |   |   |
| l |   |                                   | responsibilities are |   |   |
| l |   |                                   | no greater than for  |   |   |
| d |   |                                   | other illnesses or   |   |   |
| i |   |                                   | conditions.          |   |   |
| a |   |                                   |                      |   |   |
| g |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
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| y |   |                                   |                      |   |   |
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| c |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$20 per visit       |   |   |
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| c |   |                                   |                      |   |   |
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| t |   |                                   |                      |   |   |
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|   |   |                                   |                      |   |   |
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| m |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| g |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| m |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | Nothing              |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| D |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| g |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
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| s |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
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| c |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
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| s |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$100 per admission  |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| S |   |                                   |                      |   |   |
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| s |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
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+---+---+-----------------------------------+----------------------+---+---+

## **Section** 5.1(f) Prescription drug benefits

+---+---+--------------------------------------------------------+---+---+
|   | * | **Here are some important things to keep in mind about | * |   |
|   | * | these benefits:**                                      | * |   |
|   | I |                                                        | I |   |
|   | * | -   We cover prescribed drugs and medications, as      | * |   |
|   | * |     described in the chart beginning on the next page. | * |   |
|   |   |                                                        |   |   |
|   | * | -   All benefits are subject to the definitions,       | * |   |
|   | * |     limitations and exclusions in this brochure and    | * |   |
|   | M |     are payable only when we determine they are        | M |   |
|   | * |     medically necessary.                               | * |   |
|   | * |                                                        | * |   |
|   |   | -   Be sure to read Section 4, *Your costs for covered |   |   |
|   | * |     services,* for valuable information about how cost | * |   |
|   | * |     sharing works. Also read Section 9 about           | * |   |
|   | P |     coordinating benefits with other coverage,         | P |   |
|   | * |     including with Medicare.                           | * |   |
|   | * |                                                        | * |   |
|   |   |                                                        |   |   |
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+---+---+--------------------------------------------------------+---+---+
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| a |   |                                                        |   |   |
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| n |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| t |   |                                                        |   |   |
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|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
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| a |   |                                                        |   |   |
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|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| b |   |                                                        |   |   |
| r |   |                                                        |   |   |
| a |   |                                                        |   |   |
| n |   |                                                        |   |   |
| d |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| d |   |                                                        |   |   |
| r |   |                                                        |   |   |
| u |   |                                                        |   |   |
| g |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| a |   |                                                        |   |   |
| n |   |                                                        |   |   |
| d |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| t |   |                                                        |   |   |
| h |   |                                                        |   |   |
| e |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
|   |   |                                                        |   |   |
| g |   |                                                        |   |   |
| e |   |                                                        |   |   |
| n |   |                                                        |   |   |
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| c |   |                                                        |   |   |
| . |   |                                                        |   |   |
+---+---+--------------------------------------------------------+---+---+

*Prescription drug benefits begin on the next page*

+------------------------------------------+---------------------------+
| Prescription drugs                       |                           |
+------------------------------------------+---------------------------+
| -   **Why use generic drugs?** To reduce |                           |
|     your out-of-pocket expenses! A       |                           |
|     generic drug is the chemical         |                           |
|     equivalent of a corresponding name   |                           |
|     brand drug. Generic drugs are less   |                           |
|     expensive than name brand drugs;     |                           |
|     therefore, you may reduce your       |                           |
|     out-of-pocket costs by choosing to   |                           |
|     use a generic drug.                  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   **When you do have to file a         |                           |
|     claim.** You would only have to file |                           |
|     a claim if you were out of our       |                           |
|     service area and unable to use one   |                           |
|     of the national chains participating |                           |
|     in the Plan in an emergency          |                           |
|     situation. In this case, please      |                           |
|     submit an itemized bill to GHP with  |                           |
|     an explanation and we will reimburse |                           |
|     you all but your copayment.          |                           |
+------------------------------------------+---------------------------+
| **Benefit Description**                  | **You pay**               |
+------------------------------------------+---------------------------+
| ###### Covered medications and supplies  |                           |
+------------------------------------------+---------------------------+
| We cover the following medications and   | **At a Plan Retail        |
| supplies prescribed by a Plan physician  | Pharmacy:**               |
| and obtained from a Plan pharmacy or     |                           |
| through our mail order program:          | \$10 copay for generic    |
|                                          | formulary                 |
| -   Drugs and medicines that by Federal  |                           |
|     law of the United States require a   | \$20 copay for name brand |
|     physician's prescription for their   | formulary                 |
|     purchase, except those listed as     |                           |
|     *Not covered.*                       | \$35 copay for            |
|                                          | non-formulary             |
| -   Insulin with a copay charge applied  |                           |
|     to each vial                         | or                        |
|                                          |                           |
| -   Disposable needles and syringes for  | **Through our Mail Order  |
|     the administration of covered        | Pharmacy:**               |
|     medications                          |                           |
|                                          | \$20 copay for generic    |
| -   Drugs for sexual dysfunction (see    | formulary                 |
|     Prior authorization)                 |                           |
|                                          | \$40 copay for name brand |
| -   Contraceptive drugs and devices      | formulary                 |
|                                          |                           |
|                                          | \$70 copay for            |
|                                          | non-formulary             |
|                                          |                           |
|                                          | Note: If there is no      |
|                                          | generic equivalent        |
|                                          | available, you will still |
|                                          | have to pay the name      |
|                                          | brand copay.              |
|                                          |                           |
|                                          | Note: For commercial      |
|                                          | containers through mail   |
|                                          | order, you pay the        |
|                                          | appropriate copay for     |
|                                          | each (3) containers.      |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes*                            |                           |
|                                          |                           |
| -   *Drugs to enhance athletic           |                           |
|     performance*                         |                           |
|                                          |                           |
| -   *Drugs obtained at a non-Plan        |                           |
|     pharmacy; except for out-of-area     |                           |
|     emergencies*                         |                           |
|                                          |                           |
| -   *Vitamins, nutrients and food        |                           |
|     supplements even if a physician      |                           |
|     prescribes or administers them*      |                           |
|                                          |                           |
| -   *Nonprescription medicines*          |                           |
|                                          |                           |
| -   *Drugs available without a           |                           |
|     prescription or for which a          |                           |
|     non-prescription equivalent is       |                           |
|     available*                           |                           |
+------------------------------------------+---------------------------+
| *Covered medications and supplies --     |                           |
| continued on next page*                  |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Covere                            | You pay                   |
| d medications and supplies *(continued)* |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Vitamins and nutritional substances |                           |
|     that can be purchased without a      |                           |
|     prescription*                        |                           |
|                                          |                           |
| -   *Medical supplies such as dressings  |                           |
|     and antiseptics*                     |                           |
|                                          |                           |
| -   *Diabetic supplies, except for       |                           |
|     needles, syringes, lancets and blood |                           |
|     glucose test strips*                 |                           |
|                                          |                           |
| -   *Smoking cessation drugs and         |                           |
|     medication including nicotine        |                           |
|     patches*                             |                           |
|                                          |                           |
| -   *Drugs for weight loss*              |                           |
|                                          |                           |
| -   *Refills for prescriptions resulting |                           |
|     from loss or theft*                  |                           |
|                                          |                           |
| -   *Prescription drugs for travel*      |                           |
+------------------------------------------+---------------------------+

## **Section** 5.1(g) Special features

+----------------------+-----------------------------------------------+
| Feature              | Description                                   |
+----------------------+-----------------------------------------------+
| ##### Flex           | Under the flexible benefits option, we        |
| ible benefits option | determine the most effective way to provide   |
|                      | services.                                     |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| ####                 | The TDD toll-free number is 877-231-0573 for  |
| # Services for deaf  | people who have difficulties with hearing or  |
| and hearing impaired | speech. You do need special equipment to use  |
|                      | the TDD number.                               |
+----------------------+-----------------------------------------------+
| ###                  | Members who are precertified for surgery are  |
| ## Joint replacement | educated in hopes of the following: increase  |
|                      | knowledge about their surgery and             |
|                      | postoperative care through recovery to        |
|                      | decrease anxiety; reduce length of stay for   |
|                      | the joint replacement member; and support     |
|                      | preoperative teaching programs.               |
+----------------------+-----------------------------------------------+
| ##### H              | To help promote a healthy pregnancy, GHP has  |
| igh risk pregnancies | developed Healthy Basics for a Health Baby    |
|                      | Program for its expectant members. Healthy    |
|                      | Basics encourages prenatal care and a healthy |
|                      | lifestyle, provides educational material, and |
|                      | identifies pregnancies that may be of greater |
|                      | than average risk. Healthy Basics is an       |
|                      | enhancement to the regular obstetrical care   |
|                      | mothers received during pregnancy. Expectant  |
|                      | members are enrolled in Healthy Basics when   |
|                      | GHP is notified of the pregnancy.             |
+----------------------+-----------------------------------------------+
| ##### Ce             | GHP provides members with access to           |
| nters of excellence  | nationally recognized transplant programs.    |
|                      | The programs are "Centers of Excellence"      |
|                      | offering members quality transplant services. |
|                      | GHP provides the opportunity for members to   |
|                      | have access to some of the nation's leading   |
|                      | transplant centers.                           |
+----------------------+-----------------------------------------------+
| ##### Members Choice | GHP offers members a complimentary health     |
|                      | care program called Members Choice. Through   |
|                      | this program, GHP members have additional     |
|                      | choices for a healthier lifestyle. Members    |
|                      | Choice features discounts on massage therapy, |
|                      | acupuncture, dietary supplements and          |
|                      | vitamins, as well as health club memberships  |
|                      | at a reduced rate. Members Choice is offered  |
|                      | through GHP's relationship with American      |
|                      | Specialty Health Networks (ASHN). To find a   |
|                      | contracted provider or fitness club in your   |
|                      | area, visit GHP's Web site at                 |
|                      | [www.ghp.com](http://www.ghp.com/) and click  |
|                      | on the Members icon, then Member Benefit      |
|                      | Information, then Members Choice. Or you may  |
|                      | call ASHN Member Services toll-free at        |
|                      | 877-335-2746 for assistance.                  |
+----------------------+-----------------------------------------------+

## **Section** 5.1(h) Dental benefits

+---+---+------------------------------------+---------------------+---+---+
|   | * | **Here are some important things   |                     | * |   |
|   | * | to keep in mind about these        |                     | * |   |
|   | I | benefits:**                        |                     | I |   |
|   | * |                                    |                     | * |   |
|   | * | -   Please remember that all       |                     | * |   |
|   |   |     benefits are subject to the    |                     |   |   |
|   | * |     definitions, limitations, and  |                     | * |   |
|   | * |     exclusions in this brochure    |                     | * |   |
|   | M |     and are payable only when we   |                     | M |   |
|   | * |     determine they are medically   |                     | * |   |
|   | * |     necessary.                     |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   Plan dentists must provide or  |                     | * |   |
|   | * |     arrange your care.             |                     | * |   |
|   | P |                                    |                     | P |   |
|   | * | -   We cover hospitalization for   |                     | * |   |
|   | * |     dental procedures only when a  |                     | * |   |
|   |   |     non-dental physical impairment |                     |   |   |
|   | * |     exists which makes             |                     | * |   |
|   | * |     hospitalization necessary to   |                     | * |   |
|   | O |     safeguard the health of the    |                     | O |   |
|   | * |     patient. See Section 5.1(c)    |                     | * |   |
|   | * |     for inpatient hospital         |                     | * |   |
|   |   |     benefits. We do not cover the  |                     |   |   |
|   | * |     dental procedure unless it is  |                     | * |   |
|   | * |     described below.               |                     | * |   |
|   | R |                                    |                     | R |   |
|   | * | -   Be sure to read Section 4,     |                     | * |   |
|   | * |     *Your costs for covered        |                     | * |   |
|   |   |     services,* for valuable        |                     |   |   |
|   | * |     information about how cost     |                     | * |   |
|   | * |     sharing works. Also read       |                     | * |   |
|   | T |     Section 9 about coordinating   |                     | T |   |
|   | * |     benefits with other coverage,  |                     | * |   |
|   | * |     including with Medicare.       |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | A |                                    |                     | A |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | N |                                    |                     | N |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | T |                                    |                     | T |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
+===+===+====================================+=====================+===+===+
| # |   |                                    | You pay             |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| A |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| j |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| W |   |                                    | \$20 per visit to a |   |   |
| e |   |                                    | specialist          |   |   |
| c |   |                                    |                     |   |   |
| o |   |                                    | \$50 per visit for  |   |   |
| v |   |                                    | outpatient surgical |   |   |
| e |   |                                    | procedure           |   |   |
| r |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
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| s |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
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| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| j |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| . |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| D |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| * |   |                                    | *All charges.*      |   |   |
| W |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| . |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+

# Section 5.2 HDHP Benefits - OVERVIEW

### General features of an HDHP

-   HDHPs have higher annual deductibles and annual out-of-pocket
    maximum limits than other types of FEHB plans.

-   Preventive care services at participating network providers are
    generally paid as first dollar coverage.

-   The annual deductible must be met before Plan benefits are paid for
    care other than preventive care services.

-   You are eligible for a Health Savings Account (HSA) if you are
    enrolled in an HDHP, not covered by any other health plan that is
    not an HDHP (including a spouse's health plan, but does not include
    specific injury insurance and accident, disability, dental care,
    vision care, or long-term care coverage), not eligible for Medicare,
    and are not claimed as a dependent on someone else's tax return.

```{=html}
<!-- -->
```
-   You may use the money in your HSA to pay all or a portion of the
    annual deductible, copayments, coinsurance, or other out-of-pocket
    costs that meet the IRS definition of a qualified medical expense.
    Distributions from your HSA are tax-free for qualified medical
    expenses for you, your spouse, and your dependents, even if they are
    not covered by an HDHP. You may withdraw money from your HSA for
    items other than qualified medical expenses, but it will be subject
    to income tax and, if you are under 65 years old, an additional 10%
    penalty tax on the amount withdrawn.

-   For each month that you are enrolled in an HDHP and eligible for an
    HSA, the HDHP will pass through (contribute) a portion of the health
    plan premium to your HSA. In addition, you (the account holder) may
    contribute your own money to your HSA up to an allowable amount
    determined by IRS rules. In addition, your HSA dollars earn tax-free
    interest.

-   You may allow the contributions in your HSA to grow over time, like
    a savings account. The HSA is portable -- you may take the HSA with
    you if you leave the Federal government or switch to another plan.

```{=html}
<!-- -->
```
-   If you are not eligible for an HSA, or become ineligible to continue
    an HSA, you are eligible for a Health Reimbursement Arrangement
    (HRA). Although an HRA is similar to an HSA, there are major
    differences.

    -   An HRA does not earn interest.

    -   An HRA is not portable if you leave the Federal government or
        switch to another plan.

-   We protect you against catastrophic out-of-pocket expenses for
    covered services. Your annual out-of-pocket expenses for covered
    services, including deductibles and copayments, are limited to
    \$5,000 for Self-Only enrollment, or \$10,000 for family coverage
    for in-network services. Your annual out-of-pocket expenses for
    covered services, including deductibles and copayments, are limited
    to \$10,000 for Self-Only enrollment, or \$20,000 for family
    coverage for out-of-network services.

At your option, you may choose to obtain benefits covered by this Plan
from non-Plan doctors and hospitals whenever you need care,
[except]{.underline} for the benefits listed as "What is not covered".
When you obtain covered non-emergency medical treatment from a non-Plan
doctor without a referral from a Plan doctor, you are subject to the
deductibles, coinsurance and maximum benefit stated below.

+-----------------+----------------------------------------------------+
| #               |                                                    |
| ## HDHP Summary |                                                    |
+-----------------+----------------------------------------------------+
| Our             |                                                    |
| high-deductible |                                                    |
| health plan     |                                                    |
| option provides |                                                    |
| comprehensive   |                                                    |
| coverage for    |                                                    |
| high-cost       |                                                    |
| medical events  |                                                    |
| and a           |                                                    |
| tax-advantaged  |                                                    |
| way to help you |                                                    |
| build savings   |                                                    |
| for future      |                                                    |
| medical         |                                                    |
| expenses. The   |                                                    |
| Plan gives you  |                                                    |
| greater control |                                                    |
| over how you    |                                                    |
| use your health |                                                    |
| care benefits.  |                                                    |
|                 |                                                    |
| When you enroll |                                                    |
| in this HDHP    |                                                    |
| option, we      |                                                    |
| establish       |                                                    |
| either a Health |                                                    |
| Savings Account |                                                    |
| (HSA) or a      |                                                    |
| Health          |                                                    |
| Reimbursement   |                                                    |
| Arrangement     |                                                    |
| (HRA) for       |                                                    |
| you. Each       |                                                    |
| month, we       |                                                    |
| automatically   |                                                    |
| pass through a  |                                                    |
| portion of the  |                                                    |
| total health    |                                                    |
| Plan premium to |                                                    |
| your HSA or HRA |                                                    |
| based upon your |                                                    |
| eligibility as  |                                                    |
| of the first    |                                                    |
| day of the      |                                                    |
| month. If we    |                                                    |
| establish an    |                                                    |
| HRA for you, we |                                                    |
| will make a     |                                                    |
| monthly         |                                                    |
| contribution of |                                                    |
| \$41.67 per     |                                                    |
| employee per    |                                                    |
| month for Self  |                                                    |
| Only coverage   |                                                    |
| and \$83.33 per |                                                    |
| employee per    |                                                    |
| month for Self  |                                                    |
| and Family      |                                                    |
| coverage.       |                                                    |
|                 |                                                    |
| With this Plan, |                                                    |
| preventive care |                                                    |
| is covered in   |                                                    |
| full less the   |                                                    |
| copayment at    |                                                    |
| participating   |                                                    |
| network         |                                                    |
| providers. As   |                                                    |
| you receive     |                                                    |
| other           |                                                    |
| non-preventive  |                                                    |
| medical care,   |                                                    |
| you must meet   |                                                    |
| the Plan's      |                                                    |
| deductible      |                                                    |
| before we pay   |                                                    |
| benefits        |                                                    |
| according to    |                                                    |
| the benefit     |                                                    |
| chart on page   |                                                    |
| 50. You can     |                                                    |
| choose to use   |                                                    |
| funds available |                                                    |
| in your HSA to  |                                                    |
| make payments   |                                                    |
| toward the      |                                                    |
| deductible or   |                                                    |
| you can pay     |                                                    |
| toward your     |                                                    |
| deductible      |                                                    |
| entirely        |                                                    |
| out-of-pocket,  |                                                    |
| allowing your   |                                                    |
| savings to      |                                                    |
| continue to     |                                                    |
| grow.           |                                                    |
|                 |                                                    |
| This HDHP       |                                                    |
| includes four   |                                                    |
| key components: |                                                    |
| in-network      |                                                    |
| preventive      |                                                    |
| care; health    |                                                    |
| care that is    |                                                    |
| subject to the  |                                                    |
| deductible;     |                                                    |
| catastrophic    |                                                    |
| protection for  |                                                    |
| out-of-pocket   |                                                    |
| expenses; and,  |                                                    |
| health          |                                                    |
| education       |                                                    |
| resources and   |                                                    |
| account         |                                                    |
| management      |                                                    |
| tools.          |                                                    |
+-----------------+----------------------------------------------------+
| 1.  In-network  | The Plan covers preventive care services, such as  |
|     preventive  | periodic health evaluations (e.g., annual          |
|     care        | physicals), screening services (e.g., mammograms), |
|                 | routine prenatal and well-child care, child and    |
|                 | adult immunizations, disease management and        |
|                 | wellness programs. These services are covered at   |
|                 | 100% after copayment for participating providers   |
|                 | and are fully described in Section 5.2(a).  *You   |
|                 | do not have to meet the deductible before using    |
|                 | these services.*                                   |
+-----------------+----------------------------------------------------+
| 2.  Medical     | After you have met the Plan's deductible, we pay   |
|     care        | benefits under HDHP Medical Coverage described in  |
|                 | Section 5.2(c).  The Plan typically pays 90% for   |
|                 | in-network and 70% for out-of-network care.        |
|                 |                                                    |
|                 | Covered services include:                          |
|                 |                                                    |
|                 | -   Medical services and supplies provided by      |
|                 |     physicians and other health care professionals |
|                 |                                                    |
|                 | -   Surgical and anesthesia services provided by   |
|                 |     physicians and other health care professionals |
|                 |                                                    |
|                 | -   Hospital services; other facility or ambulance |
|                 |     services                                       |
|                 |                                                    |
|                 | -   Emergency services/accidents                   |
|                 |                                                    |
|                 | -   Mental health and substance abuse benefits     |
|                 |                                                    |
|                 | -   Prescription drug benefits                     |
|                 |                                                    |
|                 | -   Dental benefits                                |
+-----------------+----------------------------------------------------+
| -   Savings     | Health Savings Accounts or Health Reimbursement    |
|                 | Arrangements provide a means to help you pay       |
|                 | out-of-pocket expenses (see Section 5.2(k) for     |
|                 | more details).                                     |
+-----------------+----------------------------------------------------+
| -   HSA         | By law, HSAs are available to members who are not  |
|                 | eligible for Medicare or do not have other health  |
| ####  {#section | insurance coverage. In 2005, for each month you    |
| -6 .unnumbered} | are eligible for an HSA premium pass through, we   |
|                 | will contribute to your HSA \$41.67 per month for  |
|                 | a Self-Only enrollment or \$83.33 per month for a  |
|                 | Self and Family enrollment. In addition to our     |
|                 | monthly contribution, you have the option to make  |
|                 | additional tax-free contributions to your HSA, so  |
|                 | long as total contributions do not exceed the      |
|                 | limit established by law, which is \$1,000 for a   |
|                 | Self-Only enrollment and \$1,500 for a Self and    |
|                 | Family enrollment.  See maximum contribution       |
|                 | information in Section 5.2(k). You can use funds   |
|                 | in your HSA to help pay your health plan           |
|                 | deductible, copayments and non-covered medical     |
|                 | services.                                          |
|                 |                                                    |
|                 | **Federal tax tip:** There are tax advantages to   |
|                 | fully funding your HSA as quickly as possible.     |
|                 | Your HSA contribution payments are fully           |
|                 | deductible on your Federal tax return. By fully    |
|                 | funding your HSA early in the year, you have the   |
|                 | flexibility of paying medical expenses from        |
|                 | tax-free HSA dollars or after tax out-of-pocket    |
|                 | dollars. If you don't deplete your HSA and you     |
|                 | allow the contributions and the tax-free interest  |
|                 | to accumulate, your HSA grows more quickly for     |
|                 | future expenses.                                   |
|                 |                                                    |
|                 | HSA features include:                              |
|                 |                                                    |
|                 | -   Your HSA is administered by Corporate Benefit  |
|                 |     Services of America, Inc. (CBSA).              |
|                 |                                                    |
|                 | -   Your contributions to the HSA are tax          |
|                 |     deductible.                                    |
|                 |                                                    |
|                 | -   Your HSA earns tax-free interest.              |
|                 |                                                    |
|                 | -   You can make tax-free withdrawals for          |
|                 |     qualified medical expenses for you, your       |
|                 |     spouse and dependents. (See IRS publication    |
|                 |     502 for a complete list of eligible expenses.) |
|                 |                                                    |
|                 | -   Your unused HSA funds and interest accumulate  |
|                 |     from year to year.                             |
|                 |                                                    |
|                 | -   It's portable - the HSA is owned by you and is |
|                 |     yours to keep, even when you leave Federal     |
|                 |     employment or retire.                          |
|                 |                                                    |
|                 | -   When you need it, funds up to the actual HSA   |
|                 |     balance are available.                         |
+-----------------+----------------------------------------------------+
| -   HRA         | For members who aren't eligible for an HSA, are    |
|                 | eligible for Medicare or have another health plan, |
|                 | we will administer and provide an HRA.             |
|                 |                                                    |
|                 | In 2005, for each month you are eligible for an    |
|                 | HRA premium pass through, we will contribute to    |
|                 | your HRA \$41.67 per month for a Self-Only         |
|                 | enrollment or \$83.33 per month for a Self and     |
|                 | Family enrollment. You can use funds in your HRA   |
|                 | to help pay your health plan deductible and/or for |
|                 | certain expenses that don't count toward the       |
|                 | deductible.                                        |
|                 |                                                    |
|                 | HRA features include:                              |
|                 |                                                    |
|                 | -   For our HDHP option, the HRA is administered   |
|                 |     by Corporate Benefit Services of America, Inc. |
|                 |     (CBSA).                                        |
|                 |                                                    |
|                 | -   Entire HRA credit (prorated from your          |
|                 |     effective date to the end of the plan year) is |
|                 |     available from your effective date of          |
|                 |     enrollment.                                    |
|                 |                                                    |
|                 | -   Tax-free credit can be used to pay for         |
|                 |     qualified medical expenses for you and any     |
|                 |     individuals covered by this HDHP.              |
|                 |                                                    |
|                 | -   Unused credits carryover from year to year.    |
|                 |                                                    |
|                 | -   HRA credit does not earn interest.             |
|                 |                                                    |
|                 | ```{=html}                                         |
|                 | <!-- -->                                           |
|                 | ```                                                |
|                 | -   HRA credit is forfeited if you leave Federal   |
|                 |     employment or switch health insurance plans.   |
+-----------------+----------------------------------------------------+
| 3               | You are protected by an annual catastrophic        |
| .  Catastrophic | maximum on out-of-pocket expenses for covered      |
|     protection  | services. After your coinsurance, copayments and   |
|     for         | deductibles total \$5,000 per person or \$10,000   |
|                 | per family enrollment in-network and \$10,000 per  |
|   out-of-pocket | person or \$20,000 per family out-of-network in    |
|     expenses    | any calendar year, you do not have to pay any more |
|                 | for covered services from network providers.       |
|                 | However, certain expenses do not count toward your |
|                 | out-of-pocket maximum and you must continue to pay |
|                 | these expenses once you reach your out-of-pocket   |
|                 | maximum (such as expenses in excess of the Plan's  |
|                 | benefit maximum, or if you use out-of-network      |
|                 | providers, amounts in excess of the Plan           |
|                 | allowance). Refer to Section 4 *Your catastrophic  |
|                 | protection out-of-pocket maximum*, Section 5.2(b)  |
|                 | *High Deductible Health Plan*, and Section 5.2(l)  |
|                 | *Catastrophic protection for out-of-pocket         |
|                 | expenses* for more details.                        |
+-----------------+----------------------------------------------------+
| 4.  Health      | Section 5.2(m) describes the health education      |
|     education   | resources and account management tools available   |
|     resources   | to you to help you manage your health care and     |
|     and account | your health care dollars.                          |
|     management  |                                                    |
|     tools       |                                                    |
+-----------------+----------------------------------------------------+

## Section 5.2(a) Preventive care

+---+---+-------------------------------------+---------------------+---+---+
|   | * | **Here are some important things    |                     | * |   |
|   | * | you should keep in mind about these |                     | * |   |
|   | I | preventive care benefits:**         |                     | I |   |
|   | * |                                     |                     | * |   |
|   | * | -   The Plan pays 100% less your    |                     | * |   |
|   |   |     copay for the preventive care   |                     |   |   |
|   | * |     services listed in this         |                     | * |   |
|   | * |     Section.                        |                     | * |   |
|   | M |                                     |                     | M |   |
|   | * | -   For all other covered expenses, |                     | * |   |
|   | * |     please see Section 5.2(b)       |                     | * |   |
|   |   |     --High Deductible Health Plan.  |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   | P |     benefits are subject to the     |                     | P |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   |   |     are payable only when we        |                     |   |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   | O |                                     |                     | O |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | R |                                     |                     | R |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | N |                                     |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| N |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| : |   |                                     |                     |   |   |
| T |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | In-network: \$15    |   |   |
| r |   |                                     | per visit to a      |   |   |
| o |   |                                     | primary care        |   |   |
| f |   |                                     | physician, no       |   |   |
| e |   |                                     | deductible          |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     | Out-of-network: 30% |   |   |
| i |   |                                     | of covered expenses |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
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|   |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | In-network: \$15    |   |   |
| r |   |                                     | per visit to a      |   |   |
| o |   |                                     | primary care        |   |   |
| f |   |                                     | physician, no       |   |   |
| e |   |                                     | deductible          |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     | Out-of-network: 30% |   |   |
| i |   |                                     | of covered expenses |   |   |
| o |   |                                     | after deductible    |   |   |
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| ) |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | In-network: Nothing |   |   |
| r |   |                                     |                     |   |   |
| o |   |                                     | Out-of-network:     |   |   |
| f |   |                                     | Nothing             |   |   |
| e |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| h |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| A |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
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| o |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| P |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
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| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | In-network: \$15    |   |   |
| r |   |                                     | per visit to a      |   |   |
| o |   |                                     | primary care        |   |   |
| f |   |                                     | physician, no       |   |   |
| e |   |                                     | deductible          |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     | Out-of-network: 30% |   |   |
| i |   |                                     | of covered expenses |   |   |
| o |   |                                     | after deductible    |   |   |
| n |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
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| 1 |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| x |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| 2 |   |                                     |                     |   |   |
| 4 |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     | *Preventive care,   |   |   |
| # |   |                                     | children --         |   |   |
| # |   |                                     | continued on next   |   |   |
| # |   |                                     | page*               |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

+------------------------------------------+---------------------------+
| ######                                   | You pay                   |
| Preventive care, children *(continued)*  |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Physical exams required for         |                           |
|     obtaining or continuing employment   |                           |
|     or insurance, attending schools or   |                           |
|     camp, or travel.*                    |                           |
|                                          |                           |
| -   *Immunizations, boosters, and        |                           |
|     medications for travel.*             |                           |
+------------------------------------------+---------------------------+

## Section 5.2(b) High Deductible Medical Coverage subject to the deductible

+---+---+------------------------------------+--------------------+---+---+
|   | * | **Here are some important things   |                    | * |   |
|   | * | you should keep in mind about      |                    | * |   |
|   | I | these benefits:**                  |                    | I |   |
|   | * |                                    |                    | * |   |
|   | * | -   Please remember that all       |                    | * |   |
|   |   |     benefits are subject to the    |                    |   |   |
|   | * |     definitions, limitations, and  |                    | * |   |
|   | * |     exclusions in this brochure    |                    | * |   |
|   | M |     and are payable only when we   |                    | M |   |
|   | * |     determine they are medically   |                    | * |   |
|   | * |     necessary.                     |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   In-network preventive care is  |                    | * |   |
|   | * |     covered at 100% after your     |                    | * |   |
|   | P |     copay under Section 5.2(a) and |                    | P |   |
|   | * |     is not subject to the calendar |                    | * |   |
|   | * |     year deductible.               |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   The deductible is \$1,500 per  |                    | * |   |
|   | * |     person or \$2,500 per family   |                    | * |   |
|   | O |     enrollment for in-network      |                    | O |   |
|   | * |     benefits and \$3,000 per       |                    | * |   |
|   | * |     person or \$5,000 per family   |                    | * |   |
|   |   |     enrollment for out-of-network  |                    |   |   |
|   | * |     benefits. The family           |                    | * |   |
|   | * |     deductible can be satisfied by |                    | * |   |
|   | R |     one or more family members.    |                    | R |   |
|   | * |     The deductible applies to      |                    | * |   |
|   | * |     almost all benefits in Section |                    | * |   |
|   |   |     5.2. You must pay your         |                    |   |   |
|   | * |     deductible before your Medical |                    | * |   |
|   | * |     Coverage may begin.            |                    | * |   |
|   | T |                                    |                    | T |   |
|   | * | -   Under Medical Coverage, you    |                    | * |   |
|   | * |     are responsible for your       |                    | * |   |
|   |   |     coinsurance and copayments for |                    |   |   |
|   | * |     covered expenses.              |                    | * |   |
|   | * |                                    |                    | * |   |
|   | A | -   You are protected by an annual |                    | A |   |
|   | * |     catastrophic maximum on        |                    | * |   |
|   | * |     out-of-pocket expenses for     |                    | * |   |
|   |   |     covered services. After your   |                    |   |   |
|   | * |     coinsurance, copayments and    |                    | * |   |
|   | * |     deductibles total \$5,000 per  |                    | * |   |
|   | N |     person or \$10,000 per family  |                    | N |   |
|   | * |     enrollment in-network and      |                    | * |   |
|   | * |     \$10,000 per person or         |                    | * |   |
|   |   |     \$20,000 per family            |                    |   |   |
|   | * |     out-of-network in any calendar |                    | * |   |
|   | * |     year, you do not have to pay   |                    | * |   |
|   | T |     any more for covered services  |                    | T |   |
|   | * |     from network providers.        |                    | * |   |
|   | * |     However, certain expenses do   |                    | * |   |
|   |   |     not count toward your          |                    |   |   |
|   |   |     out-of-pocket maximum and you  |                    |   |   |
|   |   |     must continue to pay these     |                    |   |   |
|   |   |     expenses once you reach your   |                    |   |   |
|   |   |     out-of-pocket maximum (such as |                    |   |   |
|   |   |     expenses in excess of the      |                    |   |   |
|   |   |     Plan's benefit maximum, or if  |                    |   |   |
|   |   |     you use out-of-network         |                    |   |   |
|   |   |     providers, amounts in excess   |                    |   |   |
|   |   |     of the Plan allowance).        |                    |   |   |
|   |   |                                    |                    |   |   |
|   |   | -   In-network benefits apply only |                    |   |   |
|   |   |     when you use a network         |                    |   |   |
|   |   |     provider.                      |                    |   |   |
|   |   |                                    |                    |   |   |
|   |   | -   Be sure to read Section 4,     |                    |   |   |
|   |   |     *Your costs for covered        |                    |   |   |
|   |   |     services*, for valuable        |                    |   |   |
|   |   |     information about how cost     |                    |   |   |
|   |   |     sharing works. Also read       |                    |   |   |
|   |   |     Section 9 about coordinating   |                    |   |   |
|   |   |     benefits with other coverage.  |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| # |   |                                    | You pay            |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
| # |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| D |   |                                    |                    |   |   |
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|   |   |                                    |                    |   |   |
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| f |   |                                    |                    |   |   |
| o |   |                                    |                    |   |   |
| r |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
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| d |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| c |   |                                    |                    |   |   |
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|   |   |                                    |                    |   |   |
| C |   |                                    |                    |   |   |
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| v |   |                                    |                    |   |   |
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| r |   |                                    |                    |   |   |
| a |   |                                    |                    |   |   |
| g |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
|   |   |                                    |                    |   |   |
| b |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| g |   |                                    |                    |   |   |
| i |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| s |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+
| T |   |                                    | In-network: 100%   |   |   |
| h |   |                                    | of allowable       |   |   |
| e |   |                                    | charges until you  |   |   |
| d |   |                                    | meet the           |   |   |
| e |   |                                    | deductible of      |   |   |
| d |   |                                    | \$1,500 per person |   |   |
| u |   |                                    | or \$2,500 per     |   |   |
| c |   |                                    | family enrollment. |   |   |
| t |   |                                    |                    |   |   |
| i |   |                                    | Out-of-network:    |   |   |
| b |   |                                    | 100% of allowable  |   |   |
| l |   |                                    | charges until you  |   |   |
| e |   |                                    | meet the           |   |   |
| a |   |                                    | deductible of      |   |   |
| p |   |                                    | \$3,000 per person |   |   |
| p |   |                                    | or \$5,000 per     |   |   |
| l |   |                                    | family enrollment. |   |   |
| i |   |                                    |                    |   |   |
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+---+---+------------------------------------+--------------------+---+---+
| * |   |                                    |                    |   |   |
| D |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| d |   |                                    |                    |   |   |
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|   |   |                                    |                    |   |   |
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| n |   |                                    |                    |   |   |
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| d |   |                                    |                    |   |   |
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| n |   |                                    |                    |   |   |
| n |   |                                    |                    |   |   |
| e |   |                                    |                    |   |   |
| x |   |                                    |                    |   |   |
| t |   |                                    |                    |   |   |
| p |   |                                    |                    |   |   |
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| * |   |                                    |                    |   |   |
+---+---+------------------------------------+--------------------+---+---+

+------------------------------------------+---------------------------+
| ###### Deductible befo                   | You pay                   |
| re Medical Coverage begins *(continued)* |                           |
+------------------------------------------+---------------------------+
| After you meet the deductible, we pay    | In-network: After you     |
| the allowable charge (less your          | meet the deductible, you  |
| coinsurance or copayment) until you meet | pay the indicated         |
| the annual catastrophic out-of-pocket    | coinsurance or copayments |
| maximum.                                 | for covered services. You |
|                                          | may choose to pay the     |
|                                          | coinsurance and           |
|                                          | copayments from your HSA  |
|                                          | or HRA, or you can pay    |
|                                          | for them out-of-pocket.   |
|                                          | Maximum out-of-pocket for |
|                                          | in-network services is    |
|                                          | \$5,000 per person or     |
|                                          | \$10,000 per family in    |
|                                          | any calendar year.        |
|                                          |                           |
|                                          | Out-of-network: After you |
|                                          | meet the deductible, you  |
|                                          | pay the indicated         |
|                                          | coinsurance based on our  |
|                                          | Plan allowance and any    |
|                                          | difference between our    |
|                                          | allowance and the billed  |
|                                          | amount. Maximum           |
|                                          | out-of-pocket for         |
|                                          | out-of-network services   |
|                                          | is \$10,000 per person or |
|                                          | \$20,000 per family in    |
|                                          | any calendar year.        |
+------------------------------------------+---------------------------+

## Section 5.2(c) Medical services and supplies provided by physicians and other health care professionals

+---+-----------------------------------------+---------------------------+
| B |                                         | After the deductible, you |
| e |                                         | pay                       |
| n |                                         |                           |
| e |                                         |                           |
| f |                                         |                           |
| i |                                         |                           |
| t |                                         |                           |
| D |                                         |                           |
| e |                                         |                           |
| s |                                         |                           |
| c |                                         |                           |
| r |                                         |                           |
| i |                                         |                           |
| p |                                         |                           |
| t |                                         |                           |
| i |                                         |                           |
| o |                                         |                           |
| n |                                         |                           |
+---+-----------------------------------------+---------------------------+
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
|   |                                         |                           |
| D |                                         |                           |
| i |                                         |                           |
| a |                                         |                           |
| g |                                         |                           |
| n |                                         |                           |
| o |                                         |                           |
| s |                                         |                           |
| t |                                         |                           |
| i |                                         |                           |
| c |                                         |                           |
|   |                                         |                           |
| a |                                         |                           |
| n |                                         |                           |
| d |                                         |                           |
|   |                                         |                           |
| t |                                         |                           |
| r |                                         |                           |
| e |                                         |                           |
| a |                                         |                           |
| t |                                         |                           |
| m |                                         |                           |
| e |                                         |                           |
| n |                                         |                           |
| t |                                         |                           |
|   |                                         |                           |
| s |                                         |                           |
| e |                                         |                           |
| r |                                         |                           |
| v |                                         |                           |
| i |                                         |                           |
| c |                                         |                           |
| e |                                         |                           |
| s |                                         |                           |
+---+-----------------------------------------+---------------------------+
| P |                                         | In-network: \$15 per      |
| r |                                         | visit to a primary care   |
| o |                                         | physician; \$25 per visit |
| f |                                         | to a specialist           |
| e |                                         |                           |
| s |                                         | Out-of-network: 30% of    |
| s |                                         | the Plan allowance and    |
| i |                                         | any difference between    |
| o |                                         | our allowance and the     |
| n |                                         | billed amount             |
| a |                                         |                           |
| l |                                         |                           |
| s |                                         |                           |
| e |                                         |                           |
| r |                                         |                           |
| v |                                         |                           |
| i |                                         |                           |
| c |                                         |                           |
| e |                                         |                           |
| s |                                         |                           |
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| f |                                         |                           |
| p |                                         |                           |
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| y |                                         |                           |
| s |                                         |                           |
| i |                                         |                           |
| c |                                         |                           |
| i |                                         |                           |
| a |                                         |                           |
| n |                                         |                           |
| s |                                         |                           |
|   |                                         |                           |
| - |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
| I |                                         |                           |
| n |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
| p |                                         |                           |
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|   |                                         |                           |
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|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
| I |                                         |                           |
| n |                                         |                           |
|   |                                         |                           |
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|   |                                         |                           |
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|   |                                         |                           |
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|   |                                         |                           |
| c |                                         |                           |
| a |                                         |                           |
| r |                                         |                           |
| e |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
| c |                                         |                           |
| e |                                         |                           |
| n |                                         |                           |
| t |                                         |                           |
| e |                                         |                           |
| r |                                         |                           |
+---+-----------------------------------------+---------------------------+
| P |                                         | In-network: Nothing       |
| r |                                         |                           |
| o |                                         | Out-of-network: 30% of    |
| f |                                         | the Plan allowance and    |
| e |                                         | any difference between    |
| s |                                         | our allowance and the     |
| s |                                         | billed amount             |
| i |                                         |                           |
| o |                                         |                           |
| n |                                         |                           |
| a |                                         |                           |
| l |                                         |                           |
| s |                                         |                           |
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| c |                                         |                           |
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| s |                                         |                           |
| o |                                         |                           |
| f |                                         |                           |
| p |                                         |                           |
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| y |                                         |                           |
| s |                                         |                           |
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| a |                                         |                           |
| n |                                         |                           |
| s |                                         |                           |
|   |                                         |                           |
| - |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
| D |                                         |                           |
| u |                                         |                           |
| r |                                         |                           |
| i |                                         |                           |
| n |                                         |                           |
| g |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
| a |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
| h |                                         |                           |
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| s |                                         |                           |
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| t |                                         |                           |
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|   |                                         |                           |
|   |                                         |                           |
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| t |                                         |                           |
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|   |                                         |                           |
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|   |                                         |                           |
| I |                                         |                           |
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| d |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
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+---+-----------------------------------------+---------------------------+
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
|   |                                         |                           |
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| , |                                         |                           |
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|   |                                         |                           |
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| d |                                         |                           |
|   |                                         |                           |
| o |                                         |                           |
| t |                                         |                           |
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| s |                                         |                           |
| t |                                         |                           |
| s |                                         |                           |
+---+-----------------------------------------+---------------------------+
| T |                                         | In-network: Nothing       |
| e |                                         |                           |
| s |                                         | Out-of-network: 30% of    |
| t |                                         | the Plan allowance and    |
| s |                                         | any difference between    |
| , |                                         | our allowance and the     |
| s |                                         | billed amount             |
| u |                                         |                           |
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|   |                                         |                           |
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| m |                                         |                           |
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| - |                                         |                           |
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| ` |                                         |                           |
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| d |                                         |                           |
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| a |                                         |                           |
| m |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
| a |                                         |                           |
| n |                                         |                           |
| d |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
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| G |                                         |                           |
+---+-----------------------------------------+---------------------------+
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
| # |                                         |                           |
|   |                                         |                           |
| M |                                         |                           |
| a |                                         |                           |
| t |                                         |                           |
| e |                                         |                           |
| r |                                         |                           |
| n |                                         |                           |
| i |                                         |                           |
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|   |                                         |                           |
| c |                                         |                           |
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| r |                                         |                           |
| e |                                         |                           |
+---+-----------------------------------------+---------------------------+
| C |                                         | In-network: 10% of the    |
| o |                                         | Plan allowance            |
| m |                                         |                           |
| p |                                         | Out-of-network: 30% of    |
| l |                                         | the Plan allowance and    |
| e |                                         | any difference between    |
| t |                                         | our allowance and the     |
| e |                                         | billed amount             |
| m |                                         |                           |
| a |                                         |                           |
| t |                                         |                           |
| e |                                         |                           |
| r |                                         |                           |
| n |                                         |                           |
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| y |                                         |                           |
| ( |                                         |                           |
| o |                                         |                           |
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| t |                                         |                           |
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| c |                                         |                           |
| a |                                         |                           |
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|   |                                         |                           |
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|   |                                         |                           |
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|   |                                         |                           |
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| e |                                         |                           |
| l |                                         |                           |
| i |                                         |                           |
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| r |                                         |                           |
| y |                                         |                           |
|   |                                         |                           |
| - |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
| P |                                         |                           |
| o |                                         |                           |
| s |                                         |                           |
| t |                                         |                           |
| n |                                         |                           |
| a |                                         |                           |
| t |                                         |                           |
| a |                                         |                           |
| l |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
|   |                                         |                           |
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| e |                                         |                           |
+---+-----------------------------------------+---------------------------+
|   | ######                                  | *Maternity care --        |
|   |                                         | continued on next page*   |
+---+-----------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Maternity care *(continued)*      | After the deductible, you |
|                                          | pay                       |
+------------------------------------------+---------------------------+
| **Note:** Here are some things to keep   |                           |
| in mind:                                 |                           |
|                                          |                           |
| -   You do not need to precertify your   |                           |
|     normal delivery; see below for other |                           |
|     circumstances, such as extended      |                           |
|     stays for you or your baby.          |                           |
|                                          |                           |
| -   You may remain in the hospital up to |                           |
|     48 hours after a regular delivery    |                           |
|     and 96 hours after a cesarean        |                           |
|     delivery. We will cover an extended  |                           |
|     inpatient stay if medically          |                           |
|     necessary but you, your              |                           |
|     representatives, your doctor, or     |                           |
|     your hospital must recertify the     |                           |
|     extended stay.                       |                           |
|                                          |                           |
| -   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. Surgical benefits, not   |                           |
|     maternity benefits, apply to         |                           |
|     circumcision.                        |                           |
|                                          |                           |
| -   We pay hospitalization and surgeon   |                           |
|     services (delivery) the same as for  |                           |
|     illness and injury. See Hospital     |                           |
|     benefits and Surgery benefits.       |                           |
+------------------------------------------+---------------------------+
| Not covered:Routine sonograms to         | *All charges.*            |
| determine fetal age, sex or size         |                           |
+------------------------------------------+---------------------------+
| ###### Family planning                   |                           |
+------------------------------------------+---------------------------+
| A range of voluntary family planning     | In-network: 10% of the    |
| services, limited to:                    | Plan allowance            |
|                                          |                           |
| -   Voluntary sterilization (see         | Out-of-network: 30% of    |
|     Surgical procedures Section 5.2(d))  | the Plan allowance and    |
|                                          | any difference between    |
| -   Surgically implanted contraceptives  | our allowance and the     |
|     (such as Norplant)                   | billed amount             |
|                                          |                           |
| -   Injectable contraceptive drugs (such |                           |
|     as Depo provera)                     |                           |
|                                          |                           |
| -   Intrauterine devices (IUDs)          |                           |
|                                          |                           |
| -   Diaphragms                           |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Note: We cover oral contraceptives   |                           |
|     under the prescription drug benefit. |                           |
|     Prior authorization is required for  |                           |
|     these services.                      |                           |
+------------------------------------------+---------------------------+
| Not covered:Reversal of voluntary        | *All charges.*            |
| surgical sterilization, genetic          |                           |
| counseling                               |                           |
+------------------------------------------+---------------------------+
| ###### Infertility services              |                           |
+------------------------------------------+---------------------------+
| Diagnosis and treatment of infertility   | In-network: \$25 per      |
| such as:                                 | visit to a specialist     |
|                                          |                           |
| -   Artificial insemination:             | Out-of-network: 30% of    |
|                                          | the Plan allowance and    |
| ```{=html}                               | any difference between    |
| <!-- -->                                 | our allowance and the     |
| ```                                      | billed amount             |
| -   intravaginal insemination (IVI)      |                           |
|                                          |                           |
| -   intracervical insemination (ICI)     |                           |
|                                          |                           |
| -   intrauterine insemination (IUI)      |                           |
+------------------------------------------+---------------------------+
|                                          | *Infertility services --  |
|                                          | continued on next page*   |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| #                                        | After the deductible, you |
| ##### Infertility services *(continued)* | pay                       |
+------------------------------------------+---------------------------+
| Diagnosis and treatment of infertility   | In-network: \$25 per      |
| such as:                                 | visit to a specialist     |
|                                          |                           |
| -   Fertility drugs                      | Out-of-network: 30% of    |
|                                          | the Plan allowance and    |
| Note: We cover injectable fertility      | any difference between    |
| drugs under medical benefits and oral    | our allowance and the     |
| fertility drugs under the prescription   | billed amount             |
| drug benefit.                            |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Assisted reproductive technology    |                           |
|     (ART) procedures, such as:*          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *in vitro fertilization*             |                           |
|                                          |                           |
| -   *embryo transfer, gamete             |                           |
|     intra-fallopian transfer (GIFT) and  |                           |
|     zygote intra-fallopian transfer      |                           |
|     (ZIFT)*                              |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Services and supplies related to    |                           |
|     ART procedures*                      |                           |
|                                          |                           |
| -   *Cost of donor sperm*                |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Cost of donor egg                    |                           |
+------------------------------------------+---------------------------+
| ###### Allergy care                      |                           |
+------------------------------------------+---------------------------+
| -   Testing and treatment                | In-network: \$25 per      |
|                                          | visit to a specialist     |
| -   Allergy injections                   |                           |
|                                          | Out-of-network: 30% of    |
|                                          | the Plan allowance and    |
|                                          | any difference between    |
|                                          | our allowance and the     |
|                                          | billed amount             |
+------------------------------------------+---------------------------+
| -   Allergy serum                        | Nothing                   |
+------------------------------------------+---------------------------+
| *Not covered: Provocative food testing   | *All charges.*            |
| and sublingual allergy desensitization*  |                           |
+------------------------------------------+---------------------------+
| ###### Treatment therapies               |                           |
+------------------------------------------+---------------------------+
| -   Chemotherapy and radiation therapy   | In-network: \$15 per      |
|                                          | visit to a primary care   |
| Note: High dose chemotherapy in          | physician; \$25 per visit |
| association with autologous bone marrow  | to a specialist           |
| transplants are limited to those         |                           |
| transplants listed under Organ/Tissue    | Out-of-network: 30% of    |
| Transplants on page 63.                  | the Plan allowance and    |
|                                          | any difference between    |
| -   Respiratory and inhalation therapy   | our allowance and the     |
|                                          | billed amount             |
| -   Dialysis -- hemodialysis and         |                           |
|     peritoneal dialysis                  |                           |
|                                          |                           |
| -   Intravenous (IV)/Infusion Therapy -- |                           |
|     Home IV and antibiotic therapy       |                           |
|                                          |                           |
| -   Growth hormone therapy (GHT)         |                           |
+------------------------------------------+---------------------------+
|                                          | *Treatment therapies --   |
|                                          | continued on next page*   |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Treatment therapies *(continued)* | After the deductible, you |
|                                          | pay                       |
+------------------------------------------+---------------------------+
| Note: Growth hormone is covered under    |                           |
| the prescription drug benefit. We will   |                           |
| only cover GHT when we preauthorize the  |                           |
| treatment. Call toll-free at             |                           |
| 800-546-4603 for preauthorization. We    |                           |
| will ask you to submit information that  |                           |
| establishes that the GHT is medically    |                           |
| necessary. Ask us to authorize GHT       |                           |
| before you begin treatment; otherwise,   |                           |
| we will only cover GHT services from the |                           |
| date you submit the information. If you  |                           |
| do not ask or if we determine GHT is not |                           |
| medically necessary, we will not cover   |                           |
| the GHT or related services and          |                           |
| supplies. See *Services requiring our    |                           |
| prior approval* in Section 3.            |                           |
+------------------------------------------+---------------------------+
| ##                                       | ######                    |
| #### Physical and occupational therapies |                           |
+------------------------------------------+---------------------------+
| Limited to 60 visits per condition per   | In-network: 10% of the    |
| year for the services of each of the     | Plan allowance            |
| following:                               |                           |
|                                          | Out-of-network: 30% of    |
| -   Qualified physical therapists and    | the Plan allowance and    |
|                                          | any difference between    |
| -   Occupational therapists              | our allowance and the     |
|                                          | billed amount             |
| Note: We only cover therapy to restore   |                           |
| bodily function when there has been a    |                           |
| total or partial loss of bodily function |                           |
| due to illness or injury and if          |                           |
| significant improvement can be expected  |                           |
| within two consecutive months.           |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Long-term rehabilitative therapy*   |                           |
|                                          |                           |
| -   *Exercise programs*                  |                           |
+------------------------------------------+---------------------------+
| ###### Speech therapy                    | ######                    |
+------------------------------------------+---------------------------+
| Limited to 20 visits or two consecutive  | In-network: 10% of the    |
| months (whichever is greater) per        | Plan allowance            |
| condition per year                       |                           |
|                                          | Out-of-network: 30% of    |
|                                          | the Plan allowance and    |
|                                          | any difference between    |
|                                          | our allowance and the     |
|                                          | billed amount             |
+------------------------------------------+---------------------------+
| *Not covered: Speech therapy services    | *All charges.*            |
| that are not medically necessary*        |                           |
+------------------------------------------+---------------------------+
| ###                                      | ######                    |
| ### Pulmonary and cardiac rehabilitation |                           |
+------------------------------------------+---------------------------+
| Limited to treatment for therapy         | In-network: 10% of the    |
| conditions that, in the judgement of the | Plan allowance            |
| treating provider and the Medical        |                           |
| Director, are subject to significant     | Out-of-network: 30% of    |
| improvement of your condition through    | the Plan allowance and    |
| relatively short-term therapy. Pulmonary | any difference between    |
| rehabilitation therapy is limited to one | our allowance and the     |
| treatment program up to a maximum of 36  | billed amount             |
| visits. Cardiac rehabilitation therapy   |                           |
| is limited to 36 Phase II visits in a    |                           |
| 12-week period.                          |                           |
|                                          |                           |
| Cardiac rehabilitation following a heart |                           |
| transplant, bypass surgery or a          |                           |
| myocardial infarction is provided for up |                           |
| to 36 sessions.                          |                           |
+------------------------------------------+---------------------------+
| *Not covered: Phase III Cardiac          | *All charges.*            |
| Rehabilitation*                          |                           |
+------------------------------------------+---------------------------+
| ###### Hearing se                        | After the deductible, you |
| rvices (testing, treatment and supplies) | pay                       |
+------------------------------------------+---------------------------+
| -   First hearing aid and testing only   | In-network: 10% of the    |
|     when necessitated by accidental      | Plan allowance            |
|     injury                               |                           |
|                                          | Out-of-network: 30% of    |
| -   Hearing testing for children through | the Plan allowance and    |
|     age 17 *(see Preventive care,        | any difference between    |
|     children)*                           | our allowance and the     |
|                                          | billed amount             |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *All other hearing testing*          |                           |
|                                          |                           |
| -   *Hearing aids, testing and           |                           |
|     examinations for them*               |                           |
+------------------------------------------+---------------------------+
| ###### Vision services                   |                           |
+------------------------------------------+---------------------------+
| -   One pair of eyeglasses or contact    | Nothing                   |
|     lenses to correct an impairment      |                           |
|     directly caused by accidental ocular |                           |
|     injury or intraocular surgery (such  |                           |
|     as for cataracts)                    |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Annual eye refraction*              |                           |
|                                          |                           |
| -   *Eyeglasses or contact lenses and,   |                           |
|     after age 17, examinations for them* |                           |
|                                          |                           |
| -   *Eye exercises and orthoptics*       |                           |
|                                          |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
+------------------------------------------+---------------------------+
| ###### Foot care                         |                           |
+------------------------------------------+---------------------------+
| Routine foot care when you are under     | In-network: \$25 per      |
| active treatment for a metabolic or      | visit to a specialist     |
| peripheral vascular disease, such as     |                           |
| diabetes.                                | Out-of-network: 30% of    |
|                                          | the Plan allowance and    |
| Note: See *Orthopedic and prosthetic     | any difference between    |
| devices* for information on podiatric    | our allowance and the     |
| shoe inserts.                            | billed amount             |
+------------------------------------------+---------------------------+
| *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 | After the deductible, you |
|                                          | pay                       |
+------------------------------------------+---------------------------+
| -   Artificial limbs and eyes (initial   | In-network: 10% of the    |
|     placement only after diagnosis is    | Plan allowance            |
|     made)                                |                           |
|                                          | Out-of-network: 30% of    |
| ```{=html}                               | the Plan allowance and    |
| <!-- -->                                 | any difference between    |
| ```                                      | our allowance and the     |
| -   Stump hose                           | billed amount             |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   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: see 5.2(d) for coverage of the     |                           |
| surgery to insert the device.            |                           |
|                                          |                           |
| -   Corrective orthopedic appliances for |                           |
|     non-dental treatment of              |                           |
|     temporomandibular joint (TMJ) pain   |                           |
|     dysfunction syndrome.                |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Orthopedic, diabetic and corrective |                           |
|     shoes*                               |                           |
|                                          |                           |
| -   *Arch supports*                      |                           |
|                                          |                           |
| -   *Foot orthotics*                     |                           |
|                                          |                           |
| -   *Heel pads and heel cups*            |                           |
|                                          |                           |
| -   *Lumbosacral supports*               |                           |
|                                          |                           |
| -   *Corsets, trusses, elastic           |                           |
|     stockings, support hose and other    |                           |
|     supportive devices*                  |                           |
|                                          |                           |
| -   *Prosthetic replacements*            |                           |
|                                          |                           |
| -   *Testicular implants*                |                           |
+------------------------------------------+---------------------------+
| ###### Durable medical equipment (DME)   |                           |
+------------------------------------------+---------------------------+
| Rental or purchase, at our option,       | In-network: 10% of the    |
| including repair and adjustment, of      | Plan allowance            |
| durable medical equipment prescribed by  |                           |
| your Plan physician such as oxygen and   | Out-of-network: 30% of    |
| dialysis equipment. Under this benefit,  | the Plan allowance and    |
| we also cover:                           | any difference between    |
|                                          | our allowance and the     |
| -   Hospital beds                        | billed amount             |
|                                          |                           |
| -   Wheelchairs                          |                           |
|                                          |                           |
| -   Crutches                             |                           |
|                                          |                           |
| -   Walkers                              |                           |
|                                          |                           |
| -   Blood glucose monitors               |                           |
|                                          |                           |
| -   Insulin pumps                        |                           |
|                                          |                           |
| -   Oxygen therapy                       |                           |
+------------------------------------------+---------------------------+
| *Durable medical equipment (DME) --      |                           |
| continued on next page*                  |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Durab                             | After the deductible, you |
| le medical equipment (DME) *(continued)* | pay                       |
+------------------------------------------+---------------------------+
| Note: Your physician will arrange        |                           |
| coverage for durable medical equipment   |                           |
| with GHP and a Plan provider.            |                           |
| Out-of-network services must be prior    |                           |
| authorized.                              |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Non-durable medical supplies such   |                           |
|     as c-pap masks, foley catheters,     |                           |
|     dressings and leg bags*              |                           |
|                                          |                           |
| -   *Repair or replacement of purchased  |                           |
|     equipment*                           |                           |
+------------------------------------------+---------------------------+
| ###### Home health services              |                           |
+------------------------------------------+---------------------------+
| -   Home health care ordered by a Plan   | In-network: 10% of the    |
|     physician and provided by a          | Plan allowance            |
|     registered nurse (R.N.), licensed    |                           |
|     practical nurse (L.P.N.), licensed   | Out-of-network: 30% of    |
|     vocational nurse (L.V.N.), or home   | the Plan allowance and    |
|     health aide.                         | any difference between    |
|                                          | our allowance and the     |
| -   Services include oxygen therapy,     | billed amount             |
|     intravenous therapy and medications. |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Nursing care requested by or for    |                           |
|     the convenience of the patient or    |                           |
|     the patient's family*                |                           |
|                                          |                           |
| -   *Home care primarily for personal    |                           |
|     assistance that does not include a   |                           |
|     medical component and is not         |                           |
|     diagnostic, therapeutic or           |                           |
|     rehabilitative*                      |                           |
+------------------------------------------+---------------------------+
| ###### Chiropractic                      |                           |
+------------------------------------------+---------------------------+
| Up to 26 visits; treatment plan is       | In-network: \$15 per      |
| required.                                | visit to a primary care   |
|                                          | physician; \$25 per visit |
|                                          | to a specialist           |
|                                          |                           |
|                                          | Out-of-network: All       |
|                                          | charges.                  |
+------------------------------------------+---------------------------+
| *Not covered: Out-of-network services*   | *All charges.*            |
+------------------------------------------+---------------------------+
| ###### Alternative treatments            |                           |
+------------------------------------------+---------------------------+
| No benefit                               | All charges.              |
+------------------------------------------+---------------------------+
| ###### Educational classes and programs  |                           |
+------------------------------------------+---------------------------+
| Coverage is limited to:                  | In-network: Nothing       |
|                                          |                           |
| -   Diabetes self-management             | Out-of-network: All       |
|                                          | charges                   |
| > Living with Diabetes is an             |                           |
| > education-based program supervised by  |                           |
| > a Certified Diabetes Educator. The     |                           |
| > program is coordinated through GHP's   |                           |
| > Complex Case Management Department and |                           |
| > is directed at members who have        |                           |
| > diabetes. The program includes         |                           |
| > educational materials, quarterly       |                           |
| > newsletters, self-care guidelines,     |                           |
| > periodic health postcard reminders     |                           |
| > (for foot exams, retinal eye exams,    |                           |
| > cholesterol testing and long-term      |                           |
| > blood sugar tests), and referrals to   |                           |
| > group and individual educational       |                           |
| > programs/support groups provided by    |                           |
| > hospitals and home health agencies.    |                           |
+------------------------------------------+---------------------------+
| *Educational classes and programs --     |                           |
| continued on next page*                  |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Educat                            | After the deductible, you |
| ional classes and programs *(continued)* | pay                       |
+------------------------------------------+---------------------------+
| Coverage is limited to:                  | In-network: Nothing       |
|                                          |                           |
| -   Healthy Basics for Healthy Babies    | Out-of-network: All       |
|                                          | charges                   |
| > To help promote a healthy pregnancy,   |                           |
| > GHP has developed a Healthy Basics for |                           |
| > a Healthy Baby program for its         |                           |
| > expectant members. Healthy Basics      |                           |
| > encourages prenatal care and a healthy |                           |
| > lifestyle, provides educational        |                           |
| > material, and identifies pregnancies   |                           |
| > that may be of greater than average    |                           |
| > risk. Healthy Basics is a free         |                           |
| > enhancement to the regular obstetrical |                           |
| > care mothers receive during pregnancy. |                           |
| > Expectant members are enrolled in      |                           |
| > Healthy Basics when GHP is notified of |                           |
| > the pregnancy.                         |                           |
+------------------------------------------+---------------------------+
| *Not covered: Weight loss program*       | *All charges.*            |
+------------------------------------------+---------------------------+

## Section 5.2(d) Surgical and anesthesia services provided by physicians and other health care professionals

+------------------------------------------+-------------------------+---+
| Benefit Description                      | After the deductible,   |   |
|                                          | you pay                 |   |
+------------------------------------------+-------------------------+---+
| ###### Surgical procedures               |                         |   |
+------------------------------------------+-------------------------+---+
| **YOU MUST GET PRECERTIFICATION** **FOR  |                         |   |
| SOME SURGICAL PROCEDURES.** **Please     |                         |   |
| refer to the precertification            |                         |   |
| information in Section 3 to be sure      |                         |   |
| which services require                   |                         |   |
| precertification.**                      |                         |   |
+------------------------------------------+-------------------------+---+
| A comprehensive range of services, such  | In-network: \$15 per    |   |
| as:                                      | visit to a primary care |   |
|                                          | physician               |   |
| -   Operative procedures                 |                         |   |
|                                          | \$25 per visit to a     |   |
| -   Treatment of fractures including     | specialist              |   |
|     casting                              |                         |   |
|                                          | 10% of the Plan         |   |
| -   Normal pre- and post-operative care  | allowance for inpatient |   |
|     by the surgeon                       | or outpatient surgery   |   |
|                                          |                         |   |
| -   Correction of amblyopia and          | Out-of-network: 30% of  |   |
|     strabismus                           | the Plan allowance and  |   |
|                                          | any difference between  |   |
| -   Endoscopy procedures                 | our allowance and the   |   |
|                                          | billed amount           |   |
| -   Biopsy procedures                    |                         |   |
|                                          | Note: see 5.2(e) for    |   |
| -   Removal of tumors and cysts          | hospitalization         |   |
|                                          | coverage.               |   |
| -   Correction of congenital anomalies   |                         |   |
|     (see *Reconstructive surgery*)       |                         |   |
|                                          |                         |   |
| -   Surgical treatment of morbid obesity |                         |   |
|     -- when Plan criteria is met         |                         |   |
|                                          |                         |   |
| -   Insertion of internal prosthetic     |                         |   |
|     devices (see 5.2(c) *Orthopedic and  |                         |   |
|     prosthetic devices* for device       |                         |   |
|     coverage information)                |                         |   |
|                                          |                         |   |
| -   Voluntary sterilization (e.g., tubal |                         |   |
|     ligation, vasectomy)                 |                         |   |
|                                          |                         |   |
| -   Treatment of burns                   |                         |   |
|                                          |                         |   |
| Note: Generally, we pay for internal     |                         |   |
| prostheses (devices) according to where  |                         |   |
| the procedure is performed. 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*             |                         |   |
|                                          |                         |   |
| -   *Replacement of penile prosthesis*   |                         |   |
+------------------------------------------+-------------------------+---+
| ###### Reconstructive surgery            | After the deductible,   |   |
|                                          | you pay                 |   |
+------------------------------------------+-------------------------+---+
| -   Surgery to correct a functional      | In-network: 10% of the  |   |
|     defect                               | Plan allowance for      |   |
|                                          | inpatient or outpatient |   |
| -   Surgery to correct a condition       | surgery                 |   |
|     caused by injury or illness if:      |                         |   |
|                                          | Out-of-network: 30% of  |   |
| ```{=html}                               | the Plan allowance and  |   |
| <!-- -->                                 | any difference between  |   |
| ```                                      | our allowance and the   |   |
| -   the condition produced a major       | billed amount           |   |
|     effect on the member's appearance    |                         |   |
|     and                                  | Note: see 5.2(e) for    |   |
|                                          | hospitalization         |   |
| -   the condition can reasonably be      | coverage.               |   |
|     expected to be corrected by such     |                         |   |
|     surgery                              |                         |   |
|                                          |                         |   |
| ```{=html}                               |                         |   |
| <!-- -->                                 |                         |   |
| ```                                      |                         |   |
| -   Surgery to correct a condition that  |                         |   |
|     existed at or from birth and is a    |                         |   |
|     significant deviation from the       |                         |   |
|     common form or norm. Examples of     |                         |   |
|     congenital anomalies are: protruding |                         |   |
|     ear deformities; cleft lip; cleft    |                         |   |
|     palate; birth marks; webbed fingers; |                         |   |
|     and webbed toes.                     |                         |   |
|                                          |                         |   |
| -   All stages of breast reconstruction  |                         |   |
|     surgery following a mastectomy, such |                         |   |
|     as:                                  |                         |   |
|                                          |                         |   |
| ```{=html}                               |                         |   |
| <!-- -->                                 |                         |   |
| ```                                      |                         |   |
| -   surgery to produce a symmetrical     |                         |   |
|     appearance of breasts;               |                         |   |
|                                          |                         |   |
| -   treatment of any physical            |                         |   |
|     complications, such as lymphedemas;  |                         |   |
|                                          |                         |   |
| -   breast prostheses and surgical bras  |                         |   |
|     and replacements (see Prosthetic     |                         |   |
|     devices)                             |                         |   |
|                                          |                         |   |
| Note: If you need a mastectomy, you may  |                         |   |
| choose to have the procedure performed   |                         |   |
| on an inpatient basis and remain in the  |                         |   |
| hospital up to 48 hours after the        |                         |   |
| procedure.                               |                         |   |
+------------------------------------------+-------------------------+---+
| *Not covered:*                           | *All charges.*          |   |
|                                          |                         |   |
| -   *Cosmetic surgery -- any surgical    |                         |   |
|     procedure or any portion of a        |                         |   |
|     procedure performed primarily to     |                         |   |
|     improve physical appearance through  |                         |   |
|     change in bodily form except repair  |                         |   |
|     of accidental injury*                |                         |   |
|                                          |                         |   |
| -   *Surgeries related to sex            |                         |   |
|     transformation*                      |                         |   |
|                                          |                         |   |
| -   *Scar revision*                      |                         |   |
+------------------------------------------+-------------------------+---+
| ###### Oral and maxillofacial surgery    |                         |   |
+------------------------------------------+-------------------------+---+
| Oral surgical procedures, limited to:    | In-network: 10% of the  |   |
|                                          | Plan allowance for      |   |
| -   Reduction of fractures of the jaws   | inpatient or outpatient |   |
|     or facial bones;                     | surgery                 |   |
|                                          |                         |   |
| -   Surgical correction of cleft lip,    | Out-of-network: 30% of  |   |
|     cleft palate or severe functional    | the Plan allowance and  |   |
|     malocclusion;                        | any difference between  |   |
|                                          | our allowance and the   |   |
| -   Removal of stones from salivary      | billed amount           |   |
|     ducts;                               |                         |   |
|                                          |                         |   |
| -   Excision of leukoplakia or           |                         |   |
|     malignancies;                        |                         |   |
+------------------------------------------+-------------------------+---+
| *Oral and maxillofacial surgery --       |                         |   |
| continued on next page*                  |                         |   |
+------------------------------------------+-------------------------+---+

+------------------------------------------+-------------------------+---+
| ###### Oral                              | After the deductible,   |   |
|  and maxillofacial surgery *(continued)* | you pay                 |   |
+------------------------------------------+-------------------------+---+
| Oral surgical procedures, limited to:    | In-network: 10% of the  |   |
|                                          | Plan allowance for      |   |
| -   Excision of cysts and incision of    | inpatient or outpatient |   |
|     abscesses when done as independent   | surgery                 |   |
|     procedures; and                      |                         |   |
|                                          | Out-of-network: 30% of  |   |
| -   Other surgical procedures that do    | the Plan allowance and  |   |
|     not involve the teeth or their       | any difference between  |   |
|     supporting structures; and           | our allowance and the   |   |
|                                          | billed amount           |   |
| -   Non-dental treatment of              |                         |   |
|     Temporomandibular (TMJ) joint pain   |                         |   |
|     dysfunction syndrome                 |                         |   |
+------------------------------------------+-------------------------+---+
| *Not covered:*                           | *All charges.*          |   |
|                                          |                         |   |
| -   *Oral implants and transplants*      |                         |   |
|                                          |                         |   |
| -   *Procedures that involve the teeth   |                         |   |
|     or their supporting structures (such |                         |   |
|     as the periodontal membrane, gingiva |                         |   |
|     and alveolar bone)*                  |                         |   |
|                                          |                         |   |
| -   *Dental care involved in the         |                         |   |
|     treatment of TMJ*                    |                         |   |
+------------------------------------------+-------------------------+---+
| ###### Organ/tissue transplants          |                         |   |
+------------------------------------------+-------------------------+---+
| Limited to:                              | In-network: 10% of the  |   |
|                                          | Plan allowance for      |   |
| -   Cornea                               | inpatient or outpatient |   |
|                                          | surgery                 |   |
| -   Heart                                |                         |   |
|                                          | Out-of-network: 30% of  |   |
| -   Heart/lung                           | the Plan allowance and  |   |
|                                          | any difference between  |   |
| -   Kidney                               | our allowance and the   |   |
|                                          | billed amount           |   |
| -   Kidney/Pancreas                      |                         |   |
|                                          | Note: see 5.2(e) for    |   |
| -   Liver                                | hospitalization         |   |
|                                          | coverage.               |   |
| -   Lung: Single -- Double               |                         |   |
|                                          |                         |   |
| -   Pancreas                             |                         |   |
|                                          |                         |   |
| -   Allogeneic (donor) bone marrow       |                         |   |
|     transplants                          |                         |   |
+------------------------------------------+-------------------------+---+
| *Organ/tissue transplants -- continued   |                         |   |
| on next page*                            |                         |   |
+------------------------------------------+-------------------------+---+
| #####                                    | After the deductible,   |   |
| # Organ/tissue transplants *(continued)* | you pay                 |   |
+------------------------------------------+-------------------------+---+
| Limited to:                              | In-network: 10% of the  |   |
|                                          | Plan allowance for      |   |
| -   Autologous bone marrow transplants   | inpatient or outpatient |   |
|     (autologous stem cell and peripheral | surgery                 |   |
|     stem cell support) for the following |                         |   |
|     conditions: acute lymphocytic or     | Out-of-network: 30% of  |   |
|     non-lymphocytic leukemia; advanced   | the Plan allowance and  |   |
|     Hodgkin\'s lymphoma; advanced        | any difference between  |   |
|     non-Hodgkin's lymphoma; advanced     | our allowance and the   |   |
|     neuroblastoma; breast cancer;        | billed amount           |   |
|     multiple myeloma; epithelial ovarian |                         |   |
|     cancer; and testicular, mediastinal, | Note: see 5.2(e) for    |   |
|     retroperitoneal and ovarian germ     | hospitalization         |   |
|     cell tumors                          | coverage.               |   |
|                                          |                         |   |
| -   Intestinal transplants (small        |                         |   |
|     intestine) and the small intestine   |                         |   |
|     with the liver or small intestine    |                         |   |
|     with multiple organs such as the     |                         |   |
|     liver, stomach and pancreas          |                         |   |
|                                          |                         |   |
| Note: We cover related medical and       |                         |   |
| hospital expenses of the donor when we   |                         |   |
| cover the recipient if the donor has no  |                         |   |
| other coverage for this service.         |                         |   |
+------------------------------------------+-------------------------+---+
| *Not covered:*                           | *All charges.*          |   |
|                                          |                         |   |
| -   *Donor screening tests and donor     |                         |   |
|     search expenses except those         |                         |   |
|     performed for the actual donor*      |                         |   |
|                                          |                         |   |
| -   *Implants of artificial organs*      |                         |   |
|                                          |                         |   |
| -   *Transplants not listed as covered*  |                         |   |
|                                          |                         |   |
| -   *Non-human organs*                   |                         |   |
|                                          |                         |   |
| -   *Hair transplants*                   |                         |   |
+------------------------------------------+-------------------------+---+
| ###### Anesthesia                        | ######                  |   |
+------------------------------------------+-------------------------+---+
| Professional services provided in --     | In-network: 10% of the  |   |
|                                          | Plan allowance          |   |
| -   Hospital (inpatient)                 |                         |   |
|                                          | Out-of-network: 30% of  |   |
| ```{=html}                               | the Plan allowance and  |   |
| <!-- -->                                 | any difference between  |   |
| ```                                      | our allowance and the   |   |
| -   Hospital outpatient department       | billed amount           |   |
|                                          |                         |   |
| -   Skilled nursing facility             |                         |   |
|                                          |                         |   |
| ```{=html}                               |                         |   |
| <!-- -->                                 |                         |   |
| ```                                      |                         |   |
| -   Ambulatory surgical center           |                         |   |
+------------------------------------------+-------------------------+---+
| Professional services provided in --     | In-network: Nothing     |   |
|                                          |                         |   |
| -   Office                               | Out-of-network: 30% of  |   |
|                                          | the Plan allowance and  |   |
|                                          | any difference between  |   |
|                                          | our allowance and the   |   |
|                                          | billed amount           |   |
+------------------------------------------+-------------------------+---+

## Section 5.2(e) Services provided by a hospital or other facility, and ambulance services

+------------------------------------------+---------------------------+
| Benefit Description                      | After the deductible, you |
|                                          | pay                       |
+------------------------------------------+---------------------------+
| ###### Inpatient hospital                |                           |
+------------------------------------------+---------------------------+
| The amounts listed below are for the     |                           |
| charges billed by the facility (i.e.,    |                           |
| hospital or surgical center) or          |                           |
| ambulance service for your surgery or    |                           |
| care. Any costs associated with the      |                           |
| professional charge (i.e., physicians,   |                           |
| etc.) are in Sections 5.2(a), (b) or     |                           |
| (c).                                     |                           |
|                                          |                           |
| **YOUR PHYSICIAN MUST GET                |                           |
| PRECERTIFICATION OF HOSPITAL STAYS.**    |                           |
| Please refer to the precertification     |                           |
| information shown in Section 3 to be     |                           |
| sure which services require              |                           |
| precertification.                        |                           |
+------------------------------------------+---------------------------+
| Room and board, such as                  | In-network: 10% of the    |
|                                          | Plan allowance            |
| -   Ward, semiprivate, or intensive care |                           |
|     accommodations;                      | Note: If you use a        |
|                                          | network provider and a    |
| -   General nursing care; and            | network facility, we may  |
|                                          | still pay out-of-network  |
| -   Meals and special diets.             | benefits for treatment    |
|                                          | from a radiologist,       |
| Note: If you want a private room when it | pathologist, or           |
| is not medically necessary, you pay the  | anesthesiologist who is   |
| additional charge above the semiprivate  | not a network provider.   |
| room rate.                               | Please contact the Plan   |
|                                          | for reprocessing.         |
|                                          |                           |
|                                          | Out-of-network: 30% of    |
|                                          | the Plan allowance and    |
|                                          | any difference between    |
|                                          | our allowance and the     |
|                                          | billed amount             |
+------------------------------------------+---------------------------+
| Other hospital services and supplies,    | In-network: 10% of the    |
| such as:                                 | Plan allowance            |
|                                          |                           |
| -   Operating, recovery, maternity, and  | Out-of-network: 30% of    |
|     other treatment rooms                | the Plan allowance and    |
|                                          | any difference between    |
| -   Prescribed drugs and medicines       | our allowance and the     |
|                                          | billed amount             |
| -   Diagnostic laboratory tests and      |                           |
|     X-rays                               |                           |
|                                          |                           |
| -   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                      |                           |
|                                          |                           |
| -   Medical supplies, appliances,        |                           |
|     medical equipment, and any covered   |                           |
|     items billed by a hospital for use   |                           |
|     at home                              |                           |
+------------------------------------------+---------------------------+
| *Inpatient hospital -- continued on next |                           |
| page*                                    |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Inpatient hospital *(continued)*  | After the deductible, you |
|                                          | pay                       |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Custodial care*                     |                           |
|                                          |                           |
| -   *Non-covered facilities such as      |                           |
|     nursing homes, schools*              |                           |
|                                          |                           |
| -   *Personal comfort items such as      |                           |
|     telephone, television, barber        |                           |
|     services, guest meals and beds*      |                           |
|                                          |                           |
| -   *Private nursing care*               |                           |
+------------------------------------------+---------------------------+
| ###### Outpatien                         |                           |
| t hospital or ambulatory surgical center |                           |
+------------------------------------------+---------------------------+
| -   Operating, recovery, and other       | In-network: 10% of the    |
|     treatment rooms                      | Plan allowance            |
|                                          |                           |
| -   Prescribed drugs and medicines       | Note: If you use a        |
|                                          | network provider and a    |
| -   Diagnostic laboratory tests, X-rays, | network facility, we may  |
|     and pathology services               | still pay out-of-network  |
|                                          | benefits for treatment    |
| -   Administration of blood, blood       | from a radiologist,       |
|     plasma, and other biologicals        | pathologist, or           |
|                                          | anesthesiologist who is   |
| -   Blood and blood plasma, if not       | not a network provider.   |
|     donated or replaced                  | Please contact the Plan   |
|                                          | for reprocessing.         |
| -   Pre-surgical testing                 |                           |
|                                          | Out-of-network: 30% of    |
| -   Dressings, casts, and sterile tray   | the Plan allowance and    |
|     services                             | any difference between    |
|                                          | our allowance and the     |
| -   Medical supplies, including oxygen   | billed amount             |
|                                          |                           |
| -   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.                       |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Blood and blood derivatives not     |                           |
|     replaced by the member*              |                           |
|                                          |                           |
| -   *Storage of blood donated before     |                           |
|     surgery*                             |                           |
|                                          |                           |
| -   *Designated donor fees*              |                           |
+------------------------------------------+---------------------------+
| ###### Extended care/                    |                           |
| skilled nursing facility (SNF) benefits  |                           |
+------------------------------------------+---------------------------+
| Covered for up to 30 days per calendar   | In-network: 10% of the    |
| year when full-time skilled nursing care | Plan allowance            |
| is necessary and confinement is          |                           |
| medically appropriate as determined by a | Out-of-network: 30% of    |
| Plan doctor and approved by the Plan.    | the Plan allowance and    |
|                                          | any difference between    |
|                                          | our allowance and the     |
|                                          | billed amount             |
+------------------------------------------+---------------------------+
| *Not covered: Custodial care*            | *All charges.*            |
+------------------------------------------+---------------------------+
| ###### Hospice care                      | After the deductible, you |
|                                          | pay                       |
+------------------------------------------+---------------------------+
| -   Inpatient and home health care when  | In-network: 10% of the    |
|     authorized and approved by the Plan  | Plan allowance            |
|                                          |                           |
|                                          | Out-of-network: 30% of    |
|                                          | the Plan allowance and    |
|                                          | any difference between    |
|                                          | our allowance and the     |
|                                          | billed amount             |
+------------------------------------------+---------------------------+
| *Not covered: Independent nursing,       | *All charges.*            |
| homemaker services*                      |                           |
+------------------------------------------+---------------------------+
| ###### Ambulance                         |                           |
+------------------------------------------+---------------------------+
| -   Local professional ambulance service | In-network: 10% of the    |
|     when medically appropriate           | Plan allowance            |
|                                          |                           |
| -   Air ambulance when medically         | Out-of-network: 30% of    |
|     necessary and approved by Plan       | the Plan allowance and    |
|                                          | any difference between    |
| Note: Ambulance coverage in              | our allowance and the     |
| non-emergency situations must be prior   | billed amount             |
| authorized.                              |                           |
+------------------------------------------+---------------------------+

## **Section 5.2(f) Emergency services/accidents**

+------------------------------------------+---------------------------+
| **What is a medical emergency?**         |                           |
|                                          |                           |
| A medical emergency is the sudden and    |                           |
| unexpected onset of a condition or an    |                           |
| injury that you believe endangers your   |                           |
| life or could result in serious injury   |                           |
| or disability, and requires immediate    |                           |
| medical or surgical care. Some problems  |                           |
| are emergencies because, if not treated  |                           |
| promptly, they might become more         |                           |
| serious; examples include deep cuts and  |                           |
| broken bones. Others are emergencies     |                           |
| because they are potentially             |                           |
| life-threatening, such as heart attacks, |                           |
| strokes, poisonings, gunshot wounds, or  |                           |
| sudden inability to breathe. There are   |                           |
| many other acute conditions that we may  |                           |
| determine are medical emergencies --     |                           |
| what they all have in common is the need |                           |
| for quick action.                        |                           |
+------------------------------------------+---------------------------+
| What to do in case of emergency:         |                           |
|                                          |                           |
| If you are in an emergency situation,    |                           |
| please call your health care advisor. In |                           |
| medical emergencies, if you are unable   |                           |
| to contact your health care advisor,     |                           |
| contact the local emergency system (e.g. |                           |
| the 911-telephone system) or go to the   |                           |
| nearest emergency room. Be sure to tell  |                           |
| the emergency room personnel that you    |                           |
| are a Plan member so they can notify the |                           |
| Plan. You or a family member must notify |                           |
| the Plan within 48 hours unless it was   |                           |
| not reasonably possible to do so. It is  |                           |
| your responsibility to ensure that the   |                           |
| Plan has been timely notified.           |                           |
|                                          |                           |
| If you need to be hospitalized in a      |                           |
| non-Plan facility, the Plan should be    |                           |
| notified by you or a family member       |                           |
| within 48 hours unless it is not         |                           |
| reasonably possible to do so.            |                           |
|                                          |                           |
| **Emergencies within our service area:** |                           |
| \$100 Copay per visit after deductible;  |                           |
| waived if patient is admitted            |                           |
|                                          |                           |
| **Emergencies outside our service        |                           |
| area:** \$100 Copay per visit after      |                           |
| deductible; waived if patient is         |                           |
| admitted                                 |                           |
+------------------------------------------+---------------------------+
| ###### Benefit Description               | After deductible, you pay |
+------------------------------------------+---------------------------+
| #                                        |                           |
| ##### Emergency within our service area  |                           |
+------------------------------------------+---------------------------+
| -   Emergency care at a doctor's office  | In-network: \$15 per      |
|                                          | visit to a primary care   |
| -   Emergency care as an outpatient or   | physician; \$25 per visit |
|     inpatient at a hospital, including   | to a specialist           |
|     doctor's services                    |                           |
|                                          | \$100 Copay per visit     |
|                                          | after deductible; waived  |
|                                          | if patient is admitted    |
|                                          |                           |
|                                          | In-network: 10% of the    |
|                                          | Plan allowance for        |
|                                          | inpatient services        |
+------------------------------------------+---------------------------+
| -   Emergency care at an urgent care     | \$50 per visit            |
|     center                               |                           |
+------------------------------------------+---------------------------+
| *Not covered: Elective care or           | *All charges.*            |
| non-emergency care*                      |                           |
+------------------------------------------+---------------------------+
| #                                        | After the deductible, you |
| ##### Emergency outside our service area | pay                       |
+------------------------------------------+---------------------------+
| -   Emergency care at a doctor's office  | In-network: \$15 per      |
|                                          | visit to a primary care   |
|                                          | physician; \$25 per visit |
|                                          | to a specialist           |
|                                          |                           |
|                                          | Out-of-network: 30% of    |
|                                          | the Plan allowance and    |
|                                          | any difference between    |
|                                          | our allowance and the     |
|                                          | billed amount after       |
|                                          | deductible                |
+------------------------------------------+---------------------------+
| -   Emergency care as an outpatient or   | \$100 Copay per visit;    |
|     inpatient at a hospital, including   | waived if patient is      |
|     doctor's services                    | admitted                  |
|                                          |                           |
|                                          | In-network: 10% of the    |
|                                          | Plan allowance for        |
|                                          | inpatient services in     |
|                                          | network                   |
|                                          |                           |
|                                          | Out-of-network: 30% of    |
|                                          | the Plan allowance and    |
|                                          | any difference between    |
|                                          | our allowance and the     |
|                                          | billed amount after       |
|                                          | deductible                |
+------------------------------------------+---------------------------+
| -   Emergency care at an urgent care     | In-network: \$50 Copay    |
|     center                               | per visit                 |
|                                          |                           |
|                                          | Out-of-network: 30% of    |
|                                          | the Plan allowance and    |
|                                          | any difference between    |
|                                          | our allowance and the     |
|                                          | billed amount after       |
|                                          | deductible                |
+------------------------------------------+---------------------------+
| *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*            |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Medical and hospital costs          |                           |
|     resulting from a normal full-term    |                           |
|     delivery of a baby outside the       |                           |
|     service area*                        |                           |
+------------------------------------------+---------------------------+
| ###### Ambulance                         |                           |
+------------------------------------------+---------------------------+
| -   Professional ambulance service       | In-network: 10% of the    |
|                                          | Plan allowance            |
| -   Air ambulance when medically         |                           |
|     necessary and approved by Plan       | Out-of-network: 30% of    |
|                                          | the Plan allowance and    |
| Note: See 5.2(e) for non-emergency       | any difference between    |
| service.                                 | our allowance and the     |
|                                          | billed amount             |
+------------------------------------------+---------------------------+

## Section 5.2(g) Mental health and substance abuse benefits

+------------------------------------------+---------------------------+
| Benefit Description                      | After the deductible, you |
|                                          | pay                       |
+------------------------------------------+---------------------------+
| ###### In-network benefits               |                           |
+------------------------------------------+---------------------------+
| When you get our approval for services   | Your cost sharing         |
| and follow a treatment plan we approve,  | responsibilities are no   |
| cost-sharing and limitations for         | greater than for other    |
| in-network mental health and substance   | illnesses or conditions.  |
| abuse benefits will be no greater than   |                           |
| for similar benefits for other illnesses |                           |
| and conditions.                          |                           |
|                                          |                           |
| We provide all diagnostic and treatment  |                           |
| services recommended by a network        |                           |
| provider and contained in a treatment    |                           |
| plan that we approve. The treatment plan |                           |
| may include services, drugs, and         |                           |
| supplies described elsewhere in this     |                           |
| brochure.                                |                           |
|                                          |                           |
| Note: In-network benefits are payable    |                           |
| only when we determine the care is       |                           |
| clinically appropriate to treat your     |                           |
| condition and only when you receive the  |                           |
| care as part of a treatment plan that we |                           |
| approve.                                 |                           |
+------------------------------------------+---------------------------+
| -   Professional services, including     | In-network: \$25 per      |
|     individual or group therapy by       | visit to a specialist     |
|     providers such as psychiatrists,     |                           |
|     psychologists, or clinical social    |                           |
|     workers                              |                           |
|                                          |                           |
| -   Medication management                |                           |
+------------------------------------------+---------------------------+
| -   Diagnostic tests                     | In-network: 10% of the    |
|                                          | Plan allowance            |
+------------------------------------------+---------------------------+
| -   Services provided by a hospital or   | In-network: 10% of the    |
|     other facility                       | Plan allowance            |
|                                          |                           |
| -   Services in approved alternative     |                           |
|     care settings such as partial        |                           |
|     hospitalization, half-way house,     |                           |
|     full-day hospitalization, facility   |                           |
|     based intensive outpatient treatment |                           |
+------------------------------------------+---------------------------+
| *Not covered: Services we have not       | *All charges.*            |
| approved.*                               |                           |
|                                          |                           |
| *Note:* *OPM will base its review of     |                           |
| disputes about treatment plans on the    |                           |
| treatment plan\'s clinical               |                           |
| appropriateness. OPM will generally not  |                           |
| order us to pay or provide one           |                           |
| clinically appropriate treatment plan in |                           |
| favor of another.*                       |                           |
+------------------------------------------+---------------------------+
| **Preauthorization** To be eligible to   |                           |
| receive these benefits you must obtain a |                           |
| treatment plan and follow all of the     |                           |
| following network authorization          |                           |
| processes:                               |                           |
|                                          |                           |
| Please call GHP's Behavioral Health Line |                           |
| toll-free at 877-227-3520 to access      |                           |
| mental health and substance abuse        |                           |
| services. GHP's Behavioral Health Line   |                           |
| provides 24-hour access for these        |                           |
| benefits. The Behavioral Health Line     |                           |
| will be able to help you identify        |                           |
| participating providers and initiate     |                           |
| referral procedures.                     |                           |
+------------------------------------------+---------------------------+
| **In-network limitation** If you do not  |                           |
| obtain an approved treatment plan, we    |                           |
| will provide only out-of-network         |                           |
| benefits.                                |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ###### Out-of-network benefits           | After the deductible, you |
|                                          | pay                       |
+------------------------------------------+---------------------------+
| Professional services to treat mental    | Out-of-network: 30% of    |
| conditions and substance abuse           | the Plan allowance and    |
|                                          | any difference between    |
|                                          | our allowance and the     |
|                                          | billed amount             |
+------------------------------------------+---------------------------+
| Inpatient care to treat mental           | Out-of-network: 30% of    |
| conditions includes ward or semiprivate  | the Plan allowance and    |
| accommodations and other hospital        | any difference between    |
| charges                                  | our allowance and the     |
|                                          | billed amount             |
+------------------------------------------+---------------------------+
| Inpatient care to treat substance abuse  | Out-of-network: 30% of    |
| includes room and board and ancillary    | the Plan allowance and    |
| charges for confinements in a treatment  | any difference between    |
| facility for rehabilitative treatment of | our allowance and the     |
| alcoholism or substance abuse            | billed amount             |
+------------------------------------------+---------------------------+
| *Not covered out-of-network: Services    | *All charges.*            |
| not approved by the Plan*                |                           |
+------------------------------------------+---------------------------+
| **Lifetime maximum** Out-of-network      |                           |
| inpatient care for the treatment of      |                           |
| alcoholism and drug abuse is unlimited.  |                           |
+------------------------------------------+---------------------------+
| **Precertification** The medical         |                           |
| necessity of your admission to a         |                           |
| hospital or other covered facility must  |                           |
| be precertified for you to receive these |                           |
| out-of-network benefits. Emergency       |                           |
| admissions must be reported within two   |                           |
| business days following the day of       |                           |
| admission even if you have been          |                           |
| discharged. See Section 3 for details.   |                           |
+------------------------------------------+---------------------------+
| See these sections of the brochure for   |                           |
| more valuable information about these    |                           |
| benefits:                                |                           |
|                                          |                           |
| -   Section 3, *How you get care*, for   |                           |
|     information about catastrophic       |                           |
|     protection for these benefits.       |                           |
|                                          |                           |
| -   Section 7, *Filing a claim for       |                           |
|     covered services*, for information   |                           |
|     about submitting out-of-network      |                           |
|     claims.                              |                           |
+------------------------------------------+---------------------------+

## Section 5.2(h) Prescription drug benefits

+-----------------------------------------------------------------------+
| **There are important features you should be aware of.** These        |
| include:                                                              |
|                                                                       |
| -   **Who can write your prescription.** A licensed physician must    |
|     write the prescription.                                           |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **Where you can obtain them.** You may fill the prescription at a |
|     participating local pharmacy or for maintenance medications,      |
|     through the mail order benefit or at a participating 90-day       |
|     pharmacy. Our participating pharmacies are listed in the GHP      |
|     directory.                                                        |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **We use a formulary.** A drug formulary is a list of drugs       |
|     available for coverage under the Plan. The purpose of the         |
|     formulary is to assist physicians in prescribing cost effective,  |
|     quality drug therapy for members. Drugs from all therapeutic      |
|     groups are available on the drug formulary. The formulary has a   |
|     mandatory generic policy when there is a generic medication that  |
|     has been proven by the FDA to be equivalent of the name brand. If |
|     a member or physician prefers the name brand or non-formulary     |
|     drug when a generic is available, the member will be charged the  |
|     difference in cost plus the copayment. Since there is a copayment |
|     for non-formulary drugs, there will no longer be exceptions to    |
|     the formulary. If a doctor prescribes a non-formulary drug, you   |
|     can go back to the doctor and ask them to prescribe something     |
|     from the formulary or pay the higher copayment. You may obtain a  |
|     copy of our formulary list by contacting our Member Services      |
|     department or by visiting our Web site at                         |
|     [www.ghp.com](http://www.ghp.com/).                               |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **We cover non-formulary drugs prescribed by a Plan doctor.** We  |
|     have an open formulary. If your physician believes a name brand   |
|     product is necessary or there is no generic available, your       |
|     physician may prescribe a name brand drug from a formulary list.  |
|     This list of name brand drugs is a preferred list of drugs that   |
|     we selected to meet patient needs at a lower cost. To order a     |
|     prescription drug brochure, call 800-755-3901.                    |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **These are the dispensing limitations.** You may obtain up to a  |
|     31-day supply or 100-unit supply (whichever is less) at a         |
|     participating retail Plan pharmacy. Prescriptions dispensed as a  |
|     unit (such as 1 box, 1 tube, 1 inhaler) will have a copayment per |
|     unit. Selected products or prescription drugs may require prior   |
|     approval from the Plan or have quantity limits (such as Imitrex   |
|     or sexual dysfunction drugs). Please have your doctor call for    |
|     prior approval. When a generic substitution is permissible but    |
|     you or your doctor request the name brand drug, you pay the price |
|     difference between the generic drug and name brand drug, as well  |
|     as the appropriate copay per prescription unit or refill. Your    |
|     prescription drug copay will never exceed the retail price of the |
|     drug.                                                             |
|                                                                       |
| -   **Prescriptions by Mail-Order.** GHP's mail order program and     |
|     participating 90-day pharmacies will dispense a 90-day supply     |
|     (when the prescription is written for 90-days) for 2 copayments.  |
|     Simply ask your physician to write your maintenance medication    |
|     prescription for at least a 90-day supply. Complete a mail order  |
|     form (available through Member Services) or go to a participating |
|     90-day pharmacy. For commercially prepackaged drugs such as       |
|     topicals, inhalers and vials, you will pay the appropriate copay  |
|     for each (3) container. Please note that not all maintenance      |
|     medications are available by mail-order.                          |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **A generic equivalent will be dispensed if it is available**,    |
|     unless your physician specifically requires a name brand. If you  |
|     receive a name brand drug when a Federally-approved generic drug  |
|     is available, and your physician has not specified Dispense as    |
|     Written for the name brand drug, you have to pay the difference   |
|     in cost between the name brand drug and the generic.              |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **Why use generic drugs?** To reduce your out-of-pocket expenses! |
|     A generic drug is the chemical equivalent of a corresponding name |
|     brand drug. Generic drugs are less expensive than name brand      |
|     drugs; therefore, you may reduce your out-of-pocket costs by      |
|     choosing to use a generic drug.                                   |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **When you do have to file a claim.** You would only have to file |
|     a claim if you were out of our Service area and unable to use one |
|     of the national chains participating in the Plan in an emergency  |
|     situation. In this case, please submit an itemized bill to GHP    |
|     with an explanation and we will reimburse you all but your        |
|     copayment.                                                        |
+-----------------------------------------------------------------------+

*Prescription drug benefits begin on the next page*

+------------------------------------------+---------------------------+
| **Benefit Description**                  | **After the deductible,   |
|                                          | you pay**                 |
+------------------------------------------+---------------------------+
| ###### Covered medications and supplies  |                           |
+------------------------------------------+---------------------------+
| We cover the following medications and   | In-network:               |
| supplies prescribed by a Plan physician  |                           |
| and obtained from a Plan pharmacy or     | [At a Participating       |
| through our mail order program:          | Retail                    |
|                                          | Pharmacy]{.underline}     |
| -   Drugs and medicines that by Federal  |                           |
|     law of the United States require a   | \$15 copay for generic    |
|     physician's prescription for their   | formulary                 |
|     purchase, except those listed as     |                           |
|     *Not covered.*                       | \$25 copay for brand name |
|                                          | formulary                 |
| -   Insulin with a copay charge applied  |                           |
|     to each vial                         | \$50 copay for            |
|                                          | non-formulary             |
| -   Disposable needles and syringes for  |                           |
|     the administration of covered        | [At our Mail Order        |
|     medications                          | Pharmacy]{.underline}     |
|                                          |                           |
| -   Drugs for sexual dysfunction (see    | \$30 copay for generic    |
|     Prior authorization)                 | formulary                 |
|                                          |                           |
| -   Contraceptive drugs and devices      | \$50 copay for brand name |
|                                          | formulary                 |
| -   Intravenous fluids and medications   |                           |
|     for home use are covered under the   | \$100 copay for           |
|     medical and surgical benefits        | non-formulary             |
|                                          |                           |
|                                          | Out-of-network: All       |
|                                          | charges                   |
|                                          |                           |
|                                          | Note: Prescriptions must  |
|                                          | be filled at a            |
|                                          | participating pharmacy.   |
|                                          |                           |
|                                          | Note: If there is no      |
|                                          | generic equivalent        |
|                                          | available, you will still |
|                                          | have to pay the name      |
|                                          | brand copay.              |
+------------------------------------------+---------------------------+
| Not covered:                             | *All charges.*            |
|                                          |                           |
| -   Drugs and supplies for cosmetic      |                           |
|     purposes                             |                           |
|                                          |                           |
| -   Drugs to enhance athletic            |                           |
|     performance                          |                           |
|                                          |                           |
| -   Drugs obtained at a non-Plan         |                           |
|     pharmacy except for out-of-area      |                           |
|     emergencies                          |                           |
|                                          |                           |
| -   Vitamins, nutrients and food         |                           |
|     supplements even if a physician      |                           |
|     prescribes or administers them       |                           |
|                                          |                           |
| -   Non-prescription medicines           |                           |
+------------------------------------------+---------------------------+

## **Section** 5.2(i) Special features

+----------------------+-----------------------------------------------+
| Feature              | Description                                   |
+----------------------+-----------------------------------------------+
| ##### Flex           | -   Under the flexible benefits option, we    |
| ible benefits option |     determine the most effective way to       |
|                      |     provide services.                         |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| ####                 | The TDD toll-free number is 877-231-0573 for  |
| # Services for deaf  | people who have difficulties with hearing or  |
| and hearing impaired | speech. You do need special equipment to use  |
|                      | the TDD number.                               |
+----------------------+-----------------------------------------------+
| ###                  | Members who are precertified for surgery are  |
| ## Joint replacement | educated in hopes of the following: increase  |
|                      | knowledge about their surgery and             |
|                      | postoperative care through recovery to        |
|                      | decrease anxiety; reduce length of stay for   |
|                      | the joint replacement member; and support     |
|                      | preoperative teaching programs.               |
+----------------------+-----------------------------------------------+
| ##### H              | To help promote a healthy pregnancy, GHP has  |
| igh risk pregnancies | developed Healthy Basics for a Healthy Baby   |
|                      | Program for its expectant members. Healthy    |
|                      | Basics encourages prenatal care and a healthy |
|                      | lifestyle, provides educational material, and |
|                      | identifies pregnancies that may be of greater |
|                      | than average risk. Healthy Basics is an       |
|                      | enhancement to the regular obstetrical care   |
|                      | mothers received during pregnancy. Expectant  |
|                      | members are enrolled in Healthy Basics when   |
|                      | GHP is notified of the pregnancy.             |
+----------------------+-----------------------------------------------+
| ##### Ce             | GHP provides members with access to           |
| nters of excellence  | nationally recognized transplant programs.    |
|                      | The programs are "Centers of Excellence"      |
|                      | offering members quality transplant services. |
|                      | GHP provides the opportunity for members to   |
|                      | have access to some of the nation's leading   |
|                      | transplant centers.                           |
+----------------------+-----------------------------------------------+
| ##### Members Choice | GHP offers members a complimentary health     |
|                      | care program called Members Choice. Through   |
|                      | this program, GHP members have additional     |
|                      | choices for a healthier lifestyle. Members    |
|                      | Choice features discounts on massage therapy, |
|                      | acupuncture, dietary supplements and          |
|                      | vitamins, as well as health club memberships  |
|                      | at a reduced rate. Members Choice is offered  |
|                      | through GHP's relationship with American      |
|                      | Specialty Health Networks (ASHN). To find a   |
|                      | contracted provider or fitness club in your   |
|                      | area, visit GHP's Web site at                 |
|                      | [www.ghp.com](http://www.ghp.com/) and click  |
|                      | on the Members icon, then Member Benefit      |
|                      | Information, then Members Choice. Or you may  |
|                      | call ASHN Member Services toll-free at        |
|                      | 877-335-2746 for assistance.                  |
+----------------------+-----------------------------------------------+

## **Section** 5.2(j) Dental benefits

+---+---+------------------------------------+---------------------+---+---+
|   | * | **Here are some important things   |                     | * |   |
|   | * | to keep in mind about these        |                     | * |   |
|   | I | benefits:**                        |                     | I |   |
|   | * |                                    |                     | * |   |
|   | * | -   Please remember that all       |                     | * |   |
|   |   |     benefits are subject to the    |                     |   |   |
|   | * |     definitions, limitations, and  |                     | * |   |
|   | * |     exclusions in this brochure    |                     | * |   |
|   | M |     and are payable only when we   |                     | M |   |
|   | * |     determine they are medically   |                     | * |   |
|   | * |     necessary.                     |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   Plan dentists must provide or  |                     | * |   |
|   | * |     arrange your care.             |                     | * |   |
|   | P |                                    |                     | P |   |
|   | * | -   We cover hospitalization for   |                     | * |   |
|   | * |     dental procedures only when a  |                     | * |   |
|   |   |     non-dental physical impairment |                     |   |   |
|   | * |     exists which makes             |                     | * |   |
|   | * |     hospitalization necessary to   |                     | * |   |
|   | O |     safeguard the health of the    |                     | O |   |
|   | * |     patient. See Section 5(e) for  |                     | * |   |
|   | * |     inpatient hospital benefits.   |                     | * |   |
|   |   |     We do not cover the dental     |                     |   |   |
|   | * |     procedure unless it is         |                     | * |   |
|   | * |     described below.               |                     | * |   |
|   | R |                                    |                     | R |   |
|   | * | -   Be sure to read Section 4,     |                     | * |   |
|   | * |     *Your costs for covered        |                     | * |   |
|   |   |     services,* for valuable        |                     |   |   |
|   | * |     information about how cost     |                     | * |   |
|   | * |     sharing works. Also read       |                     | * |   |
|   | T |     Section 9 about coordinating   |                     | T |   |
|   | * |     benefits with other coverage,  |                     | * |   |
|   | * |     including with Medicare.       |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | A |                                    |                     | A |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | N |                                    |                     | N |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | T |                                    |                     | T |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
+===+===+====================================+=====================+===+===+
| # |   |                                    | You pay             |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| A |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| j |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| W |   |                                    | 10% of the Plan     |   |   |
| e |   |                                    | allowance and any   |   |   |
| c |   |                                    | difference between  |   |   |
| o |   |                                    | our allowance and   |   |   |
| v |   |                                    | the billed amount   |   |   |
| e |   |                                    | for outpatient      |   |   |
| r |   |                                    | surgical procedure  |   |   |
| r |   |                                    |                     |   |   |
| e |   |                                    | Out-of-network: 30% |   |   |
| s |   |                                    | of the Plan         |   |   |
| t |   |                                    | allowance and any   |   |   |
| o |   |                                    | difference between  |   |   |
| r |   |                                    | our allowance and   |   |   |
| a |   |                                    | the billed amount   |   |   |
| t |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| ( |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| ) |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| w |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| w |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| . |   |                                    |                     |   |   |
| T |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| j |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
| . |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+

  ------------------------------------------------ ----------------------
  Dental benefits                                  

  Service                                          You pay

  *We have no other dental benefits.*              *All charges.*
  ------------------------------------------------ ----------------------

## Section 5.2(k) Savings -- HSAs and HRAs

+------------------+---------------------------+-----------------------+
| ###### Fe        | ###### Hea                | ###                   |
| ature Comparison | lth Savings Account (HSA) | ### Health Reimbursem |
|                  |                           | ent Arrangement (HRA) |
|                  |                           |                       |
|                  |                           | ###### P              |
|                  |                           | rovided when you are  |
|                  |                           | ineligible for an HSA |
+==================+===========================+=======================+
| ###              | The Plan will establish   | Corporate Benefit     |
| ## Administrator | an HSA for you with       | Services of America,  |
|                  | Corporate Benefit         | Inc. (CBSA) is the    |
|                  | Services of America, Inc. | HRA administrator for |
|                  | (CBSA), an administrator, | this Plan.            |
|                  | trustee or custodian as   |                       |
|                  | defined by Federal tax    | **Corporate Benefit   |
|                  | code and approved by IRS. | Services of America,  |
|                  |                           | Inc.**                |
|                  | **Corporate Benefit       |                       |
|                  | Services of America,      | **PO Box 270520**     |
|                  | Inc.**                    |                       |
|                  |                           | **Golden Valley, MN   |
|                  | **PO Box 270520**         | 55427**               |
|                  |                           |                       |
|                  | **Golden Valley, MN       | **800-566-9311**      |
|                  | 55427**                   |                       |
|                  |                           | [*                    |
|                  | **800-566-9311**          | *https://services.cbs |
|                  |                           | ainc.com/eehome.asp** |
|                  | [**https://               | ](https://services.cb |
|                  | services.cbsainc.com/eeho | sainc.com/eehome.asp) |
|                  | me.asp**](https://service |                       |
|                  | s.cbsainc.com/eehome.asp) |                       |
+------------------+---------------------------+-----------------------+
| ##### Fees       | Set-up fee is paid by GHP | Set-up fee is paid by |
|                  | HDHP.                     | GHP HDHP.             |
|                  |                           |                       |
|                  | \$5.50 per month          |                       |
|                  | administrative fee        |                       |
|                  | charged by the fiduciary  |                       |
|                  | and taken out of the      |                       |
|                  | account balance.          |                       |
+------------------+---------------------------+-----------------------+
| #                | -   Enrolled in GHP's     | -   Enrolled in GHP's |
| #### Eligibility |     HDHP Plan             |     HDHP Plan         |
|                  |                           |                       |
|                  | -   No other health       | -   Medicare eligible |
|                  |     insurance coverage    |                       |
|                  |     (does not apply to    | -   Complete and      |
|                  |     specific injury,      |     return all        |
|                  |     accident, disability, |     banking paperwork |
|                  |     dental, vision or     |                       |
|                  |     long-term care        | -   Eligibility is    |
|                  |     coverage)             |     determined on the |
|                  |                           |     first day of the  |
|                  | -   Not eligible for      |     month             |
|                  |     Medicare Part A or    |                       |
|                  |     Part B                |                       |
|                  |                           |                       |
|                  | -   Not claimed as a      |                       |
|                  |     dependent on someone  |                       |
|                  |     else's tax return     |                       |
|                  |                           |                       |
|                  | -   Complete and return   |                       |
|                  |     all banking paperwork |                       |
|                  |                           |                       |
|                  | -   Eligibility is        |                       |
|                  |     determined on the     |                       |
|                  |     first day of the      |                       |
|                  |     month                 |                       |
+------------------+---------------------------+-----------------------+
| *HSAs and HRAs   |                           |                       |
| -- continued on  |                           |                       |
| next page*       |                           |                       |
+------------------+---------------------------+-----------------------+
| ##### Funding    | \$500 annual premium pass | \$500 annual credit   |
|                  | through by HDHP directly  | (prorated monthly and |
| -   **Self Only  | into account prorated on  | credited to the       |
|     coverage**   | a monthly basis           | account) provided by  |
|                  |                           | the HDHP upon         |
|                  |                           | effective date        |
+------------------+---------------------------+-----------------------+
| -   **Self and   | \$1,000 annual premium    | \$1,000 annual credit |
|     Family\      | pass through by HDHP      | (prorated monthly and |
|     coverage**   | directly into account     | credited to the       |
|                  | prorated on a monthly     | account) provided by  |
|                  | basis                     | the HDHP upon         |
|                  |                           | effective date        |
|                  | Eligibility for           |                       |
|                  | contributions will be     | Eligibility for       |
|                  | determined on the first   | annual credit will be |
|                  | day of the month and will | determined on the     |
|                  | be prorated for length of | first day of the      |
|                  | enrollment.               | month and will be     |
|                  |                           | prorated for length   |
|                  |                           | of enrollment.        |
+------------------+---------------------------+-----------------------+
| ##### Contr      | The maximum that can be   | \$500 annual credit   |
| ibutions/credits | contributed to your HSA   | provided by the HDHP  |
|                  | is an annual combination  |                       |
| -   **Self Only  | of HDHP premium pass      | The full HRA credit   |
|     coverage**   | through and enrollee      | will be available,    |
|                  | contribution funds, which | subject to proration. |
|                  | when combined, do not     | The HRA does not earn |
|                  | exceed the amount of the  | interest. You cannot  |
|                  | deductible, which is      | contribute to the     |
|                  | \$1,500.                  | HRA.                  |
|                  |                           |                       |
|                  | For each month you are    | For each month you    |
|                  | eligible for HSA          | are eligible for HRA  |
|                  | contributions,            | contributions,        |
|                  |                           |                       |
|                  | The HDHP will make a      | The HDHP will make a  |
|                  | premium pass through of   | premium pass through  |
|                  | \$41.67 per employee per  | of \$41.67 per        |
|                  | month. You may make a     | employee per month.   |
|                  | maximum annual            |                       |
|                  | contribution of \$1,000.  |                       |
+------------------+---------------------------+-----------------------+
| *HSAs and HRAs   |                           |                       |
| -- continued on  |                           |                       |
| next page*       |                           |                       |
+------------------+---------------------------+-----------------------+
| -   **Self and   | The HDHP will make a      | The HDHP will make a  |
|     Family\      | premium pass through of   | premium pass through  |
|     coverage**   | \$83.33 per employee per  | of \$83.33 per        |
|                  | month. Your annual        | employee per month.   |
|                  | maximum contribution      |                       |
|                  | cannot exceed \$1,500.    | \$1,000 annual credit |
|                  |                           | provided by the HDHP  |
|                  | If you choose to          |                       |
|                  | contribute to your HSA,   | HRAs do not earn      |
|                  |                           | interest.             |
|                  | -You must deduct 1/12 of  |                       |
|                  | total annual maximum      | You cannot contribute |
|                  | contribution for every    | to the HRA.           |
|                  | month you are not         |                       |
|                  | eligible for the HDHP the |                       |
|                  | whole month. For          |                       |
|                  | instance, if your         |                       |
|                  | enrollment in this Plan   |                       |
|                  | was not effective on      |                       |
|                  | January 1, 2005, you      |                       |
|                  | cannot receive a credit   |                       |
|                  | for January and you would |                       |
|                  | need to deduct 1/12 of    |                       |
|                  | the annual maximum        |                       |
|                  | contribution.             |                       |
|                  |                           |                       |
|                  | -You may rollover funds   |                       |
|                  | you have in other HSAs to |                       |
|                  | this HDHP HSA (rollover   |                       |
|                  | funds do not affect your  |                       |
|                  | annual maximum            |                       |
|                  | contribution under this   |                       |
|                  | HDHP).                    |                       |
|                  |                           |                       |
|                  | \- HSAs earn tax-free     |                       |
|                  | interest (does not affect |                       |
|                  | your annual maximum       |                       |
|                  | contribution).            |                       |
+------------------+---------------------------+-----------------------+
| ##               | You can access your HSA   | For qualified medical |
| ### Access funds | by the following methods: | expenses under your   |
|                  |                           | HDHP, you will be     |
|                  | -   Debit card            | automatically         |
|                  |                           | reimbursed when       |
|                  | -   Withdrawal form       | claims are submitted  |
|                  |                           | through your HDHP.    |
|                  | -   Check                 | For expenses not      |
|                  |                           | covered by the HDHP,  |
|                  |                           | such as orthodontia   |
|                  |                           | and cosmetic surgery, |
|                  |                           | a reimbursement form  |
|                  |                           | will be sent to you.  |
+------------------+---------------------------+-----------------------+
| *HSAs and HRAs   |                           |                       |
| -- continued on  |                           |                       |
| next page*       |                           |                       |
+------------------+---------------------------+-----------------------+
| ##### Distribut  | After meeting the         | After meeting the     |
| ions/withdrawals | deductible, pay the       | deductible, pay the   |
|                  | out-of-pocket expenses    | out-of-pocket         |
| -   **Medical**  | for yourself, your spouse | expenses for          |
|                  | or your dependents even   | qualified medical     |
|                  | if they are not covered   | expenses for          |
|                  | by the HDHP from the      | individuals covered   |
|                  | funds available in your   | under the HDHP.       |
|                  | HSA.                      |                       |
|                  |                           | Non-reimbursed        |
|                  | Medical expenses are      | qualified medical     |
|                  | **[not]{.underline}**     | expenses are          |
|                  | allowable if they occur   | allowable if they     |
|                  | before the first full     | occur after the       |
|                  | month your enrollment is  | effective date of     |
|                  | effective, and they are   | your enrollment in    |
|                  | not reimbursable from     | this Plan.            |
|                  | your HSA until the first  |                       |
|                  | of the month following    | See *Availability of  |
|                  | the effective date of     | funds* below for      |
|                  | your enrollment in this   | information on when   |
|                  | HDHP and the date your    | funds are available   |
|                  | HSA account is            | in the HRA.           |
|                  | established.              |                       |
|                  |                           | See IRS Publication   |
|                  | For most Federal          | 502 for a complete    |
|                  | enrollees (those not paid | list of eligible      |
|                  | on a monthly basis), the  | expenses.             |
|                  | earliest date medical     |                       |
|                  | expenses will be          |                       |
|                  | allowable is February 1,  |                       |
|                  | 2005.                     |                       |
|                  |                           |                       |
|                  | See IRS Publication 502   |                       |
|                  | for a complete list of    |                       |
|                  | eligible expenses.        |                       |
+------------------+---------------------------+-----------------------+
| -                | If you are under age 65,  | Not applicable --     |
|  **Non-medical** | withdrawal of funds for   | distributions will    |
|                  | non-medical expenses will | not be made for       |
| #####            | create a 10% income tax   | anything other than   |
|                  | penalty in addition to    | non-reimbursed        |
|                  | any other income taxes    | qualified medical     |
|                  | you may owe on the        | expenses.             |
|                  | accumulated funds.        |                       |
|                  |                           |                       |
|                  | When you turn age 65,     |                       |
|                  | distributions can be used |                       |
|                  | for any reason without    |                       |
|                  | being subject to the 10%  |                       |
|                  | penalty.                  |                       |
+------------------+---------------------------+-----------------------+
| *HSAs and HRAs   |                           |                       |
| -- continued on  |                           |                       |
| next page*       |                           |                       |
+------------------+---------------------------+-----------------------+
| ##### Avail      | Funds are not available   | Funds are not         |
| ability of funds | until:                    | available until:      |
|                  |                           |                       |
|                  | -   Your enrollment in    | -   Your enrollment   |
|                  |     this HDHP is          |     in this HDHP is   |
|                  |     effective (effective  |     effective         |
|                  |     date is determined by |     (effective date   |
|                  |     your agency in accord |     is determined by  |
|                  |     with the event        |     your agency in    |
|                  |     permitting the        |     accord with the   |
|                  |     enrollment change).   |     event permitting  |
|                  |                           |     the enrollment    |
|                  | -   The HDHP receives     |     change).          |
|                  |     record of your        |                       |
|                  |     enrollment and        | -   The HDHP receives |
|                  |     initially establishes |     record of your    |
|                  |     your HSA account with |     enrollment and    |
|                  |     the fiduciary by      |     initially         |
|                  |     providing information |     establishes your  |
|                  |     it must furnish and   |     HRA account with  |
|                  |     by contributing the   |     the fiduciary by  |
|                  |     minimum amount        |     providing         |
|                  |     required to establish |     information it    |
|                  |     an HSA.               |     must furnish and  |
|                  |                           |     by contributing   |
|                  | -   The fiduciary sends   |     the minimum       |
|                  |     out HSA paperwork for |     amount required   |
|                  |     the enrollee to       |     to establish an   |
|                  |     complete and the      |     HRA.              |
|                  |     fiduciary receives    |                       |
|                  |     the completed         |                       |
|                  |     paperwork.            |                       |
|                  |                           |                       |
|                  | After the fiduciary       |                       |
|                  | receives the completed    |                       |
|                  | paperwork from the        |                       |
|                  | enrollee, the enrollee    |                       |
|                  | can withdraw funds for    |                       |
|                  | any expenses incurred on  |                       |
|                  | or after the date the HSA |                       |
|                  | was initially             |                       |
|                  | established.              |                       |
+------------------+---------------------------+-----------------------+
| ###              | GHP HDHP                  | GHP HDHP              |
| ## Account owner |                           |                       |
+------------------+---------------------------+-----------------------+
| ##### Portable   | Yes, you can take this    | If you retire and     |
|                  | account with you when you | remain in this HDHP,  |
|                  | separate or retire.       | you may continue to   |
|                  |                           | use and accumulate    |
|                  |                           | credits in your HRA.  |
|                  |                           |                       |
|                  |                           | If you terminate      |
|                  |                           | employment or change  |
|                  |                           | health plans, only    |
|                  |                           | eligible expenses     |
|                  |                           | incurred while        |
|                  |                           | covered under the     |
|                  |                           | HDHP will be eligible |
|                  |                           | for reimbursement     |
|                  |                           | subject to timely     |
|                  |                           | filing requirements.  |
|                  |                           | Unused funds are      |
|                  |                           | forfeited.            |
+------------------+---------------------------+-----------------------+
| #####            | Yes, accumulates without  | Yes, accumulates      |
|  Annual rollover | a maximum cap.            | without a maximum     |
|                  |                           | cap.                  |
+------------------+---------------------------+-----------------------+

+-------------------+--------------------------------------------------+
| **HSAs**          |                                                  |
+-------------------+--------------------------------------------------+
| **Is the "premium | "Premium pass through" contributions by the HDHP |
| pass through" to  | are not considered taxable income.               |
| my HSA considered |                                                  |
| taxable income?** |                                                  |
+-------------------+--------------------------------------------------+
| **Can I           | Yes. All contributions are aggregated and cannot |
| contribute to my  | exceed the annual maximum contribution. You may  |
| HSA?**            | contribute your own money to your account        |
|                   | through payroll deductions (if available), or    |
|                   | you may make a lump sum contribution at any      |
|                   | time, in any amount up to an annual maximum      |
|                   | limit. Others can also make contributions to     |
|                   | your HSA on your behalf. If you (or someone on   |
|                   | your behalf) contribute a lump-sum, you can      |
|                   | claim the total amount contributed for the year  |
|                   | as a tax deduction when you file your income     |
|                   | taxes. You receive tax advantages in any case.   |
|                   | [You have until April 15 of the following year   |
|                   | to make HSA contributions for the current        |
|                   | year.]{.mark}                                    |
|                   |                                                  |
|                   | IRS contribution rules reduce the total annual   |
|                   | maximum contribution if you are not eligible for |
|                   | the HDHP during the whole month. For instance,   |
|                   | if your enrollment in this Plan was not          |
|                   | effective on January 1, 2005, you cannot receive |
|                   | a credit for January and you would need to       |
|                   | deduct 1/12 of the annual maximum contribution.  |
|                   | Contact CBSA for more details.                   |
+-------------------+--------------------------------------------------+
| **Catch-up        | If you are age 55 or older, the IRS permits you  |
| contributions**   | to make additional catch-up contributions to     |
|                   | your HSA. In 2005, you may contribute up to      |
|                   | \$500 in "catch-up" contributions. Catch-up      |
|                   | contributions in later years increase up to a    |
|                   | maximum of \$1,000 in 2009 and beyond.           |
|                   | Contributions must stop once an individual is    |
|                   | eligible for Medicare. Additional details are    |
|                   | available on the IRS Web site at                 |
|                   | [www.irs.gov](http://www.irs.gov/).              |
+-------------------+--------------------------------------------------+
| **Rate of         | Depending on how you choose to invest your HSA   |
| interest earned** | savings, the interest rate and payment of        |
|                   | interest will vary. Contact CBSA for more        |
|                   | details on the investment options available to   |
|                   | you.                                             |
+-------------------+--------------------------------------------------+
| **What happens to | You own your account, so you keep your HSA even  |
| my HSA if I leave | if you change health plans, leave Federal        |
| my health plan or | employment, become eligible for Medicare, or any |
| job?**            | of the other events which may make you           |
|                   | ineligible for further contributions to your     |
|                   | HSA. Even when you are not eligible to make      |
|                   | contributions to your HSA, you may request       |
|                   | withdrawals.                                     |
+-------------------+--------------------------------------------------+
| **What happens to | Your HSA would pass to your surviving spouse or  |
| my HSA if I       | named beneficiary tax free. If you do not have a |
| die?**            | named beneficiary, the money is disbursed to     |
|                   | your estate and is taxable.                      |
+-------------------+--------------------------------------------------+
| **What expenses   | You can pay for "qualified medical expenses," as |
| can I pay for     | defined by IRS Code 213(d). These expenses       |
| with my HSA?**    | include, but are not limited to, medical plan    |
|                   | deductibles, diagnostic services covered by your |
|                   | plan, long-term care premiums, and health        |
|                   | insurance premiums if you are receiving Federal  |
|                   | unemployment compensation, over-the-counter      |
|                   | drugs, LASIK surgery, and some nursing services. |
|                   |                                                  |
|                   | When you become Medicare-eligible, you can use   |
|                   | the account to purchase any health insurance     |
|                   | other than a Medigap policy. You may not,        |
|                   | however, continue to make contributions to your  |
|                   | HSA once you are Medicare eligible.              |
|                   |                                                  |
|                   | For the complete list of IRS-allowable expenses, |
|                   | request a copy of IRS Publication 502 by calling |
|                   | 1-800-829-3676, or visit the IRS Web site at     |
|                   | [www.irs.gov](http://www.irs.gov/) and click on  |
|                   | "Forms and Publications."                        |
+-------------------+--------------------------------------------------+
| **Non-qualified   | You may withdraw money from your HSA for items   |
| health expenses** | other than qualified health expenses, but it     |
|                   | will be subject to income tax and if you are     |
|                   | under 65 years old, an additional 10% penalty    |
|                   | tax on the amount withdrawn.                     |
+-------------------+--------------------------------------------------+
| **Tracking your   | You will receive a periodic statement that shows |
| HSA balance**     | the "premium pass through" and withdrawals, and  |
|                   | interest earned on your account. In addition,    |
|                   | you will receive an Explanation of Payment       |
|                   | statement when you withdraw money from your HSA. |
+-------------------+--------------------------------------------------+
| **Minimum         | You can request reimbursement in any amount.     |
| reimbursements    | However, funds will not be disbursed until your  |
| from your HSA**   | reimbursement totals at least \$25.              |
+-------------------+--------------------------------------------------+
| **HRAs**          |                                                  |
+-------------------+--------------------------------------------------+
| **How do I know   | If you don't qualify for an HSA when you enroll, |
| if I qualify for  | or later become ineligible for an HSA, the HDHP  |
| an HRA?**         | will establish an HRA for you. If you are        |
|                   | Medicare eligible, even if you have not elected  |
|                   | to enroll in Medicare, you are ineligible for an |
|                   | HSA and your HDHP will establish an HRA for you. |
+-------------------+--------------------------------------------------+
| **HRA and HSA     | Please review the chart at the beginning of this |
| differences**     | Section which details the differences. The major |
|                   | differences are:                                 |
|                   |                                                  |
|                   | -   you cannot make contributions to an HRA      |
|                   |                                                  |
|                   | -   HRA funds are forfeited if you leave the     |
|                   |     HDHP                                         |
|                   |                                                  |
|                   | -   an HRA does not earn interest, and           |
|                   |                                                  |
|                   | -   HRAs can only pay for qualified medical      |
|                   |     expenses, such as deductibles, copayments,   |
|                   |     and coinsurance expenses, for individuals    |
|                   |     covered by the HDHP.                         |
+-------------------+--------------------------------------------------+

## Section 5.2(l) Catastrophic protection for out-of-pocket expenses

GHP's system will monitor (auto-calculate) out-of-pocket expenses for
HDHP. Once the out of pocket threshold is met, claims will pay at 100%.
Pursuant to IRS regulations for qualified HDHPs, out-of-pocket expenses
are calculated the same way as the deductible for both Family and Single
coverage.

For a qualified HDHP, copayments, deductibles and coinsurance amounts
apply toward the member\'s out-of-pocket maximum. Items that do not
apply toward the maximum include: Charges over Usual and Customary that
are the member\'s responsibility when they use non-participating
providers; Charges for services that are not eligible under the plan
(Cosmetic Surgery, for example); and any penalty applied to the member
for non-compliance to utilization rules outlined in a member\'s plan
documents.

## Section 5.2(m) Health education resources and account management tools

+------------------+---------------------------------------------------+
| #####            | ###### Description                                |
| Special features |                                                   |
+------------------+---------------------------------------------------+
| ##### Health edu | We publish an e-newsletter to keep you informed   |
| cation resources | on a variety of issues related to your good       |
|                  | health. Visit our Web site at                     |
|                  | [www.ghp.com](http://www.ghp.com/) for            |
|                  | information to help you take command of your      |
|                  | health. This section is organized in simple,      |
|                  | user-friendly, sections:                          |
|                  |                                                   |
|                  | -   ***Assess Your Health*** -- where you will    |
|                  |     find a simple, free, online health risk       |
|                  |     assessment tool to benchmark your wellness,   |
|                  |     and better understand your overall health     |
|                  |     status and risks.                             |
|                  |                                                   |
|                  | -   ***About Your Health*** -- for information    |
|                  |     about a specific condition or general         |
|                  |     preventive guidelines.                        |
|                  |                                                   |
|                  | -   ***Patient Safety***                          |
|                  |                                                   |
|                  | -   ***WebMD*** -- our link to this health site   |
|                  |     also provides wellness and disease            |
|                  |     information to help improve health.           |
|                  |                                                   |
|                  | -   ***Prescription Drugs*** - educational        |
|                  |     materials are also accessible through our Web |
|                  |     site, through a link to our pharmacy benefit  |
|                  |     manager, Caremark. There, you will find:      |
|                  |                                                   |
|                  | ```{=html}                                        |
|                  | <!-- -->                                          |
|                  | ```                                               |
|                  | -   Detailed information about a wide range of    |
|                  |     prescription drugs;                           |
|                  |                                                   |
|                  | -   A drug interaction tool to help easily        |
|                  |     determine if a specific drug can have any     |
|                  |     adverse interactions with each other, with    |
|                  |     over-the-counter drugs, or with herbals and   |
|                  |     vitamins;                                     |
|                  |                                                   |
|                  | -   Facts about why FDA-approved generic drugs    |
|                  |     should be a first choice for effective,       |
|                  |     economical treatment.                         |
|                  |                                                   |
|                  | Another key health information tool that we make  |
|                  | available to you is our online quality tools,     |
|                  | powered by HealthShare. You can review the        |
|                  | frequency of procedures performed by a provider,  |
|                  | knowing the correlation between frequency of      |
|                  | service and quality of outcomes. We post          |
|                  | additional quality outcome information, such as   |
|                  | re-admission rates within 30 days, post-operative |
|                  | complications and even death rates.               |
|                  |                                                   |
|                  | We also publish an e-newsletter to keep you       |
|                  | informed on a variety of issues related to your   |
|                  | good health. Visit our Web site at                |
|                  | [www.ghp.com](http://www.ghp.com/) for past       |
|                  | editions of this publication, *Living Well*.      |
|                  |                                                   |
|                  | -   In addition, we augment our health education  |
|                  |     tools with access to our ***Nurse Advisor     |
|                  |     Services***. Experienced RNs are available    |
|                  |     through an inbound call center 24 hours a     |
|                  |     day, 7 days a week, 365 days a year to assist |
|                  |     you and help you to maximize your benefits by |
|                  |     providing clinical and economic information   |
|                  |     to make an informed decision on how to        |
|                  |     proceed with care.                            |
+------------------+---------------------------------------------------+
| ##### Account    | For each HSA and HRA account holder, we maintain  |
| management tools | a complete claims payment history online through  |
|                  | [www.ghp.com](http://www.ghp.com/).               |
|                  |                                                   |
|                  | -   Your balance will also be shown on your       |
|                  |     explanation of benefits (EOB) form.           |
|                  |                                                   |
|                  | -   You will receive an EOB after every claim.    |
|                  |                                                   |
|                  | -   If you have an **HSA**,                       |
|                  |                                                   |
|                  | ```{=html}                                        |
|                  | <!-- -->                                          |
|                  | ```                                               |
|                  | -   You will receive a quarterly statement by     |
|                  |     mail outlining your account balance and       |
|                  |     activity for the month.                       |
|                  |                                                   |
|                  | -   You may also access your account and review   |
|                  |     your activity on a daily basis online via My  |
|                  |     Online Services at                            |
|                  |     [www.ghp.com](http://www.ghp.com/).           |
|                  |                                                   |
|                  | If you have an **HRA**,                           |
|                  |                                                   |
|                  | -   You will receive a quarterly statement by     |
|                  |     mail outlining your account balance and       |
|                  |     activity for the month.                       |
|                  |                                                   |
|                  | ```{=html}                                        |
|                  | <!-- -->                                          |
|                  | ```                                               |
|                  | -   You may also access your account and review   |
|                  |     your activity on a daily basis online via My  |
|                  |     Online Services at                            |
|                  |     [www.ghp.com](http://www.ghp.com/).           |
+------------------+---------------------------------------------------+
| #                | -   As a member of this HDHP, you may choose any  |
| #### Consumer ch |     provider. However, you will receive discounts |
| oice information |     when you see a network provider. Our provider |
|                  |     search function on our Web site               |
|                  |     ([www.ghp.com](http://www.ghp.com/)) is       |
|                  |     updated every week. It lets you easily search |
|                  |     for a participating physician based on the    |
|                  |     criteria *[you]{.underline}* choose, such as  |
|                  |     provider specialty, gender, secondary         |
|                  |     languages spoken, or hospital affiliation.    |
|                  |     You can even specify the maximum distance     |
|                  |     you're willing to travel and, in most         |
|                  |     instances, get driving directions and a map   |
|                  |     to the offices of identified providers.       |
|                  |                                                   |
|                  | -   Pricing information for medical care is       |
|                  |     available at                                  |
|                  |     [www.ghp.com](http://www.ghp.com/). There,    |
|                  |     you will find our ***Health Services Pricing  |
|                  |     Tools*** which provide average cost           |
|                  |     information for some of the most common       |
|                  |     categories of service. The easy-to-understand |
|                  |     information is sorted by categories of        |
|                  |     service including physician office visits,    |
|                  |     diagnostic tests, surgical procedures and     |
|                  |     hospitalization.                              |
|                  |                                                   |
|                  | -   Pricing information for prescription drugs is |
|                  |     available through our link to the Web site of |
|                  |     our pharmacy benefit manager, Caremark (which |
|                  |     you can access via                            |
|                  |     [www.ghp.com](http://www.ghp.com/)). Through  |
|                  |     a password-protected account, you will have   |
|                  |     the ability to estimate prescription costs    |
|                  |     before ordering.                              |
|                  |                                                   |
|                  | Link to online pharmacy through the Web site of   |
|                  | our pharmacy benefit manager, Caremark (which you |
|                  | can access via                                    |
|                  | [www.ghp.com](http://www.ghp.com/)).              |
|                  |                                                   |
|                  | Educational materials on the topics of HSAs, HRAs |
|                  | and HDHPs are available at                        |
|                  | [www.ghp.com](http://www.ghp.com/).               |
+------------------+---------------------------------------------------+
| ##               | -   Our complex case management programs offer    |
| ### Care support |     special assistance to members with intricate, |
|                  |     long-term medical needs. Our disease          |
|                  |     management program fosters a proactive        |
|                  |     approach to managing care from prevention     |
|                  |     through treatment and management. Your        |
|                  |     physician can help arrange for participation  |
|                  |     in these programs, or you can simply contact  |
|                  |     our Member Service Department.                |
|                  |                                                   |
|                  | -   Patient safety information is available       |
|                  |     online at [www.ghp.com](http://www.ghp.com/). |
|                  |                                                   |
|                  | Care support is also available to you in the form |
|                  | of a relationship that we have established with   |
|                  | the *College of American Pathologists* for e-mail |
|                  | reminder notifications. We'll send a message to   |
|                  | the e-mail address you provide on a scheduled     |
|                  | basis reminding you to arrange for screening      |
|                  | tests.                                            |
+------------------+---------------------------------------------------+

# **Section** 5.3 Non-FEHB benefits available to Plan members

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

MEMBERS CHOICE PROGRAM

GHP offers members a complimentary health care program called Members
Choice. Through this program, GHP members have additional choices for a
healthier lifestyle. Members Choice features discounts on massage
therapy, acupuncture, dietary supplements and vitamins, as well as
health club memberships at a reduced rate. Members Choice is offered
through GHP's relationship with American Specialty Health Networks
(ASHN). To find a contracted provider or fitness club in your area,
visit GHP's Web site at [www.ghp.com](http://www.ghp.com/) and click on
the Members icon, then Member Benefit Information, then Members Choice.
Or you may call ASHN Member Services toll-free at 877-355-2746 for
assistance.

VOLUNTARY DENTAL PROGRAM

With your continued or new enrollment with GHP for 2005, you have the
opportunity to select a low-cost voluntary dental program offered by
CompDent. Highlights of the benefits available with this plan are as
follows:

-   No waiting periods

-   No deductible

-   No benefit maximum

-   No claims to file

-   Oral evaluations at no charge

-   X-rays at no charge

-   Cleanings -- once every six months at no charge

-   Basic and major services

-   25% discount for specialty services including orthodontia

COST PER MONTH: Employee Only [\$7.66]{.underline} Employee + Family
[\$17.04]{.underline}

If you choose to enroll in this value-added benefit, the cost for single
coverage or family coverage will be automatically deducted from your
checking account on a monthly basis, or you may pay on an annual basis
by using a major credit card. Participation is voluntary so you will not
be automatically enrolled in this program.

**For more information regarding this voluntary dental program, please
refer to the CompDent introduction letter in your GHP enrollment
packet.**

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

The exclusions in this section apply to all benefits. **Although we may
list a specific service as a benefit, we will not cover it unless your
Plan doctor determines it is medically necessary to prevent, diagnose,
or treat your illness, disease, injury, or condition and we agree, as
discussed under *Services requiring our prior approval* on page 13.**

We do not cover the following:

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

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

-   Services, drugs, or supplies not medically necessary;

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

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

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

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

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

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

# Section 7. Filing a claim for covered services

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

You may be responsible for filing a claim for out-of-network services.
Sometimes these providers bill us directly. Check with the provider. If
you need to file the claim, here is the process:

+------------------+---------------------------------------------------+
| Medical and      | In most cases, providers and facilities file      |
| hospital         | claims for you. Physicians must file on the form  |
| benefits         | HCFA-1500, Health Insurance Claim Form. Your      |
|                  | facility will file on the UB-92 form. For claims  |
|                  | questions and assistance, call us at              |
|                  | 800-755-3901.                                     |
|                  |                                                   |
|                  | When you must file a claim -- such as for         |
|                  | services you receive outside the Plan's service   |
|                  | area -- submit it on the HCFA-1500 or a claim     |
|                  | form that includes the information shown below.   |
|                  | Bills and receipts should be itemized and show:   |
|                  |                                                   |
|                  | -   Covered member's name and ID number;          |
|                  |                                                   |
|                  | -   Name and address of the physician or facility |
|                  |     that provided the service or supply;          |
|                  |                                                   |
|                  | -   Dates you received the services or supplies;  |
|                  |                                                   |
|                  | -   Diagnosis;                                    |
|                  |                                                   |
|                  | -   Type of each service or supply;               |
|                  |                                                   |
|                  | -   The charge for each service or supply;        |
|                  |                                                   |
|                  | -   A copy of the explanation of benefits,        |
|                  |     payments, or denial from any primary payer -- |
|                  |     such as the Medicare Summary Notice (MSN);    |
|                  |     and                                           |
|                  |                                                   |
|                  | -   Receipts, if you paid for your services.      |
|                  |                                                   |
|                  | **Submit your claims to:**                        |
|                  |                                                   |
|                  | **Group Health Plan, PO Box 7374, London, KY      |
|                  | 40742-7374**                                      |
+------------------+---------------------------------------------------+
| Prescription     | **Submit your claims to:**                        |
| drugs            |                                                   |
|                  | **Group Health Plan, Attn: Pharmacy Department,   |
|                  | 111 Corporate Office Drive, Suite 400, Earth      |
|                  | City, MO 63045**                                  |
+------------------+---------------------------------------------------+
| Deadline for     | Send us all of the documents for your claim as    |
| filing your      | soon as possible. You must submit the claim by    |
| claim            | December 31 of the year after the year you        |
|                  | received the service, unless timely filing was    |
|                  | prevented by administrative operations of         |
|                  | Government or legal incapacity, provided the      |
|                  | claim was submitted as soon as reasonably         |
|                  | possible.                                         |
+------------------+---------------------------------------------------+
| When we need     | Please reply promptly when we ask for additional  |
| more information | information. We may delay processing or deny your |
|                  | claim if you do not respond.                      |
+------------------+---------------------------------------------------+

# Section 8. The disputed claims process

Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on your claim or request for
services, drugs, or supplies -- including a request for
preauthorization/prior approval. Disagreements between you and the HDHP
fiduciary regarding the administration of an HSA or HRA are not subject
to the disputed claims process.

+----+-----------------------------------------------------------------+
| St | Description                                                     |
| ep |                                                                 |
+----+-----------------------------------------------------------------+
| 1  | Ask us in writing to reconsider our initial decision. You must: |
|    |                                                                 |
|    | a)  Write to us within 6 months from the date of our decision;  |
|    |     and                                                         |
|    |                                                                 |
|    | b)  Send your request to us at: Group Health Plan, Attn: Member |
|    |     Correspondence Unit, 111 Corporate Office Drive, Suite 400, |
|    |     Earth City, MO 63045; and                                   |
|    |                                                                 |
|    | c)  Include a statement about why you believe our initial       |
|    |     decision was wrong, based on specific benefit provisions in |
|    |     this brochure; and                                          |
|    |                                                                 |
|    | d)  Include copies of documents that support your claim, such   |
|    |     as physicians\' letters, operative reports, bills, medical  |
|    |     records, and explanation of benefits (EOB) forms.           |
+----+-----------------------------------------------------------------+
| 2  | We have 30 days from the date we receive your request to:       |
|    |                                                                 |
|    | a)  Pay the claim (or, if applicable, arrange for the health    |
|    |     care provider to give you the care); or                     |
|    |                                                                 |
|    | b)  Write to you and maintain our denial go to step 4; or       |
|    |                                                                 |
|    | c)  Ask you or your provider for more information. If we ask    |
|    |     your provider, we will send you a copy of our request---go  |
|    |     to step 3.                                                  |
+----+-----------------------------------------------------------------+
| 3  | You or your provider must send the information so that we       |
|    | receive it within 60 days of our request. We will then decide   |
|    | within 30 more days.                                            |
|    |                                                                 |
|    | If we do not receive the information within 60 days, we will    |
|    | decide within 30 days of the date the information was due. We   |
|    | will base our decision on the information we already have.      |
|    |                                                                 |
|    | We will write to you with our decision.                         |
+----+-----------------------------------------------------------------+
| 4  | If you do not agree with our decision, you may ask OPM to       |
|    | review it.                                                      |
+----+-----------------------------------------------------------------+
|    | You must write to OPM within:                                   |
|    |                                                                 |
|    | -   90 days after the date of our letter upholding our initial  |
|    |     decision; or                                                |
|    |                                                                 |
|    | -   120 days after you first wrote to us if we did not answer   |
|    |     that request in some way within 30 days; or                 |
|    |                                                                 |
|    | -   120 days after we asked for additional information.         |
+----+-----------------------------------------------------------------+
|    | Write to OPM at: United States Office of Personnel Management,  |
|    | Insurance Services Programs, Health Insurance Group 3, 1900 E   |
|    | Street, NW, Washington, DC 20415-3630.                          |
+----+-----------------------------------------------------------------+
| T  |                                                                 |
| he |                                                                 |
| di |                                                                 |
| sp |                                                                 |
| ut |                                                                 |
| ed |                                                                 |
| cl |                                                                 |
| ai |                                                                 |
| ms |                                                                 |
| p  |                                                                 |
| ro |                                                                 |
| ce |                                                                 |
| ss |                                                                 |
| *  |                                                                 |
| (c |                                                                 |
| on |                                                                 |
| ti |                                                                 |
| nu |                                                                 |
| ed |                                                                 |
| )* |                                                                 |
+----+-----------------------------------------------------------------+
|    | Send OPM the following information:                             |
|    |                                                                 |
|    | -   A statement about why you believe our decision was wrong,   |
|    |     based on specific benefit provisions in this brochure;      |
|    |                                                                 |
|    | -   Copies of documents that support your claim, such as        |
|    |     physicians\' letters, operative reports, bills, medical     |
|    |     records, and explanation of benefits (EOB) forms;           |
|    |                                                                 |
|    | -   Copies of all letters you sent to us about the claim;       |
|    |                                                                 |
|    | -   Copies of all letters we sent to you about the claim; and   |
|    |                                                                 |
|    | -   Your daytime phone number and the best time to call.        |
|    |                                                                 |
|    | Note: If you want OPM to review more than one claim, you must   |
|    | clearly identify which documents apply to which claim.          |
+----+-----------------------------------------------------------------+
|    | Note: You are the only person who has a right to file a         |
|    | disputed claim with OPM. Parties acting as your representative, |
|    | such as medical providers, must include a copy of your specific |
|    | written consent with the review request.                        |
|    |                                                                 |
|    | Note: The above deadlines may be extended if you show that you  |
|    | were unable to meet the deadline because of reasons beyond your |
|    | control.                                                        |
+----+-----------------------------------------------------------------+
| *  | OPM will review your disputed claim request and will use the    |
| *5 | information it collects from you and us to decide whether our   |
| ** | decision is correct. OPM will send you a final decision within  |
|    | 60 days. There are no other administrative appeals.             |
+----+-----------------------------------------------------------------+
|    | If you do not agree with OPM's decision, your only recourse is  |
|    | to sue. If you decide to sue, you must file the suit against    |
|    | OPM in Federal court by December 31 of the third year after the |
|    | year in which you received the disputed services, drugs, or     |
|    | supplies or from the year in which you were denied              |
|    | precertification or prior approval. This is the only deadline   |
|    | that may not be extended.                                       |
|    |                                                                 |
|    | OPM may disclose the information it collects during the review  |
|    | process to support their disputed claim decision. This          |
|    | information will become part of the court record.               |
+----+-----------------------------------------------------------------+
|    | You may not sue until you have completed the disputed claims    |
|    | process. Further, Federal law governs your lawsuit, benefits,   |
|    | and payment of benefits. The Federal court will base its review |
|    | on the record that was before OPM when OPM decided to uphold or |
|    | overturn our decision. You may recover only the amount of       |
|    | benefits in dispute.                                            |
+----+-----------------------------------------------------------------+

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

a)  We haven't responded yet to your initial request for care or
    preauthorization/prior approval, then call us at 800-755-3901 and we
    will expedite our review; or

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

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

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

# Section 9. Coordinating benefits with other coverage

+------------------+---------------------------------------------------+
| ### Whe          | You must tell us if you or a covered family       |
| n you have other | member have coverage under another group health   |
|  health coverage | plan or have automobile insurance that pays       |
|                  | health care expenses without regard to fault.     |
|                  | This is called "double coverage".                 |
|                  |                                                   |
|                  | When you have double coverage, one plan normally  |
|                  | pays its benefits in full as the primary payer    |
|                  | and the other plan pays a reduced benefit as the  |
|                  | secondary payer. We, like other insurers,         |
|                  | determine which coverage is primary according to  |
|                  | the National Association of Insurance             |
|                  | Commissioners' guidelines.                        |
|                  |                                                   |
|                  | When we are the primary payer, we will pay the    |
|                  | benefits described in this brochure.              |
|                  |                                                   |
|                  | When we are the secondary payer, we will          |
|                  | determine our allowance. After the primary plan   |
|                  | pays, we will pay what is left of our allowance,  |
|                  | up to our regular benefit. We will not pay more   |
|                  | than our allowance.                               |
+------------------+---------------------------------------------------+
| ### W            | Medicare is a Health Insurance Program for:       |
| hat is Medicare? |                                                   |
|                  | -   People 65 years of age or older.              |
|                  |                                                   |
|                  | -   Some people with disabilities under 65 years  |
|                  |     of age.                                       |
|                  |                                                   |
|                  | -   People with End-Stage Renal Disease           |
|                  |     (permanent kidney failure requiring dialysis  |
|                  |     or a transplant).                             |
|                  |                                                   |
|                  | Medicare has two parts:                           |
|                  |                                                   |
|                  | -   Part A (Hospital Insurance). Most people do   |
|                  |     not have to pay for Part A. If you or your    |
|                  |     spouse worked for at least 10 years in        |
|                  |     Medicare-covered employment, you should be    |
|                  |     able to qualify for premium-free Part A       |
|                  |     insurance. (Someone who was a Federal         |
|                  |     employee on January 1, 1983 or since          |
|                  |     automatically qualifies.) Otherwise, if you   |
|                  |     are age 65 or older, you may be able to buy   |
|                  |     it. Contact 1-800-MEDICARE for more           |
|                  |     information.                                  |
|                  |                                                   |
|                  | -   Part B (Medical Insurance). Most people pay   |
|                  |     monthly for Part B. Generally, Part B         |
|                  |     premiums are withheld from your monthly       |
|                  |     Social Security check or your retirement      |
|                  |     check.                                        |
+------------------+---------------------------------------------------+
| #                | The decision to enroll in Medicare is yours. We   |
| ### Should I enr | encourage you to apply for Medicare benefits 3    |
| oll in Medicare? | months before you turn age 65. It's easy. Just    |
|                  | call the Social Security Administration toll-free |
|                  | number 1-800-772-1213 to set up an appointment to |
|                  | apply. If you do not apply for one or both Parts  |
|                  | of Medicare, you can still be covered under the   |
|                  | FEHB Program.                                     |
|                  |                                                   |
|                  | If you can get premium-free Part A coverage, we   |
|                  | advise you to enroll in it. Most Federal          |
|                  | employees and annuitants are entitled to Medicare |
|                  | Part A at age 65 **without cost**. When you don't |
|                  | have to pay premiums for Medicare Part A, it      |
|                  | makes good sense to obtain the coverage. It can   |
|                  | reduce your out-of-pocket expenses as well as     |
|                  | costs to the FEHB, which can help keep FEHB       |
|                  | premiums down.                                    |
|                  |                                                   |
|                  | Everyone is charged a premium for Medicare Part B |
|                  | coverage. The Social Security Administration can  |
|                  | provide you with premium and benefit information. |
|                  | Review the information and decide if it makes     |
|                  | sense for you to buy the Medicare Part B          |
|                  | coverage.                                         |
+------------------+---------------------------------------------------+

+------------------+---------------------------------------------------+
| ####  {#section  | If you are eligible for Medicare, you may have    |
| -14 .unnumbered} | choices in how you get your health care. Medicare |
|                  | Advantage is the term used to describe the        |
|                  | various private health plan choices available to  |
|                  | Medicare beneficiaries. The information in the    |
|                  | next few pages shows how we coordinate benefits   |
|                  | with Medicare, depending on whether you are in    |
|                  | the Original Medicare Plan or a private Medicare  |
|                  | Advantage plan.                                   |
+------------------+---------------------------------------------------+
| ##               | The Original Medicare Plan (Original Medicare) is |
| ## The Original  | available everywhere in the United States. It is  |
| Medicare Plan (P | the way everyone used to get Medicare benefits    |
| art A or Part B) | and is the way most people get their Medicare     |
|                  | Part A and Part B benefits now. You may go to any |
|                  | doctor, specialist, or hospital that accepts      |
|                  | Medicare. The Original Medicare Plan pays its     |
|                  | share and you pay your share. Some things are not |
|                  | covered under Original Medicare, such as most     |
|                  | prescription drugs (but coverage through private  |
|                  | prescription drug plans will be available         |
|                  | starting in 2006).                                |
|                  |                                                   |
|                  | 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 arranged by the GHP |
|                  | participating physician or the Plan.              |
+------------------+---------------------------------------------------+
|                  | **Claims process when you have the Original       |
|                  | Medicare Plan** -- You probably will never have   |
|                  | to file a claim form when you have both our Plan  |
|                  | and the Original Medicare Plan.                   |
|                  |                                                   |
|                  | -   When we are the primary payer, we process the |
|                  |     claim first.                                  |
|                  |                                                   |
|                  | -   When Original Medicare is the primary payer,  |
|                  |     Medicare processes your claim first. In most  |
|                  |     cases, your claim will be coordinated         |
|                  |     automatically and we will then provide        |
|                  |     secondary benefits for covered charges. You   |
|                  |     will not need to do anything. To find out if  |
|                  |     you need to do something to file your claim,  |
|                  |     call us at 800-755-3901 or see our Web site   |
|                  |     at [www.ghp.com](http://www.ghp.com/).        |
|                  |                                                   |
|                  | **We waive some costs if the Original Medicare    |
|                  | Plan is your primary payer** -- We will waive     |
|                  | some out-of-pocket costs as follows:              |
|                  |                                                   |
|                  | -   Medical services and supplies provided by     |
|                  |     physicians and other health care              |
|                  |     professionals. If you are enrolled in         |
|                  |     Medicare Part B, we will waive                |
|                  |     precertification guidelines, copayments and   |
|                  |     any applicable coinsurance.                   |
+------------------+---------------------------------------------------+

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

+----------------------------------------------------+-------+--------+
| > **Primary Payer Chart**                          |       |        |
+----------------------------------------------------+-------+--------+
| **A. When you - or your covered spouse - are age   | **The |        |
| 65 or over and have Medicare and you...**          | pr    |        |
|                                                    | imary |        |
|                                                    | payer |        |
|                                                    | for   |        |
|                                                    | the   |        |
|                                                    | indiv |        |
|                                                    | idual |        |
|                                                    | with  |        |
|                                                    | Med   |        |
|                                                    | icare |        |
|                                                    | is    |        |
|                                                    | ...** |        |
+----------------------------------------------------+-------+--------+
|                                                    | **    | **This |
|                                                    | Medic | Plan** |
|                                                    | are** |        |
+----------------------------------------------------+-------+--------+
| 1)  Have FEHB coverage on your own as an active    |       |        |
|     employee or through your spouse who is an      |       |        |
|     active employee                                |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Have FEHB coverage on your own as an annuitant |       |        |
|     or through your spouse who is an annuitant     |       |        |
+----------------------------------------------------+-------+--------+
| 3)  Are a reemployed annuitant with the Federal    |       |        |
|     government and your position is excluded from  |       |        |
|     the FEHB (your employing office will know if   |       |        |
|     this is the case) and you are not covered      |       |        |
|     under FEHB through your spouse under #1 above  |       |        |
+----------------------------------------------------+-------+--------+
| 4)  Are a reemployed annuitant with the Federal    |       |        |
|     government and your position is not excluded   |       |        |
|     from the FEHB (your employing office will know |       |        |
|     if this is the case) and ...                   |       |        |
|                                                    |       |        |
|     You have FEHB coverage on your own or through  |       |        |
|     your spouse who is also an active employee     |       |        |
+----------------------------------------------------+-------+--------+
| You have FEHB coverage through your spouse who is  |       |        |
| an annuitant                                       |       |        |
+----------------------------------------------------+-------+--------+
| 5)  Are a Federal judge who retired under title    | ##    |        |
|     28, U.S.C., or a Tax Court judge who retired   | ####  |        |
|     under Section 7447 of title 26, U.S.C. (or if  |       |        |
|     your covered spouse is this type of judge) and |       |        |
|     you are not covered under FEHB through your    |       |        |
|     spouse under #1 above                          |       |        |
+----------------------------------------------------+-------+--------+
| 6)  Are enrolled in Part B only, regardless of     | for   | for    |
|     your employment status                         | Part  | other  |
|                                                    | B     | se     |
|                                                    | ser   | rvices |
|                                                    | vices |        |
+----------------------------------------------------+-------+--------+
| 7)  Are a former Federal employee receiving        | *     |        |
|     Workers' Compensation and the Office of        | *\*** |        |
|     Workers' Compensation Programs has determined  |       |        |
|     that you are unable to return to duty          |       |        |
+----------------------------------------------------+-------+--------+
| **B. When you or a covered family member...**      |       |        |
+----------------------------------------------------+-------+--------+
| 1)  Have Medicare solely based on end stage renal  |       |        |
|     disease (ESRD) and...                          |       |        |
|                                                    |       |        |
| -   It is within the first 30 months of            |       |        |
|     eligibility for or entitlement to Medicare due |       |        |
|     to ESRD (30-month coordination period)         |       |        |
+----------------------------------------------------+-------+--------+
| -   It is beyond the 30-month coordination period  |       |        |
|     and you or a family member are still entitled  |       |        |
|     to Medicare due to ESRD                        |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Become eligible for Medicare due to ESRD while |       | for    |
|     already a Medicare beneficiary and**...**      |       | 30     |
|                                                    |       | -month |
| -   This Plan was the primary payer before         |       | coordi |
|     eligibility due to ESRD                        |       | nation |
|                                                    |       | period |
+----------------------------------------------------+-------+--------+
| -   Medicare was the primary payer before          |       |        |
|     eligibility due to ESRD                        |       |        |
+----------------------------------------------------+-------+--------+
| **C. When either you or a covered family member    |       |        |
| are eligible for Medicare solely due to disability |       |        |
| and you...**                                       |       |        |
+----------------------------------------------------+-------+--------+
| 1)  Have FEHB coverage on your own as an active    |       |        |
|     employee or through a family member who is an  |       |        |
|     active employee                                |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Have FEHB coverage on your own as an annuitant |       | []{    |
|     or through a family member who is an annuitant |       | .mark} |
+----------------------------------------------------+-------+--------+
| **D. When you are covered under the FEHB Spouse    |       |        |
| Equity provision as a former spouse**              |       |        |
+----------------------------------------------------+-------+--------+

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

+--------------------+-------------------------------------------------+
| ####               | If you are eligible for Medicare, you may       |
| Medicare Advantage | choose to enroll in and get your Medicare       |
|                    | benefits from a Medicare Advantage plan. These  |
|                    | are private health care choices (like HMOs) in  |
|                    | some areas of the country. In most Medicare     |
|                    | Advantage plans, you can only go to doctors,    |
|                    | specialists, or hospitals that are part of the  |
|                    | plan. Medicare Advantage plans provide all the  |
|                    | benefits that Original Medicare covers. Some    |
|                    | cover extras, like prescription drugs. To learn |
|                    | more about enrolling in a Medicare Advantage    |
|                    | plan, contact Medicare at 1-800-MEDICARE        |
|                    | (1-800-633-4227) or at                          |
|                    | [www.medicare.gov](http://www.medicare.gov/).   |
|                    |                                                 |
|                    | If you enroll in a Medicare Advantage plan, the |
|                    | following options are available to you:         |
|                    |                                                 |
|                    | **This Plan and another plan's Medicare         |
|                    | Advantage plan:** You may enroll in another     |
|                    | plan's Medicare Advantage plan and also remain  |
|                    | enrolled in our FEHB plan. We will still        |
|                    | provide benefits when your Medicare Advantage   |
|                    | plan is primary, even out of the Medicare       |
|                    | Advantage plan's network and/or service area    |
|                    | (if you use our Plan providers), but we will    |
|                    | not waive any of our copayments, coinsurance,   |
|                    | or deductibles. If you enroll in a Medicare     |
|                    | Advantage plan, tell us. We will need to know   |
|                    | whether you are in the Original Medicare Plan   |
|                    | or in a Medicare Advantage plan so we can       |
|                    | correctly coordinate benefits with Medicare.    |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in a        |
|                    | Medicare Advantage plan:** If you are an        |
|                    | annuitant or former spouse, you can suspend     |
|                    | your FEHB coverage to enroll in a Medicare      |
|                    | Advantage plan, eliminating your FEHB premium.  |
|                    | (OPM does not contribute to your Medicare       |
|                    | Advantage plan premium.) For information on     |
|                    | suspending your FEHB enrollment, contact your   |
|                    | retirement office. If you later want to         |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage or move out of  |
|                    | the Medicare Advantage plan's service area.     |
+--------------------+-------------------------------------------------+
| ### T              | TRICARE is the health care program for eligible |
| RICARE and CHAMPVA | dependents of military persons, and retirees of |
|                    | the military. TRICARE includes the CHAMPUS      |
|                    | program. CHAMPVA provides health coverage to    |
|                    | disabled Veterans and their eligible            |
|                    | dependents. IF TRICARE or CHAMPVA and this Plan |
|                    | cover you, we pay first. See your TRICARE or    |
|                    | CHAMPVA Health Benefits Advisor if you have     |
|                    | questions about these programs.                 |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in TRICARE  |
|                    | or CHAMPVA:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these programs, eliminating    |
|                    | your FEHB premium. (OPM does not contribute to  |
|                    | any applicable plan premiums.) For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the       |
|                    | program.                                        |
+--------------------+-------------------------------------------------+
| ### Wor            | We do not cover services that:                  |
| kers' Compensation |                                                 |
|                    | You need because of a workplace-related illness |
|                    | or injury that the Office of Workers'           |
|                    | Compensation Programs (OWCP) or a similar       |
|                    | Federal or State agency determines they must    |
|                    | provide; or                                     |
|                    |                                                 |
|                    | OWCP or a similar agency pays for through a     |
|                    | third-party injury settlement or other similar  |
|                    | proceeding that is based on a claim you filed   |
|                    | under OWCP or similar laws.                     |
+--------------------+-------------------------------------------------+

+--------------------+-------------------------------------------------+
| ###                | Once OWCP or similar agency pays its maximum    |
|                    | benefits for your treatment, we will cover your |
|                    | care.                                           |
+--------------------+-------------------------------------------------+
| ### Medicaid       | When you have this Plan and Medicaid, we pay    |
|                    | first.                                          |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in Medicaid |
|                    | or a similar State-sponsored program of medical |
|                    | assistance:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these State programs,          |
|                    | eliminating your FEHB premium. For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the State |
|                    | program.                                        |
+--------------------+-------------------------------------------------+
| ### When o         | We do not cover services and supplies when a    |
| ther Government ag | local, State, or Federal government agency      |
| encies are respons | directly or indirectly pays for them.           |
| ible for your care |                                                 |
+--------------------+-------------------------------------------------+
| ### When           | If you do not seek damages you must agree to    |
|  others are respon | let us try. This is called subrogation. If you  |
| sible for injuries | need more information, contact us for our       |
|                    | subrogation procedures.                         |
+--------------------+-------------------------------------------------+

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

+-----------------+----------------------------------------------------+
| Calendar year   | January 1 through December 31 of the same year.    |
|                 | For new enrollees, the calendar year begins on the |
|                 | effective date of their enrollment and ends on     |
|                 | December 31 of the same year.                      |
+-----------------+----------------------------------------------------+
| Coinsurance     | Coinsurance is the percentage of our allowance     |
|                 | that you must pay for your care. You may also be   |
|                 | responsible for additional amounts. See page 14.   |
+-----------------+----------------------------------------------------+
| Copayment       | A copayment is a fixed amount of money you pay     |
|                 | when you receive covered services. See page 14.    |
+-----------------+----------------------------------------------------+
| Covered         | Care we provide benefits for, as described in this |
| services        | brochure.                                          |
+-----------------+----------------------------------------------------+
| Custodial care  | Care that is primarily for the purpose of helping  |
|                 | the plan member with activities of daily living or |
|                 | meeting personal needs and can be provided safely  |
|                 | and reasonably by people without professional      |
|                 | skills or training. Examples of custodial care     |
|                 | include rest cures, respite care and home care.    |
|                 | See *Long Term Care* for information that can help |
|                 | you with custodial care.                           |
+-----------------+----------------------------------------------------+
| Deductible      | A deductible is a fixed amount of covered expenses |
|                 | you must incur for certain covered services and    |
|                 | supplies before we start paying benefits for those |
|                 | services. See page 14.                             |
+-----------------+----------------------------------------------------+
| Experimental or | A drug device, treatment, therapy, procedure,      |
| investigational | service or supply of any kind whatsoever (a        |
| services        | "Service") that:                                   |
|                 |                                                    |
|                 | 1.  cannot be lawfully marketed without the        |
|                 |     approval of the Food and Drug Administration   |
|                 |     (FDA) and such approval has not been granted   |
|                 |     at that time of use or proposed use, and/or    |
|                 |                                                    |
|                 | 2.  is the subject of a current investigational    |
|                 |     new drug or new device application on file     |
|                 |     with the FDA, and/or                           |
|                 |                                                    |
|                 | 3.  in the predominant opinion of experts, as      |
|                 |     expressed in the published authoritative       |
|                 |     literature, that usage should be substantially |
|                 |     confined to research settings or that further  |
|                 |     research is needed in order to define safety,  |
|                 |     toxicity, efficacy or effectiveness of that    |
|                 |     Services compared with conventional            |
|                 |     alternatives.                                  |
+-----------------+----------------------------------------------------+
| Group health    | A corporation, partnership, union or other entity  |
| coverage        | that is eligible for group coverage under State or |
|                 | Federal laws and which enters into Agreement with  |
|                 | the Plan to offer coverage to employees and their  |
|                 | eligible dependents.                               |
+-----------------+----------------------------------------------------+
| Medical         | Services which are provided for the diagnosis or   |
| necessity       | care and treatment of medical condition;           |
|                 | appropriate and necessary for the symptoms,        |
|                 | diagnosis or treatment of that condition; rendered |
|                 | within standards of generally accepted medical     |
|                 | practice; not primarily for the convenience of     |
|                 | you, your family, or a provider; and performed in  |
|                 | the most appropriate setting manner for treating   |
|                 | your condition, as determined by the Medical       |
|                 | Director.                                          |
+-----------------+----------------------------------------------------+
| Plan allowance  | Plan allowance is the amount we use to determine   |
|                 | our payment and your coinsurance for covered       |
|                 | services. Plans determine their allowances in      |
|                 | different ways. We determine our allowance as      |
|                 | follows:                                           |
|                 |                                                    |
|                 | Group Health Plan determines the plan allowance    |
|                 | with each participating provider based upon        |
|                 | negotiated charges contained within the provider's |
|                 | participation agreement. The negotiated charge     |
|                 | represents the amount a participating provider     |
|                 | must accept as payment in full for covered         |
|                 | services provided to Plan members.                 |
+-----------------+----------------------------------------------------+
| Us/We           | Us and We refer to Group Health Plan.              |
+-----------------+----------------------------------------------------+
| You             | You refers to the enrollee and each covered family |
|                 | member.                                            |
+-----------------+----------------------------------------------------+

# Section 11. FEHB Facts

### Coverage information

+------------------+---------------------------------------------------+
| #### No p        | We will not refuse to cover the treatment of a    |
| re-existing cond | condition you had before you enrolled in this     |
| ition limitation | Plan solely because you had the condition before  |
|                  | you enrolled.                                     |
+------------------+---------------------------------------------------+
| #### W           | See                                               |
| here you can get | [www.opm.gov/insure](http://www.opm.gov/insure).  |
|  information abo | Also, your employing or retirement office can     |
| ut enrolling in  | answer your questions, and give you a *Guide to   |
| the FEHB Program | Federal Employees Health Benefits Plans,*         |
|                  | brochures for other plans, and other materials    |
|                  | you need to make an informed decision about your  |
|                  | FEHB coverage. These materials tell you:          |
|                  |                                                   |
|                  | -   When you may change your enrollment;          |
|                  |                                                   |
|                  | -   How you can cover your family members;        |
|                  |                                                   |
|                  | -   What happens when you transfer to another     |
|                  |     Federal agency, go on leave without pay,      |
|                  |     enter military service, or retire;            |
|                  |                                                   |
|                  | -   When your enrollment ends; and                |
|                  |                                                   |
|                  | -   When the next open season for enrollment      |
|                  |     begins.                                       |
|                  |                                                   |
|                  | We don't determine who is eligible for coverage   |
|                  | and, in most cases, cannot change your enrollment |
|                  | status without information from your employing or |
|                  | retirement office.                                |
+------------------+---------------------------------------------------+
| #### Typ         | Self Only coverage is for you alone. Self and     |
| es of coverage a | Family coverage is for you, your spouse, and your |
| vailable for you | unmarried dependent children under age 22,        |
|  and your family | including any foster children or stepchildren     |
|                  | your employing or retirement office authorizes    |
|                  | coverage for. Under certain circumstances, you    |
|                  | may also continue coverage for a disabled child   |
|                  | 22 years of age or older who is incapable of      |
|                  | self-support.                                     |
|                  |                                                   |
|                  | If you have a Self Only enrollment, you may       |
|                  | change to a Self and Family enrollment if you     |
|                  | marry, give birth, or add a child to your family. |
|                  | You may change your enrollment 31 days before to  |
|                  | 60 days after that event. The Self and Family     |
|                  | enrollment begins on the first day of the pay     |
|                  | period in which the child is born or becomes an   |
|                  | eligible family member. When you change to Self   |
|                  | and Family because you marry, the change is       |
|                  | effective on the first day of the pay period that |
|                  | begins after your employing office receives your  |
|                  | enrollment form; benefits will not be available   |
|                  | to your spouse until you marry.                   |
|                  |                                                   |
|                  | Your employing or retirement office will **not**  |
|                  | notify you when a family member is no longer      |
|                  | eligible to receive benefits, nor will we. Please |
|                  | tell us immediately when you add or remove family |
|                  | members from your coverage for any reason,        |
|                  | including divorce, or when your child under age   |
|                  | 22 marries or turns 22.                           |
|                  |                                                   |
|                  | If you or one of your family members is enrolled  |
|                  | in one FEHB plan, that person may not be enrolled |
|                  | in or covered as a family member by another FEHB  |
|                  | plan.                                             |
+------------------+---------------------------------------------------+
| #### Child       | OPM has implemented the Federal Employees Health  |
| ren's Equity Act | Benefits Children's Equity Act of 2000. This law  |
|                  | mandates that you be enrolled for Self and Family |
|                  | coverage in the FEHB Program, if you are an       |
|                  | employee subject to a court or administrative     |
|                  | order requiring you to provide health benefits    |
|                  | for your child(ren).                              |
|                  |                                                   |
|                  | If this law applies to you, you must enroll for   |
|                  | Self and Family coverage in a health plan that    |
|                  | provides full benefits in the area where your     |
|                  | children live or provide documentation to your    |
|                  | employing office that you have obtained other     |
|                  | health benefits coverage for your children. If    |
|                  | you do not do so, your employing office will      |
|                  | enroll you involuntarily as follows:              |
|                  |                                                   |
|                  | -   If you have no FEHB coverage, your employing  |
|                  |     office will enroll you for Self and Family    |
|                  |     coverage in the Blue Cross and Blue Shield    |
|                  |     Service Benefit Plan's Basic Option;          |
|                  |                                                   |
|                  | -   If you have a Self Only enrollment in a       |
|                  |     fee-for-service plan or in 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.                                      |
+------------------+---------------------------------------------------+
| ####             | The benefits in this brochure are effective       |
| When benefits an | January 1. If you joined this Plan during Open    |
| d premiums start | Season, your coverage begins on the first day of  |
|                  | your first pay period that starts on or after     |
|                  | January 1. If you changed plans or plan options   |
|                  | during Open Season and you receive care between   |
|                  | January 1 and the effective date of coverage      |
|                  | under your new plan or option, your claims will   |
|                  | be paid according to the 2005 benefits of your    |
|                  | old plan or option. However, if your old plan     |
|                  | left the FEHB Program at the end of the year, you |
|                  | are covered under that plan's 2004 benefits until |
|                  | the effective date of your coverage with your new |
|                  | plan. Annuitants' coverage and premiums begin on  |
|                  | January 1. If you joined at any other time during |
|                  | the year, your employing office will tell you the |
|                  | effective date of coverage.                       |
+------------------+---------------------------------------------------+
| ####             | When you retire, you can usually stay in the FEHB |
|  When you retire | Program. Generally, you must have been enrolled   |
|                  | in the FEHB Program for the last five years of    |
|                  | your Federal service. If you do not meet this     |
|                  | requirement, you may be eligible for other forms  |
|                  | of coverage, such as Temporary Continuation of    |
|                  | Coverage (TCC).                                   |
+------------------+---------------------------------------------------+

### When you lose benefits

+------------------+---------------------------------------------------+
| #### When FE     | You will receive an additional 31 days of         |
| HB coverage ends | coverage, for no additional premium, when:        |
|                  |                                                   |
|                  | -   Your enrollment ends, unless you cancel your  |
|                  |     enrollment, or                                |
|                  |                                                   |
|                  | -   You are a family member no longer eligible    |
|                  |     for coverage.                                 |
|                  |                                                   |
|                  | You may be eligible for spouse equity coverage or |
|                  | Temporary Continuation of Coverage (TCC), or a    |
|                  | conversion policy (a non-FEHB individual policy.) |
+------------------+---------------------------------------------------+
| #### Spouse      | If you are divorced from a Federal employee or    |
|  equity coverage | annuitant, you may not continue to get benefits   |
|                  | under your former spouse's enrollment. This is    |
|                  | the case even when the court has ordered your     |
|                  | former spouse to provide health coverage to you.  |
|                  | But, you may be eligible for your own FEHB        |
|                  | coverage under the spouse equity law or Temporary |
|                  | Continuation of Coverage (TCC). If you are        |
|                  | recently divorced or are anticipating a divorce,  |
|                  | contact your ex-spouse's employing or retirement  |
|                  | office to get RI 70-5, the *Guide To Federal      |
|                  | Employees Health Benefits Plans for Temporary     |
|                  | Continuation of Coverage and Former Spouse        |
|                  | Enrollees,* or other information about your       |
|                  | coverage choices. You can also download the guide |
|                  | from OPM's Web site,                              |
|                  | [www.opm.gov/insure](http://www.opm.gov/insure).  |
+------------------+---------------------------------------------------+
| #### Temporar    | If you leave Federal service, or if you lose      |
| y Continuation o | coverage because you no longer qualify as a       |
| f Coverage (TCC) | family member, you may be eligible for Temporary  |
|                  | Continuation of Coverage (TCC). For example, you  |
|                  | can receive TCC if you are not able to continue   |
|                  | your FEHB enrollment after you retire, if you     |
|                  | lose your Federal job, if you are a covered       |
|                  | dependent child and you turn 22 or marry, etc.    |
|                  |                                                   |
|                  | You may not elect TCC if you are fired from your  |
|                  | Federal job due to gross misconduct.              |
|                  |                                                   |
|                  | **Enrolling in TCC.** Get the RI 79-27, which     |
|                  | describes TCC, and the RI 70-5, the *Guide to     |
|                  | Federal Employees Health Benefits Plans for       |
|                  | Temporary Continuation of Coverage and Former     |
|                  | Spouse Enrollees,* from your employing or         |
|                  | retirement office or from                         |
|                  | [www.opm.gov/insure](http://www.opm/gov/insure).  |
|                  | It explains what you have to do to enroll.        |
+------------------+---------------------------------------------------+
| #### C           | You may convert to a non-FEHB individual policy   |
| onverting to ind | if:                                               |
| ividual coverage |                                                   |
|                  | -   Your coverage under TCC or the spouse equity  |
|                  |     law ends (If you canceled your coverage or    |
|                  |     did not pay your premium, you cannot          |
|                  |     convert);                                     |
|                  |                                                   |
|                  | -   You decided not to receive coverage under TCC |
|                  |     or the spouse equity law; or                  |
|                  |                                                   |
|                  | -   You are not eligible for coverage under TCC   |
|                  |     or the spouse equity law.                     |
|                  |                                                   |
|                  | If you leave Federal service, your employing      |
|                  | office will notify you of your right to convert.  |
|                  | You must apply in writing to us within 31 days    |
|                  | after you receive this notice. However, if you    |
|                  | are a family member who is losing coverage, the   |
|                  | employing or retirement office will **not**       |
|                  | notify you. You must apply in writing to us       |
|                  | within 31 days after you are no longer eligible   |
|                  | for coverage.                                     |
|                  |                                                   |
|                  | Your benefits and rates will differ from those    |
|                  | under the FEHB Program; however, you will not     |
|                  | have to answer questions about your health, and   |
|                  | we will not impose a waiting period or limit your |
|                  | coverage due to pre-existing conditions.          |
+------------------+---------------------------------------------------+

+------------------+---------------------------------------------------+
| #### Get         | The Health Insurance Portability and              |
| ting a Certifica | Accountability Act of 1996 (HIPAA) is a Federal   |
| te of Group Heal | law that offers limited Federal protections for   |
| th Plan Coverage | health coverage availability and continuity to    |
|                  | people who lose employer group coverage. If you   |
|                  | leave the FEHB Program, we will give you a        |
|                  | Certificate of Group Health Plan Coverage that    |
|                  | indicates how long you have been enrolled with    |
|                  | us. You can use this certificate when getting     |
|                  | health insurance or other health care coverage.   |
|                  | Your new plan must reduce or eliminate waiting    |
|                  | periods, limitations, or exclusions for health    |
|                  | related conditions based on the information in    |
|                  | the certificate, as long as you enroll within 63  |
|                  | days of losing coverage under this Plan. If you   |
|                  | have been enrolled with us for less than 12       |
|                  | months, but were previously enrolled in other     |
|                  | FEHB plans, you may also request a certificate    |
|                  | from those plans.                                 |
+------------------+---------------------------------------------------+
| ####  {#section  | For more information, get OPM pamphlet RI 79-27,  |
| -17 .unnumbered} | *Temporary Continuation of Coverage* *(TCC) under |
|                  | the FEHB Program*. See also the FEHB Web site at  |
|                  | [www.opm.gov/                                     |
|                  | insure/health](http://www.opm.gov/insure/health); |
|                  | refer to the "TCC and HIPAA" frequently asked     |
|                  | questions. These highlight HIPAA rules, such as   |
|                  | the requirement that Federal employees must       |
|                  | exhaust any TCC eligibility as one condition for  |
|                  | guaranteed access to individual health coverage   |
|                  | under HIPAA, and information about Federal and    |
|                  | State agencies you can contact for more           |
|                  | information.                                      |
+------------------+---------------------------------------------------+

# Section 12.Two Federal Programs complement FEHB benefits

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

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

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

+------------------+---------------------------------------------------+
| -   What is an   | It is a tax-favored benefit that allows you to    |
|     FSA?         | set aside pre-tax money from your paychecks to    |
|                  | pay for a variety of eligible expenses. *By using |
|                  | an FSA, you can reduce your taxes while paying    |
|                  | for services you would have to pay for anyway,    |
|                  | producing a discount that can be over 40%.*       |
|                  |                                                   |
|                  | There are two types of FSAs offered by FSAFEDS:   |
+------------------+---------------------------------------------------+
| Health Care      | -   Covers eligible health care expenses not      |
| Flexible         |     reimbursed by this Plan, or any other         |
| Spending Account |     medical, dental, or vision care plan you or   |
| (HCFSA)          |     your dependents may have.                     |
|                  |                                                   |
|                  | -   Eligible dependents for this account include  |
|                  |     anyone you claim on your Federal Income Tax   |
|                  |     return as a qualified dependent under the     |
|                  |     U.S. Internal Revenue Service (IRS)           |
|                  |     definition and/or with whom you jointly file  |
|                  |     your Federal Income Tax return, even if you   |
|                  |     don't have self and family health benefits    |
|                  |     coverage. *Note:* The IRS has a broader       |
|                  |     definition of a "family member" than is used  |
|                  |     under the FEHB Program to provide benefits by |
|                  |     your FEHB Plan.                               |
|                  |                                                   |
|                  | -   The maximum annual amount that can be         |
|                  |     allotted for the HCFSA is \$4,000. *Note:*    |
|                  |     The Federal workforce includes a number of    |
|                  |     employees married to each other. If each      |
|                  |     spouse/employee is eligible for FEHB          |
|                  |     coverage, both may enroll for a HCFSA up to   |
|                  |     the maximum of \$4,000 each (\$8,000 total).  |
|                  |     Both are covered under each other's HCFSA.    |
|                  |     The minimum annual amount is \$250.           |
+------------------+---------------------------------------------------+
| Dependent Care   | -   Covers eligible dependent care expenses       |
| Flexible         |     incurred so you, and your spouse, if married, |
| Spending Account |     can work, look for work, or attend school     |
| (DCFSA)          |     full-time.                                    |
|                  |                                                   |
|                  | -   Qualifying dependents for this account        |
|                  |     include your dependent children under age 13, |
|                  |     or any person of any age whom you claim as a  |
|                  |     dependent on your Federal Income Tax return   |
|                  |     (and who is mentally or physically incapable  |
|                  |     of self care).                                |
|                  |                                                   |
|                  | -   The maximum annual amount that can be         |
|                  |     allotted for the DCFSA is \$5,000. The        |
|                  |     minimum annual amount is \$250. *Note:* The   |
|                  |     IRS limits contributions to a DCFSA. For      |
|                  |     single taxpayers and taxpayers filing a joint |
|                  |     return, the maximum is \$5,000 per year. For  |
|                  |     taxpayers who file their taxes separately     |
|                  |     with a spouse, the maximum is \$2,500 per     |
|                  |     year. The limit includes any child care       |
|                  |     subsidy you may receive.                      |
+------------------+---------------------------------------------------+
| -   Enroll       | You **must make an election** to enroll in an FSA |
|     during Open  | during the 2005 FEHB Open Season. Even if you     |
|     Season       | enrolled during 2004, you must make a new         |
|                  | election to continue participating in 2005.       |
|                  | Enrollment is easy!                               |
|                  |                                                   |
|                  | -   **Online: visit                               |
|                  |     [www.FSAFEDS.com](http://www.FSAFEDS.com/)    |
|                  |     and click on [Enroll]{.underline}.**          |
|                  |                                                   |
|                  | -   Telephone: call an FSAFEDS Benefits Counselor |
|                  |     toll-free at 1-877-FSAFEDS (372-3337), Monday |
|                  |     through Friday, from 9 a.m. until 9 p.m.,     |
|                  |     Eastern Time. TTY: 1-800-952-0450.            |
+------------------+---------------------------------------------------+

+------------------+--------------------------------+--------+--------+
| What is SHPS?    | SHPS is a third-party          |        |        |
|                  | administrator hired by OPM to  |        |        |
|                  | manage the FSAFEDS Program.    |        |        |
|                  | SHPS is the largest FSA        |        |        |
|                  | administrator in the nation    |        |        |
|                  | and is responsible for         |        |        |
|                  | enrollment, claims processing, |        |        |
|                  | customer service, and          |        |        |
|                  | day-to-day operations of       |        |        |
|                  | FSAFEDS.                       |        |        |
+------------------+--------------------------------+--------+--------+
| Who is eligible  | If you are a Federal employee  |        |        |
| to enroll?       | eligible for FEHB -- even if   |        |        |
|                  | you're not enrolled in FEHB -- |        |        |
|                  | you can choose to participate  |        |        |
|                  | in either, or both, of the     |        |        |
|                  | FSAs. *However, if you enroll  |        |        |
|                  | in a High Deductible Health    |        |        |
|                  | Plan (HDHP) with a Health      |        |        |
|                  | Savings Account (HSA), you are |        |        |
|                  | not eligible to participate in |        |        |
|                  | an HCFSA*.                     |        |        |
|                  |                                |        |        |
|                  | Almost all Federal employees   |        |        |
|                  | are eligible to enroll for a   |        |        |
|                  | DCFSA. The only exception is   |        |        |
|                  | intermittent (also called      |        |        |
|                  | "when actually employed"       |        |        |
|                  | \[WAE\]) employees expected to |        |        |
|                  | work fewer than 180 days       |        |        |
|                  | during the year.               |        |        |
|                  |                                |        |        |
|                  | *Note:* FSAFEDS is the FSA     |        |        |
|                  | Program established for all    |        |        |
|                  | Executive Branch employees and |        |        |
|                  | Legislative Branch employees   |        |        |
|                  | whose employers have signed on |        |        |
|                  | to participate. Under IRS law, |        |        |
|                  | FSAs are not available to      |        |        |
|                  | annuitants. Also, the U.S.     |        |        |
|                  | Postal Service and the         |        |        |
|                  | Judicial Branch, among others, |        |        |
|                  | have their own plans with      |        |        |
|                  | slightly different rules.      |        |        |
|                  | However, the advantages of     |        |        |
|                  | having an FSA are the same     |        |        |
|                  | regardless of the agency for   |        |        |
|                  | which you work.                |        |        |
+------------------+--------------------------------+--------+--------+
| -   How much     | Plan carefully when deciding   |        |        |
|     should I     | how much to contribute to an   |        |        |
|     contribute   | FSA. Because of the tax        |        |        |
|     to my FSA?   | benefits an FSA provides, the  |        |        |
|                  | IRS places strict guidelines   |        |        |
|                  | on how the money can be used.  |        |        |
|                  | Under current IRS tax rules,   |        |        |
|                  | you are required to forfeit    |        |        |
|                  | any money for which you did    |        |        |
|                  | not incur an eligible expense  |        |        |
|                  | under your FSA account(s)      |        |        |
|                  | during the Plan Year. This is  |        |        |
|                  | known as the                   |        |        |
|                  | "use-it-or-lose-it" rule. You  |        |        |
|                  | will have until April 30,      |        |        |
|                  | following the end of the Plan  |        |        |
|                  | Year to submit claims for your |        |        |
|                  | eligible expenses incurred     |        |        |
|                  | from January 1through December |        |        |
|                  | 31. For example if you enroll  |        |        |
|                  | in FSAFEDS for the 2005 Plan   |        |        |
|                  | Year, you will have until      |        |        |
|                  | April 30, 2006 to submit       |        |        |
|                  | claims for eligible expenses.  |        |        |
|                  |                                |        |        |
|                  | The [FSAFEDS                   |        |        |
|                  | Calculator]{.underline} at     |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.fsafeds.com/) |        |        |
|                  | will help you plan your FSA    |        |        |
|                  | allocations and provide an     |        |        |
|                  | estimate of your tax savings   |        |        |
|                  | based on your individual       |        |        |
|                  | situation.                     |        |        |
+------------------+--------------------------------+--------+--------+
| -   What can my  | Every FEHB plan includes cost  |        |        |
|     HCFSA pay    | sharing features, such as      |        |        |
|     for?         | deductibles you must meet      |        |        |
|                  | before the Plan provides       |        |        |
|                  | benefits, coinsurance or       |        |        |
|                  | copayments that you pay when   |        |        |
|                  | you and the Plan share costs,  |        |        |
|                  | and medical services and       |        |        |
|                  | supplies that are not covered  |        |        |
|                  | by the Plan and for which you  |        |        |
|                  | must pay. These out-of-pocket  |        |        |
|                  | costs are summarized on page   |        |        |
|                  | 48 and detailed throughout     |        |        |
|                  | this brochure. Your HCFSA will |        |        |
|                  | reimburse you when those costs |        |        |
|                  | are for qualified medical care |        |        |
|                  | that you, your spouse and/or   |        |        |
|                  | your dependents receive that   |        |        |
|                  | is NOT covered or reimbursed   |        |        |
|                  | by this FEHB Plan or any other |        |        |
|                  | coverage that you have.        |        |        |
|                  |                                |        |        |
|                  | Under the HMO plan, typical    |        |        |
|                  | out-of-pocket expenses include |        |        |
|                  | coinsurance and copayments.    |        |        |
|                  |                                |        |        |
|                  | Under the HDHP plan, typical   |        |        |
|                  | out-of-pocket expenses include |        |        |
|                  | coinsurance, deductibles and   |        |        |
|                  | copayments.                    |        |        |
|                  |                                |        |        |
|                  | The IRS governs expenses       |        |        |
|                  | reimbursable by a HCFSA. See   |        |        |
|                  | Publication 502 for a          |        |        |
|                  | comprehensive list of          |        |        |
|                  | tax-deductible medical         |        |        |
|                  | expenses. ***Note:* While you  |        |        |
|                  | will see insurance premiums    |        |        |
|                  | listed in Publication 502,     |        |        |
|                  | they are NOT a reimbursable    |        |        |
|                  | expense for FSA purposes.**    |        |        |
|                  | Publication 502 can be found   |        |        |
|                  | on the IRS Web site at         |        |        |
|                  | <http://www.                   |        |        |
|                  | irs.gov/pub/irs-pdf/p502.pdf>. |        |        |
|                  | The FSAFEDS Web site also has  |        |        |
|                  | a comprehensive list of        |        |        |
|                  | eligible expenses at           |        |        |
|                  | [www.FSAFEDS.com/fsafeds/eli   |        |        |
|                  | gibleexpenses.asp](http://www. |        |        |
|                  | irs.gov/pub/irs-pdf/p502.pdf). |        |        |
|                  | If you do not see your service |        |        |
|                  | or expense listed, please call |        |        |
|                  | an FSAFEDS Benefits Counselor  |        |        |
|                  | at 1-877-FSAFEDS (372-3337),   |        |        |
|                  | who will be able to answer     |        |        |
|                  | your specific questions.       |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax savings  | An FSA lets you allot money    |        |        |
|     with an FSA  | for eligible expenses          |        |        |
|                  | ***before*** your agency       |        |        |
|                  | deducts taxes from your        |        |        |
|                  | paycheck. This means the       |        |        |
|                  | amount of income that your     |        |        |
|                  | taxes are based on will be     |        |        |
|                  | lower, so your tax liability   |        |        |
|                  | will be less. Without an FSA,  |        |        |
|                  | you would still pay for these  |        |        |
|                  | expenses, but you would do so  |        |        |
|                  | using money remaining in your  |        |        |
|                  | paycheck after Federal (and    |        |        |
|                  | often state and local) taxes   |        |        |
|                  | are deducted. The following    |        |        |
|                  | chart illustrates a typical    |        |        |
|                  | tax savings example:           |        |        |
+------------------+--------------------------------+--------+--------+
|                  | **Annual Tax Savings Example** | **With | **Wi   |
|                  |                                | FSA**  | thout\ |
|                  |                                |        | FSA**  |
+------------------+--------------------------------+--------+--------+
|                  | If your taxable income is:     | \$     | \$     |
|                  |                                | 50,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | And you deposit this amount    | \      | -\$0-  |
|                  | into an FSA:                   | $2,000 |        |
+------------------+--------------------------------+--------+--------+
|                  | Your taxable income is now:    | \$     | \$     |
|                  |                                | 48,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | Subtract Federal & Social      | \$     | \$     |
|                  | Security taxes:                | 13,807 | 14,383 |
+------------------+--------------------------------+--------+--------+
|                  | If you spend after-tax dollars | -\$0-  | \      |
|                  | for expenses:                  |        | $2,000 |
+------------------+--------------------------------+--------+--------+
|                  | Your real spendable income is: | \$     | \$     |
|                  |                                | 34,193 | 33,617 |
+------------------+--------------------------------+--------+--------+
|                  | **Your tax savings:**          | **\    | **-    |
|                  |                                | $576** | \$0-** |
+------------------+--------------------------------+--------+--------+
|                  | **Note:** This example is      |        |        |
|                  | intended to demonstrate a      |        |        |
|                  | typical tax savings based on   |        |        |
|                  | 27% Federal and 7.65% FICA     |        |        |
|                  | taxes. Actual savings will     |        |        |
|                  | vary based upon the retirement |        |        |
|                  | system in which you are        |        |        |
|                  | enrolled (CSRS or FERS), your  |        |        |
|                  | state of residence, and your   |        |        |
|                  | individual tax situation. In   |        |        |
|                  | this example, the individual   |        |        |
|                  | received \$2,000 in services   |        |        |
|                  | for \$1,424 - a discount of    |        |        |
|                  | almost 36%! You may also wish  |        |        |
|                  | to consult a tax professional  |        |        |
|                  | for more information on the    |        |        |
|                  | tax implications of an FSA.    |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax credits  | You *cannot* claim expenses on |        |        |
|     and          | your Federal Income Tax return |        |        |
|     deductions   | if you receive reimbursement   |        |        |
|                  | for them from your HCFSA or    |        |        |
|                  | DCFSA. Below are some          |        |        |
|                  | guidelines that may help you   |        |        |
|                  | decide whether to participate  |        |        |
|                  | in FSAFEDS.                    |        |        |
+------------------+--------------------------------+--------+--------+
| Health care      | The HCFSA is Federal Income    |        |        |
| expenses         | Tax-free from the first        |        |        |
|                  | dollar. In addition, you may   |        |        |
|                  | be reimbursed from your HCFSA  |        |        |
|                  | at any time during the year    |        |        |
|                  | for expenses up to the annual  |        |        |
|                  | amount you've elected to       |        |        |
|                  | contribute.                    |        |        |
|                  |                                |        |        |
|                  | Only health care expenses      |        |        |
|                  | exceeding 7.5% of your         |        |        |
|                  | adjusted gross income are      |        |        |
|                  | eligible to be deducted on     |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return. Using the example      |        |        |
|                  | shown above, only health care  |        |        |
|                  | expenses exceeding \$3,750     |        |        |
|                  | (7.5% of \$50,000) would be    |        |        |
|                  | eligible to be deducted on     |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return. In addition, money set |        |        |
|                  | aside through an HCFSA is also |        |        |
|                  | exempt from FICA taxes. This   |        |        |
|                  | exemption is not available on  |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return.                        |        |        |
+------------------+--------------------------------+--------+--------+
| Dependent care   | The DCFSA generally allows     |        |        |
| expenses         | many families to save more     |        |        |
|                  | than they would with the       |        |        |
|                  | Federal tax credit for         |        |        |
|                  | dependent care expenses. Note  |        |        |
|                  | that you may only be           |        |        |
|                  | reimbursed from the DCFSA up   |        |        |
|                  | to your current account        |        |        |
|                  | balance. If you file a claim   |        |        |
|                  | for more than your current     |        |        |
|                  | balance, it will be held until |        |        |
|                  | additional payroll allotments  |        |        |
|                  | have been added to your        |        |        |
|                  | account.                       |        |        |
|                  |                                |        |        |
|                  | Visit                          |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.FSAFEDS.com/) |        |        |
|                  | and download the [Dependent    |        |        |
|                  | Care Tax Credit                |        |        |
|                  | Worksheet]{.underline} from    |        |        |
|                  | the Forms and Literature page  |        |        |
|                  | to help you determine what is  |        |        |
|                  | best for your situation. You   |        |        |
|                  | may also wish to consult a tax |        |        |
|                  | professional for more details. |        |        |
+------------------+--------------------------------+--------+--------+

+------------------+---------------------------------------------------+
| -   Does it cost | No. Section 1127 of the National Defense          |
|     me anything  | Authorization Act (Public Law 108-136) requires   |
|     to           | agencies that offer FSAFEDS to employees to cover |
|     participate  | the administrative fee(s) on behalf of their      |
|     in FSAFEDS?  | employees. However, remember that participating   |
|                  | in FSAFEDS can cost you money if you don't spend  |
|                  | your entire account balance by the end of the     |
|                  | Plan Year, resulting in the forfeiture of funds   |
|                  | remaining in your account (the IRS                |
|                  | "use-it-or-lose-it" rule).                        |
+------------------+---------------------------------------------------+
| -   Contact us   | To learn more or to enroll, please visit the      |
|                  | **FSAFEDS Web site** at                           |
|                  | [www.FSAFEDS.com](http://www.fsafeds.com/), or    |
|                  | contact SHPS directly via email or by phone.      |
|                  | FSAFEDS Benefits Counselors are available Monday  |
|                  | through Friday, from 9:00 a.m. until 9:00 p.m.    |
|                  | Eastern Time.                                     |
|                  |                                                   |
|                  | -   E-mail: <FSAFEDS@shps.net>                    |
|                  |                                                   |
|                  | -   Telephone: 1-877-FSAFEDS (1-877-372-3337)     |
|                  |                                                   |
|                  | -   TTY: 1-800-952-0450                           |
+------------------+---------------------------------------------------+

### The Federal Long Term Care Insurance Program

+------------------+---------------------------------------------------+
| -   It's         | Why should you consider applying for coverage     |
|     important    | under the Federal Long Term Care Insurance        |
|     protection   | Program (FLTCIP)?                                 |
|                  |                                                   |
|                  | -   **FEHB plans do not cover the cost of long    |
|                  |     term care.** Also called "custodial care,"    |
|                  |     long term care is help you receive to perform |
|                  |     activities of daily living -- such as bathing |
|                  |     or dressing yourself - or supervision you     |
|                  |     receive because of a severe cognitive         |
|                  |     impairment. The need for long term care can   |
|                  |     strike anyone at any age and the cost of care |
|                  |     can be substantial.                           |
|                  |                                                   |
|                  | -   **The Federal Long Term Care Insurance        |
|                  |     Program can help protect you from the         |
|                  |     potentially high cost of long term care.**    |
|                  |     This coverage gives you options regarding the |
|                  |     type of care you receive and where you        |
|                  |     receive it. With FLTCIP coverage, you won't   |
|                  |     have to worry about relying on your loved     |
|                  |     ones to provide or pay for your care.         |
|                  |                                                   |
|                  | -   **It's to your advantage to apply sooner      |
|                  |     rather than later.** In order to qualify for  |
|                  |     coverage under the FLTCIP, you must apply and |
|                  |     pass a medical screening (called              |
|                  |     underwriting). Certain medical conditions, or |
|                  |     combinations of conditions, will prevent some |
|                  |     people from being approved for coverage. By   |
|                  |     applying while you're in good health, you     |
|                  |     could avoid the risk of having a future       |
|                  |     change in your health disqualify you from     |
|                  |     obtaining coverage. Also, the younger you are |
|                  |     when you apply, the lower your premiums.      |
|                  |                                                   |
|                  | -   **You don't have to wait for an open season   |
|                  |     to apply.** The Federal Long Term Care        |
|                  |     Insurance Program accepts applications from   |
|                  |     eligible persons at any time. You will have   |
|                  |     to complete a full underwriting application,  |
|                  |     which asks a number of questions about your   |
|                  |     health. However, if you are a new or newly    |
|                  |     eligible employee, you (and your spouse, if   |
|                  |     applicable) have a limited opportunity to     |
|                  |     apply using the abbreviated underwriting      |
|                  |     application, which asks fewer questions.      |
|                  |     Newly married spouses of employees also have  |
|                  |     a limited opportunity to apply using          |
|                  |     abbreviated underwriting.                     |
|                  |                                                   |
|                  | ```{=html}                                        |
|                  | <!-- -->                                          |
|                  | ```                                               |
|                  | -   **Qualified relatives are also eligible to    |
|                  |     apply.** Qualified relatives include spouses  |
|                  |     and adult children of employees and           |
|                  |     annuitants, and parents, parents-in-law, and  |
|                  |     stepparents of employees.                     |
+------------------+---------------------------------------------------+

+------------------+---------------------------------------------------+
| -   To find out  | Call 1-800-LTC-FEDS (1-800-582-3337) (TTY         |
|     more and to  | 1-800-843-3557) or visit                          |
|     request an   | [www.ltcfeds.com](http://www.ltcfeds.com/).       |
|     application  |                                                   |
+------------------+---------------------------------------------------+

# Index

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

Accidental injury 25, 32, 45, 76

Allergy tests 24, 56

Allogeneic (donor) bone marrow transplant 33

Ambulance 35, 37, 66, 68, 70

Anesthesia 7, 30, 67

Autologous bone marrow transplant 24, 33

Biopsy 30

Blood and blood plasma 36, 67

Casts 36, 66, 67

Catastrophic protection out-of-pocket maximum 15, 37, 86, 107, 109

**Changes for 2005** 10

Chemotherapy 24

Cholesterol tests 21

Claims 17, 72, 88, 89, 93, 98, 102

Coinsurance 8, 15, 16, 46, 88, 94, 96, 102

Colorectal cancer screening 21

Congenital anomalies 30, 31, 63

Contraceptive drugs and devices 23, 42, 74

Covered charges 16, 92

Crutches 27

Deductible 15, 16, 52, 86, 88, 94, 102

Definitions 20, 30, 35, 38, 40, 41, 45, 50, 52, 76, 96, 107, 108

Dental care 45, 76, 107, 108

Diagnostic services 20, 35, 40, 107, 108

Disputed claims review 44, 75

Donor expenses 33

Dressings 36, 66, 67

Effective date of enrollment 12

Emergency 8, 38, 39, 46, 69, 70, 72, 87, 107, 108

Experimental or investigational 87

Eyeglasses 25, 26

Family planning 23

Fecal occult blood test 21

Fraud 3, 4, 5

General exclusions 87

General Exclusions 17

Hearing services 25

High Deductible Health Plan

facts 8

general features 46

network providers 8

Home health services 27, 60

Hospital 6, 7, 8, 11, 12, 27, 30, 31, 33, 35, 36, 38, 39, 40, 45, 46,
63, 65, 67, 69, 70, 71, 76, 88, 92, 94, 107, 108

Immunizations 8, 22

Infertility 23, 55, 56

Inpatient hospital benefits 88

Insulin 42, 74

Magnetic Resonance Imagings (MRIs) 21

Mammograms 21

Maternity benefits 23

Medicaid 95

Medically necessary 20, 22, 24, 30, 35, 38, 40, 41, 45, 50, 51, 52, 76,
87

Medicare 40, 91, 93

Original 92

Members

Associate 110

Family 97

Plan 11, 31, 86

Mental conditions/Substance abuse benefits 71

Mental Health/Substance Abuse Benefits 40

Newborn care 23

Non-FEHB benefits 86

Nurse

Licensed Practical Nurse (LPN) 27, 60

Nurse Anesthetist 66

Nurse Anesthetist (NA) 36

Occupational therapy 25

Ocular injury 25

Office visits 8, 15

Oral and maxillofacial surgical 32, 63, 64

Out-of-pocket expenses 91, 102

Oxygen 27, 36, 60, 66, 67

Pap test 21

Physician 16, 30

Point of Service (POS) 108

Precertification 62, 66, 72, 90

Prescription drugs 24, 88, 94, 107, 108

Preventive care, adult 21

Preventive care, children 22

Preventive services 8

Prior approval 89, 90

Prosthetic devices 26, 31

Psychologist 40, 71

Radiation therapy 24

Room and board 35, 66, 72

Second surgical opinion 20

Skilled nursing facility care 12, 20, 34, 65

Social worker 40, 71

Speech therapy 25

Splints 36, 66

Subrogation 95

Substance abuse 71, 107, 108

Surgery 7, 23, 25, 26, 66

Anesthesia 36

Oral 32, 64

Outpatient 36, 67

Reconstructive 30, 31, 63

Syringes 42, 74

Temporary Continuation of Coverage (TCC) 98

Transplants 24, 33

Treatment therapies 24

Vision care 107, 108

Vision services 25

Wheelchairs 27

Workers Compensation 94

X-rays 21, 35, 36, 66, 67

# Summary of HMO benefits for Group Health Plan *-* 2005

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

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

We only cover services provided or arranged by Plan physicians, except
in emergencies.

+----------------------------------------+-----------------------+----+
| **Benefits**                           | **You pay**           | ** |
|                                        |                       | Pa |
|                                        |                       | ge |
|                                        |                       | ** |
+========================================+=======================+====+
| Medical services provided by           | Office visit copay:   | 19 |
| physicians:                            | \$10 primary care     |    |
|                                        | physician; \$20       |    |
| Diagnostic and treatment services      | specialist            |    |
| provided in the office                 |                       |    |
+----------------------------------------+-----------------------+----+
| Services provided by a hospital:       | \$100 per admission   | 34 |
|                                        | copay                 |    |
| Inpatient                              |                       | 35 |
|                                        | \$50 per visit for    |    |
| Outpatient                             | outpatient surgery    |    |
+----------------------------------------+-----------------------+----+
| Emergency benefits                     | \$10 primary care     | 37 |
|                                        | physician; \$20       |    |
| In-area                                | specialist; \$75 per  | 38 |
|                                        | visit (waived if      |    |
| Out-of-area                            | admitted)             |    |
|                                        |                       |    |
|                                        | \$10 primary care     |    |
|                                        | physician; \$20       |    |
|                                        | specialist; \$75 per  |    |
|                                        | visit (waived if      |    |
|                                        | admitted)             |    |
+----------------------------------------+-----------------------+----+
| Mental health and substance abuse      | Regular cost sharing  | 39 |
| treatment                              |                       |    |
+----------------------------------------+-----------------------+----+
| Prescription drugs                     | Retail: \$10 generic  | 40 |
|                                        | formulary; \$20 name  |    |
|                                        | brand formulary; \$35 |    |
|                                        | non-formulary         |    |
|                                        |                       |    |
|                                        | Mail: \$20 generic    |    |
|                                        | formulary; \$40 name  |    |
|                                        | brand formulary; \$70 |    |
|                                        | non-formulary         |    |
+----------------------------------------+-----------------------+----+
| Dental care .                          | \$20 specialist copay | 44 |
|                                        | for restorative       |    |
|                                        | services due to       |    |
|                                        | accidental injury     |    |
+----------------------------------------+-----------------------+----+
| Vision care .                          | \$10 primary care     | 24 |
|                                        | physician; \$20       |    |
|                                        | specialist            |    |
+----------------------------------------+-----------------------+----+
| Special features: flexible benefits    |                       | 43 |
| option, services for deaf and hearing  |                       |    |
| impaired, joint replacement, high risk |                       |    |
| pregnancies, Centers of Excellence,    |                       |    |
| Members Choice.                        |                       |    |
+----------------------------------------+-----------------------+----+
| Protection against catastrophic costs  | Nothing after         | 14 |
|                                        | \$1,000/Self Only or  |    |
| (your catastrophic protection          | \$2,000/Family        |    |
| out-of-pocket maximum)                 | enrollment per year   |    |
|                                        |                       |    |
|                                        | Some costs do not     |    |
|                                        | count toward this     |    |
|                                        | protection            |    |
+----------------------------------------+-----------------------+----+

# Summary of HDHP benefits for Group Health Plan *-* 2005

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

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

Under this Plan, most traditional medical care (other than some
preventive care) is subject to a deductible. After you meet the
deductible, you pay the indicated copayments or coinsurance up to the
annual catastrophic protection maximum for out-of-pocket expenses. And,
after we pay, you generally pay any difference between our allowance and
the billed amount if you use an out-of-network provider.

+----------------------------------------+-----------------------+----+
| **Benefits**                           | **You pay**           | ** |
|                                        |                       | Pa |
|                                        |                       | ge |
|                                        |                       | ** |
+========================================+=======================+====+
| Medical services provided by           | In-Network: Office    | 53 |
| physicians:                            | visit copay: \$15     |    |
|                                        | primary care          |    |
| Diagnostic and treatment services      | physician; \$25       |    |
| provided in the office                 | specialist            |    |
|                                        |                       |    |
|                                        | Out-of-Network: 30%   |    |
|                                        | of covered expenses   |    |
|                                        | after deductible      |    |
+----------------------------------------+-----------------------+----+
| Services provided by a hospital:       | In-Network: 10% of    | 65 |
|                                        | the Plan allowance    |    |
| Inpatient                              |                       | 66 |
|                                        | Out-of-Network: 30%   |    |
| Outpatient                             | of the Plan allowance |    |
|                                        | and any difference    |    |
|                                        | between our allowance |    |
|                                        | and the billed amount |    |
+----------------------------------------+-----------------------+----+
| Emergency benefits                     | \$15 primary care     | 68 |
|                                        | physician; \$25       |    |
| In-area                                | specialist; 10% of    | 69 |
|                                        | the Plan allowance    |    |
| Out-of-area                            | and any difference    |    |
|                                        | between our allowance |    |
|                                        | and the billed amount |    |
|                                        | for outpatient or     |    |
|                                        | inpatient services    |    |
+----------------------------------------+-----------------------+----+
| Mental health and substance abuse      | Regular cost sharing  | 70 |
| treatment                              |                       |    |
+----------------------------------------+-----------------------+----+
| Prescription drugs                     | Retail: \$15 generic  | 72 |
|                                        | formulary; \$25 name  |    |
|                                        | brand formulary; \$50 |    |
|                                        | non-formulary         |    |
|                                        |                       |    |
|                                        | Mail: \$30 generic    |    |
|                                        | formulary; \$50 name  |    |
|                                        | brand formulary;      |    |
|                                        | \$100 non-formulary   |    |
+----------------------------------------+-----------------------+----+
| Dental care .                          | In-Network: \$15      | 75 |
|                                        | primary care          |    |
|                                        | physician; \$25       |    |
|                                        | specialist for        |    |
|                                        | restorative services  |    |
|                                        | due to accidental     |    |
|                                        | injury                |    |
|                                        |                       |    |
|                                        | Out-of-Network: 30%   |    |
|                                        | of the Plan allowance |    |
|                                        | and any difference    |    |
|                                        | between our allowance |    |
|                                        | and the billed amount |    |
|                                        | for restorative       |    |
|                                        | services due to       |    |
|                                        | accidental injury     |    |
+----------------------------------------+-----------------------+----+
| Vision care .                          | In-Network: \$25      | 57 |
|                                        | specialist copay per  |    |
|                                        | visit                 |    |
|                                        |                       |    |
|                                        | Out-of-Network: All   |    |
|                                        | charges               |    |
+----------------------------------------+-----------------------+----+
| Special features: flexible benefits    |                       | 74 |
| option, services for deaf and hearing  |                       |    |
| impaired, joint replacement, high risk |                       |    |
| pregnancies, Centers of Excellence,    |                       |    |
| Members Choice.                        |                       |    |
+----------------------------------------+-----------------------+----+
| Point of Service benefits -- Yes       |                       | 45 |
+----------------------------------------+-----------------------+----+
| Protection against catastrophic costs  | In-Network: Nothing   | 82 |
|                                        | after \$5,000/Self    |    |
| (your catastrophic protection          | Only or               |    |
| out-of-pocket maximum)                 | \$10,000/Family       |    |
|                                        | enrollment per year   |    |
|                                        |                       |    |
|                                        | Out-of-Network:       |    |
|                                        | Nothing after         |    |
|                                        | \$10,000/Self Only or |    |
|                                        | \$20,000/Family       |    |
|                                        | enrollment per year   |    |
|                                        |                       |    |
|                                        | Some costs do not     |    |
|                                        | count toward this     |    |
|                                        | protection            |    |
+----------------------------------------+-----------------------+----+

# 2005 Rate Information for Group Health Plan

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

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

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

+-------------+--------+------+------+-----+--------+--------+--------+
|             |        | *    |      |     |        | ***    |        |
|             |        | **No |      |     |        | Postal |        |
|             |        | n-Po |      |     |        | Prem   |        |
|             |        | stal |      |     |        | ium*** |        |
|             |        | Pr   |      |     |        |        |        |
|             |        | emiu |      |     |        |        |        |
|             |        | m*** |      |     |        |        |        |
+-------------+--------+------+------+-----+--------+--------+--------+
| **Type**    |        | **   |      | *   |        | **     |        |
|             |        | [Biw |      | *[M |        | [Biwee |        |
|             |        | eekl |      | ont |        | kly]{. |        |
|             |        | y]{. |      | hly |        | underl |        |
|             |        | unde |      | ]{. |        | ine}** |        |
|             |        | rlin |      | und |        |        |        |
|             |        | e}** |      | erl |        |        |        |
|             |        |      |      | ine |        |        |        |
|             |        |      |      | }** |        |        |        |
+-------------+--------+------+------+-----+--------+--------+--------+
| **of**      | **     | *    | **Yo | **G | **     | **     | **     |
|             | Code** | *Gov | ur** | ov' | Your** | USPS** | Your** |
| **E         |        | 't** |      | t** |        |        |        |
| nrollment** |        |      | *    |     | **S    | **S    | **S    |
|             |        | *    | *Sha | **S | hare** | hare** | hare** |
|             |        | *Sha | re** | har |        |        |        |
|             |        | re** |      | e** |        |        |        |
+-------------+--------+------+------+-----+--------+--------+--------+

  -------------- --------- -------------- -------------- -------------- -------------- -------------- -------------
  **Self Only**  **MM1**   **\$131.08**   **\$74.73**    **\$284.01**   **\$161.91**   **\$154.74**   **\$51.07**

  **Self &       **MM2**   **\$298.23**   **\$146.30**   **\$646.17**   **\$316.98**   **\$352.08**   **\$92.45**
  Family**                                                                                            
  -------------- --------- -------------- -------------- -------------- -------------- -------------- -------------

+-------------+--------+------+------+-----+--------+--------+--------+
| **HDHP**    | *      | **\$ | **\  | **\ | **\$9  | **\$15 | **\$1  |
|             | *MM4** | 127. | $42. | $27 | 2.24** | 1.14** | 9.16** |
| **Self      |        | 73** | 57** | 6.7 |        |        |        |
| Only**      |        |      |      | 4** |        |        |        |
+-------------+--------+------+------+-----+--------+--------+--------+
| **HDHP**    | *      | **\$ | **\  | **\ | **\$19 | **\$32 | **\$4  |
|             | *MM5** | 273. | $91. | $59 | 7.50** | 3.60** | 1.02** |
| **Self &    |        | 47** | 15** | 2.5 |        |        |        |
| Family**    |        |      |      | 1** |        |        |        |
+-------------+--------+------+------+-----+--------+--------+--------+