Lovelace Health Plan

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

**2004**

**A Health Maintenance Organization**

**Serving:** The State of New Mexico

**Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 8 for requirements.**

**Enrollment codes for this Plan:**

**Q11 Self Only**

########  Q12 Self and Family

**RI 73-079**

![](media/image3.png){width="4.804861111111111in"
height="1.1215277777777777in"}

Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

> Sincerely,
>
> ![](media/image4.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

# Notice of the Office of Personnel Management's ![](media/image5.png){width="1.1715277777777777in" height="0.9208333333333333in"}

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

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  Table of Contents
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Introduction 4

Plain Language 4

Stop Health Care Fraud! 5

Preventing medical
mistakes.........................................................................................................6

Section 1. Facts about this HMO plan 7

How we pay providers 7

Who provides my health care? 8

Your Rights 8

Service Area 8

Section 2. How we change for 2004 9

Program-wide changes 9

Changes to this Plan 9

Section 3. How you get care 10

Identification cards 10

Where you get covered care 10

• Plan providers 10

• Plan facilities 10

What you must do to get covered care 10

• Primary care 11

• Specialty care 11

• Hospital care 11

Circumstances beyond our control 12

Services requiring our prior approval 12

Section 4. Your costs for covered services 13

• Copayments 13

• Deductible 13

• Coinsurance 13

Your catastrophic protection out-of-pocket maximum 13

Section 5. Benefits 14

Overview 14

(a) Medical services and supplies provided by physicians and other
    health care professionals 15

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 23

(c) Services provided by a hospital or other facility, and ambulance
    services 26

(d) Emergency services/accidents 29

(e) Mental health and substance abuse benefits 31

(f) Prescription drug benefits 33

(g) Special features 35

-   Flexible benefits option

-   24 hour nurse line

-   Services for deaf and hearing impaired

-   Centers of Excellence

-   Travel benefits/services overseas

(h) Dental benefits 36

(i) Non-FEHB benefits available to Plan Members 37

Section 6. General exclusions \-- things we don\'t cover 38

Section 7. Filing a claim for covered services 39

Section 8. The disputed claims process 40

Section 9. Coordinating benefits with other coverage 42

When you have other health coverage 42

• What is
Medicare?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....42

-   Should I enroll in
    Medicare\...\..................................................................................42

• Medicare + Choice 46

• TRICARE and CHAMPVA 46

• Workers\' Compensation 47

• Medicaid 47

• Other Government agencies 47

• When others are responsible for injuries 47

Section 10. Definitions of terms we use in this brochure 48

Section 11. FEHB facts 49

Coverage information 49

• No pre-existing condition limitation 49

• Where you can get information about enrolling in the FEHB Program 49

• Types of coverage available for you and your family 49

• Children's Equity Act 50

• When benefits and premiums start 50

• When you retire 50

When you lose benefits 51

• When FEHB coverage ends 51

• Spouse equity coverage 51

• Temporary Continuation of Coverage (TCC) 51

• Converting to individual coverage 51

• Getting a Certificate of Group Health Plan Coverage 52

Two new Federal Programs complement FEHB
benefits...................................................................53

The Federal Flexible Spending Account Program
--FSAFEDS.................................\............\...53

The Federal Long Term Care Insurance
Program...............................................................56

Index 58

Summary of benefits 59

Rates Back cover

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

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This brochure describes the benefits of Lovelace Health Systems, Inc.
under our contract (CS 1911) with the United States Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits
law. This Plan is a business of Lovelace Health Systems, Inc. The
address for Lovelace Health Plan's administrative office is:

Lovelace Health Plan

Altura Office Complex

4101 Indian School Road, NE

Albuquerque, NM 87110

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

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

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

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

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

-   Except for necessary technical terms, we use common words. For
    instance, "you" means the enrollee or family member; \"we\" means
    Lovelace 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](http://www.opm.gov/reitre) or e-mail OPM at
<fehbwebcomments@opm.gov>. You may also write to OPM at the United
States Office of Personnel Management, Insurance Services Program,
Program Planning and Evaluation Group, 1900 E Street, NW Washington, DC
20415-3650.

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  Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at (505)
    262-7363 Albuquerque Area or (1-800-808-7363 statewide) and explain
    the situation.

-   If we do not resolve the issue;

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

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

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

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

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

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

Preventing Medical Mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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

    Want more information on patient safety?

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

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

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

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

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

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

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

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

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

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

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

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

How we pay providers

We contract with individual physicians, medical groups, and hospitals to
provide the benefits in this brochure. These Plan providers accept a
negotiated payment from us, and you will only be responsible for your
copayments or coinsurance. We compensate our participating providers in
ways that are intended to emphasize preventive care, promote quality of
care, and assure the most appropriate use of medical services. You can
discuss with your provider how he is compensated by us. The methods we
use to compensate participating providers are:

[Discounted fee for service]{.underline} -- payment for service is based
on an agreed upon discounted amount for the services provided.

[Capitation]{.underline} **--** Physicians, provider groups and
physician/hospital organizations are paid a fixed amount at regular
intervals for each Member assigned to the physician, provider group or
physician/hospital organization, whether or not services are provided.
This payment covers the physician and/or, where applicable, hospital or
other services covered under the benefit plan. Medical groups and
physician/hospital organizations may in turn compensate providers using
a variety of methods.

Capitation offers health care providers a predictable income, encourages
Physicians to keep people well through preventive care, eliminates the
financial incentive to provide services that will not benefit the
patient, and reduces paperwork.

Providers paid on a "capitated" basis may participate with us in a risk
sharing arrangement. They agree upon a target amount for the cost of
certain health care services, and they share all or some of the amount
by which actual costs are over target. Provider services are monitored
for appropriate utilization, accessibility, quality and Member
satisfaction.

We may also work with third parties who administer payments to
Participating Providers. Under these arrangements, we pay the third
party a fixed monthly amount for these services. Providers are
compensated by the third party for services provided to Healthplan
participants from the fixed amount. The compensation varies based on
overall utilization.

[Salary]{.underline} -- Physicians and other providers who are employed
to work in our medical facilities are paid a salary. The compensation is
based on a dollar amount, decided in advance each year, that is
guaranteed regardless of the services provided. Physicians are eligible
for any annual bonus based on quality of care, quality of service and
appropriate use of Medical Services.

[Bonuses and Incentives]{.underline} -- Eligible Physicians may receive
additional payments based on their performance. To determine who
qualifies, we evaluate Physician performance using criteria that may
include quality of care, quality of service, accountability and
appropriate use of Medical Services.

[Per Diem]{.underline} -- A specific amount is paid to a hospital per
day for all health care received. The payment may vary by type of
service and length of stay.

[Case Rate]{.underline} -- A specific amount is paid for all the care
received in the hospital for each standard service category as specified
in our contract with the provider (e.g., for a normal maternity
delivery).

**Who provides my health care?**

We contract with a group of doctors to provide your health care. You
will select a primary care physician who supervises your total health
care needs. You may see a Plan gynecologist for annual routine
examination without a referral.

**Your Rights**

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

-   Lovelace Health Plan is in compliance with all State and Federal
    licensing and certification requirements and has received its 3 year
    commendable accreditation by the National Committee on Quality
    Assurance (NCQA) in October, 1999.

-   Lovelace Health Plan is a Health Maintenance Organization licensed
    in the State of New Mexico since 1981.

If you want more information about us, call at (505) 262-7363
Albuquerque area or 1-800-808-7363 statewide, or write to Lovelace
Health Plan, Altura Office Complex, 4101 Indian School Road, NE,
Albuquerque, NM 87110. You may also visit our website at
www.Lovelacehealthplan.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 State of
New Mexico.

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

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

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

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program - *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 53.

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

-   We added information regarding enrolling in Medicare. See page 42.

-   We revised the Medicare Primary Payer Chart. See page 44, 45.

**Changes to this Plan**

-   Your share of the non-Postal premium will increase by 15% for Self
    Only or 2.3% for Self and Family.

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

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

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

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
(505) 262-7363 Albuquerque area or 1-800-808-7363 statewide. You may
also request replacement cards through our website at
www.Lovelacehealthplan.com .

**Where you get covered care** You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and coinsurance, and you
will not have to file claims unless you receive emergency services from
a provider who does not have a contract with us.

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

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.

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

**What you must do to get** It depends on the type of care you need.
First, you and each family

**covered care** member must choose a primary care physician. This
decision is important since your primary care physician provides or
arranges for most of your health care. When you enroll, you choose a
Primary Care Physician (PCP). Each family member also chooses a PCP.
Your PCP is your personal doctor and serves as your health care manager.
If you do not select a PCP, we will assign one for you. If your PCP
leaves our network, you will be able to choose a new PCP. You may
voluntarily change your PCP for other reasons but not more than once in
any calendar month. We reserve the right to determine the number of
times during a year that you will be allowed to change your PCP. If you
select a new PCP before the fifteenth day of the month, the designation
will be effective on the first day of the month following your
selection. If you select a new PCP on or after the fifteenth day of the
month, the designation will be effective on the first day of the month
following the next full month. For example, if you notify us on June 10,
the change will be effective on July 1. If you notify us on June 15, the
change will be effective on August 1.

> Some Primary Care Physicians belong to provider organizations which
> usually refer to a network of Specialty Care Physicians and Hospitals
> that are in the provider organization. Your choice of Primary Care
> Physician may affect the Hospital(s) and Specialty Care Physicians to
> which you may be referred. Therefore, you may not have access to every
> specialist or Participating Provider in your Service Area. Before you
> select a PCP, you should check to see if that PCP is associated with
> the specialist or facility you prefer to use.

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

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

**• Specialty care** Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your
primary care physician, you must return to the primary care physician
after the consultation, unless your primary care physician authorized a
certain number of visits without additional referrals. The primary care
physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives
you a referral. However, you may see an OB/GYN for well-woman care or go
to a hospital for emergency care without a referral.

Here are other things you should know about specialty care:

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

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

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

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

>  terminate our contract with your specialist for other than cause; or
>
>  drop out of the Federal Employees Health Benefits (FEHB) Program and
> you enroll in another FEHB Plan; or reduce our service area and you
> enroll in another FEHB Plan,

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

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

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

If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at (505) 262-7363
Albuquerque area or 1-800-808-7363 statewide. If you are new to the FEHB
Program, we will arrange for you to receive care.

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

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

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

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

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

**Circumstances beyond** Under certain extraordinary circumstances, such
as natural disasters, we

**our control** may have to delay your services or we may be unable to
provide them. In that case, we will make all reasonable efforts to
provide you with the necessary care.

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

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

> A referral or Prior Authorization must be obtained prior to receiving
> services performed by any health care provider EXCEPT:
>
> For services provided by

-   Your Primary Care Physician;

```{=html}
<!-- -->
```
-   OB/GYN Services; and

-   Emergency Services or Urgently Needed Care.

> A referral must be obtained directly from your Primary Care Physician.
> Your Primary Care Physician must provide a referral if you receive
> services and benefits such as Specialty Care Physician services. If
> you receive services which require a referral without a referral from
> your Primary Care Physician, you will be obligated to pay for the
> unauthorized services. **We will not pay for such unauthorized
> services.**
>
> Certain benefits and services require Prior Authorization from us.
> Prior Authorization must always be obtained through your Plan
> Provider. If Prior Authorization is required from us, your Primary
> Care Physician or Specialty Care Physician will make arrangements with
> our Medical Director. Prior Authorization is required for the
> following types of benefits and services such as: Inpatient and
> Outpatient Hospital Services, Rehabilitative Therapy, Skilled Nursing
> Facility Services, Home Health Services, Second Surgical Opinions,
> Services provided by a Non-Plan Provider, Durable Medical Equipment
> and Prosthetic Devices.
>
> If your coverage is terminated prior to the date of service, the
> service will not be covered, regardless of any Prior Authorization
> given by us or your Primary or Specialty Care Physician.

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

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

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

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

> Example: When you see your primary care physician you pay a copayment
> of \$15 per office visit.

**• Deductible** A deductible is a fixed expense you must incur for
certain covered services and supplies before we start paying benefits
for them.

Example: When you need an orthopedic/prosthetic device, you pay the
first \$200*.*

Note: If you change plans during open season, you do not have to start a
new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the
year, you must begin a new deductible under your new plan.

**• Coinsurance** Coinsurance is the percentage of our negotiated fee
that you must pay for your care. Example: In our Plan, you pay 50% of
our allowance for infertility services.

**Your catastrophic protection** After your copayments total \$1,500 per
person or \$3,000 per family

**out-of-pocket maximum for** enrollment in any calendar year, you do
not have to pay any more for **deductibles coinsurance and** covered
services.

**copayments**

. However, copayments for the following services do not count toward
your catastrophic protection out-of-pocket maximum, and you must
continue to pay copayments for these services:

-   Prescription drugs

-   Dental services

-   Mental Health/Substance Abuse

-   External prosthetic appliances

-   Infertility services

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

+-----------------------------------------------------------------------+
| ####### Section 5. Benefits -- OVERVIEW                               |
|                                                                       |
| ***(See page 9 for how our benefits changed this year and page 59 for |
| a benefits summary.)***                                               |
+-----------------------------------------------------------------------+

**Note**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
(505) 262-7363 Albuquerque area or 1-800-808-7363 statewide. You may
also visit our website at
[www.Lovelacehealthplan.com](http://www.Lovelacehealthplan.com/).

(a) Medical services and supplies provided by physicians and other
    health care professionals..........................15-22

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 23-25

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

(c) Services provided by a hospital or other facility, and ambulance
    services 26-28

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

(d) Emergency services/accidents 29-30

  ------------------------------ ----------------------------------------
  •Medical emergency             •Ambulance

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

(e) Mental health and substance abuse benefits 31-32

(f) Prescription drug benefits 33-34

(g) Special features 35

• Flexible benefits option

• 24 hour nurse line

• Services for deaf and hearing impaired

-   Centers of Excellence

• Travel benefit/services overseas

(h) Dental benefits 36

(i) Non-FEHB benefits available to Plan members 37

> Summary of benefits 59

+---+---+-------------------------------------+---+----------------+---+---+
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| * |   |                                     |   |                |   |   |
| * |   |                                     |   |                |   |   |
+---+---+-------------------------------------+---+----------------+---+---+
|   | * | **Here are some important things to |   |                | * |   |
|   | * | keep in mind about these            |   |                | * |   |
|   | I | benefits:**                         |   |                | I |   |
|   | * |                                     |   |                | * |   |
|   | * | -   Please remember that all        |   |                | * |   |
|   |   |     benefits are subject to the     |   |                |   |   |
|   | * |     definitions, limitations, and   |   |                | * |   |
|   | * |     exclusions in this brochure and |   |                | * |   |
|   | M |     are payable only when we        |   |                | M |   |
|   | * |     determine they are medically    |   |                | * |   |
|   | * |     necessary.                      |   |                | * |   |
|   |   |                                     |   |                |   |   |
|   | * | -   Plan physicians must provide or |   |                | * |   |
|   | * |     arrange your care.              |   |                | * |   |
|   | P |                                     |   |                | P |   |
|   | * | -   We have no calendar year        |   |                | * |   |
|   | * |     deductible.                     |   |                | * |   |
|   |   |                                     |   |                |   |   |
|   | * | ```{=html}                          |   |                | * |   |
|   | * | <!-- -->                            |   |                | * |   |
|   | O | ```                                 |   |                | O |   |
|   | * | -   Be sure to read Section 4,      |   |                | * |   |
|   | * |     *Your costs for covered         |   |                | * |   |
|   |   |     services,* for valuable         |   |                |   |   |
|   | * |     information about how cost      |   |                | * |   |
|   | * |     sharing works. Also read        |   |                | * |   |
|   | R |     Section 9 about coordinating    |   |                | R |   |
|   | * |     benefits with other coverage,   |   |                | * |   |
|   | * |     including with Medicare.        |   |                | * |   |
|   |   |                                     |   |                |   |   |
|   | * |                                     |   |                | * |   |
|   | * |                                     |   |                | * |   |
|   | T |                                     |   |                | T |   |
|   | * |                                     |   |                | * |   |
|   | * |                                     |   |                | * |   |
|   |   |                                     |   |                |   |   |
|   | * |                                     |   |                | * |   |
|   | * |                                     |   |                | * |   |
|   | A |                                     |   |                | A |   |
|   | * |                                     |   |                | * |   |
|   | * |                                     |   |                | * |   |
|   |   |                                     |   |                |   |   |
|   | * |                                     |   |                | * |   |
|   | * |                                     |   |                | * |   |
|   | N |                                     |   |                | N |   |
|   | * |                                     |   |                | * |   |
|   | * |                                     |   |                | * |   |
|   |   |                                     |   |                |   |   |
|   | * |                                     |   |                | * |   |
|   | * |                                     |   |                | * |   |
|   | T |                                     |   |                | T |   |
|   | * |                                     |   |                | * |   |
|   | * |                                     |   |                | * |   |
+---+---+-------------------------------------+---+----------------+---+---+
| > |   |                                     |   | **You pay**    |   |   |
|   |   |                                     |   |                |   |   |
| * |   |                                     |   |                |   |   |
| * |   |                                     |   |                |   |   |
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| * |   |                                     |   |                |   |   |
+---+---+-------------------------------------+---+----------------+---+---+
| # |   |                                     |   |                |   |   |
| # |   |                                     |   |                |   |   |
| # |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
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| * |   |                                     |   |                |   |   |
+---+---+-------------------------------------+---+----------------+---+---+
| > |   |                                     |   | > \$15 per     |   |   |
|   |   |                                     |   | > visit to     |   |   |
| P |   |                                     |   | > your primary |   |   |
| r |   |                                     |   | > care         |   |   |
| o |   |                                     |   | > physician    |   |   |
| f |   |                                     |   | >              |   |   |
| e |   |                                     |   | > \$25 per     |   |   |
| s |   |                                     |   | > visit to a   |   |   |
| s |   |                                     |   | > specialist   |   |   |
| i |   |                                     |   |                |   |   |
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|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
| k |   |                                     |   |                |   |   |
| i |   |                                     |   |                |   |   |
| l |   |                                     |   |                |   |   |
| l |   |                                     |   |                |   |   |
| e |   |                                     |   |                |   |   |
| d |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
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|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| n |   |                                     |   |                |   |   |
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|   |   |                                     |   |                |   |   |
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| f |   |                                     |   |                |   |   |
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| i |   |                                     |   |                |   |   |
| l |   |                                     |   |                |   |   |
| i |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
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|   |   |                                     |   |                |   |   |
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| f |   |                                     |   |                |   |   |
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|   |   |                                     |   |                |   |   |
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| d |   |                                     |   |                |   |   |
| i |   |                                     |   |                |   |   |
| c |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| l |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| c |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| n |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
| u |   |                                     |   |                |   |   |
| l |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| i |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| n |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| S |   |                                     |   |                |   |   |
| e |   |                                     |   |                |   |   |
| c |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| n |   |                                     |   |                |   |   |
| d |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
| u |   |                                     |   |                |   |   |
| r |   |                                     |   |                |   |   |
| g |   |                                     |   |                |   |   |
| i |   |                                     |   |                |   |   |
| c |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| l |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| p |   |                                     |   |                |   |   |
| i |   |                                     |   |                |   |   |
| n |   |                                     |   |                |   |   |
| i |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| n |   |                                     |   |                |   |   |
+---+---+-------------------------------------+---+----------------+---+---+
| - |   |                                     |   | > Nothing      |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| A |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| h |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| m |   |                                     |   |                |   |   |
| e |   |                                     |   |                |   |   |
+---+---+-------------------------------------+---+----------------+---+---+
| # |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| L |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| b |   |                                     |   |                |   |   |
| , |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| X |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
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|   |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| n |   |                                     |   |                |   |   |
| d |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| h |   |                                     |   |                |   |   |
| e |   |                                     |   |                |   |   |
| r |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| d |   |                                     |   |                |   |   |
| i |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| g |   |                                     |   |                |   |   |
| n |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| i |   |                                     |   |                |   |   |
| c |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| e |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
+---+---+-------------------------------------+---+----------------+---+---+
| > |   |                                     |   | > Nothing      |   |   |
|   |   |                                     |   |                |   |   |
| T |   |                                     |   |                |   |   |
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| s |   |                                     |   |                |   |   |
| , |   |                                     |   |                |   |   |
| > |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
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|   |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
| : |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| B |   |                                     |   |                |   |   |
| l |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| d |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| e |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| U |   |                                     |   |                |   |   |
| r |   |                                     |   |                |   |   |
| i |   |                                     |   |                |   |   |
| n |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| l |   |                                     |   |                |   |   |
| y |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
| i |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| P |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| p |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| e |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| P |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| h |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| l |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| g |   |                                     |   |                |   |   |
| y |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| X |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
| r |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| y |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| M |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| m |   |                                     |   |                |   |   |
| m |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| g |   |                                     |   |                |   |   |
| r |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| m |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| C |   |                                     |   |                |   |   |
| A |   |                                     |   |                |   |   |
| T |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| S |   |                                     |   |                |   |   |
| c |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| n |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
| / |   |                                     |   |                |   |   |
| M |   |                                     |   |                |   |   |
| R |   |                                     |   |                |   |   |
| I |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| U |   |                                     |   |                |   |   |
| l |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| r |   |                                     |   |                |   |   |
| a |   |                                     |   |                |   |   |
| s |   |                                     |   |                |   |   |
| o |   |                                     |   |                |   |   |
| u |   |                                     |   |                |   |   |
| n |   |                                     |   |                |   |   |
| d |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| - |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
|   |   |                                     |   |                |   |   |
| E |   |                                     |   |                |   |   |
| l |   |                                     |   |                |   |   |
| e |   |                                     |   |                |   |   |
| c |   |                                     |   |                |   |   |
| t |   |                                     |   |                |   |   |
| r |   |                                     |   |                |   |   |
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+---+---+-------------------------------------+---+----------------+---+---+
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+---+---+-------------------------------------+---+----------------+---+---+
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| . |   |                                     |   |                |   |   |
+---+---+-------------------------------------+---+----------------+---+---+
| > |   |                                     |   |                |   |   |
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| > |   |                                     |   | > \$15 per     |   |   |
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| a |   |                                     |   | > physician    |   |   |
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| n |   |                                     |   | > \$25 per     |   |   |
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| > |   |                                     |   | > 50% per      |   |   |
|   |   |                                     |   | > trea         |   |   |
| T |   |                                     |   | tment/surgical |   |   |
| r |   |                                     |   | > procedure    |   |   |
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+---+---+-------------------------------------+---+----------------+---+---+
| > |   |                                     |   | > *All         |   |   |
|   |   |                                     |   | > charges*     |   |   |
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| > |   |                                     |   | **You pay**    |   |   |
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| - |   |                                     |   | > \$25 per     |   |   |
|   |   |                                     |   | > visit        |   |   |
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| - |   |                                     |   | > \$15 per     |   |   |
|   |   |                                     |   | > visit to     |   |   |
|   |   |                                     |   | > your primary |   |   |
|   |   |                                     |   | > care         |   |   |
| H |   |                                     |   | > physician    |   |   |
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| a |   |                                     |   | > \$25 per     |   |   |
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|   |   |                                     |   | > charges*     |   |   |
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| - |   |                                     |   | > \$15 per     |   |   |
|   |   |                                     |   | > visit to     |   |   |
|   |   |                                     |   | > your primary |   |   |
|   |   |                                     |   | > care         |   |   |
| O |   |                                     |   | > physician    |   |   |
| n |   |                                     |   | >              |   |   |
| e |   |                                     |   | > \$25 per     |   |   |
|   |   |                                     |   | > visit to a   |   |   |
|   |   |                                     |   | > specialist   |   |   |
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| - |   |                                     |   | > All charges  |   |   |
|   |   |                                     |   | > above the    |   |   |
|   |   |                                     |   | > maximum Plan |   |   |
|   |   |                                     |   | > payment      |   |   |
| O |   |                                     |   | > amount shown |   |   |
| n |   |                                     |   | > for lenses   |   |   |
| e |   |                                     |   | > and frames.  |   |   |
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| # |   |                                     |   |                |   |   |
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| > |   |                                     |   | > \$15 per     |   |   |
|   |   |                                     |   | > visit to     |   |   |
| R |   |                                     |   | > your primary |   |   |
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| u |   |                                     |   | > physician    |   |   |
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| . |   |                                     |   |                |   |   |
+---+---+-------------------------------------+---+----------------+---+---+
| > |   |                                     |   | > *All         |   |   |
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| > |   |                                     |   | > Same as      |   |   |
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| > |   |                                     |   | > \$15 per     |   |   |
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| # |   |                                     |   | > *All         |   |   |
| # |   |                                     |   | > charges*     |   |   |
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| > |   |                                     |   | > Costs vary   |   |   |
|   |   |                                     |   | > by class     |   |   |
| C |   |                                     |   | > and/or       |   |   |
| o |   |                                     |   | > program.     |   |   |
| v |   |                                     |   | > Call Plan    |   |   |
| e |   |                                     |   | > for details. |   |   |
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+---+---+-------------------------------------+---+----------------+---+---+

+---+---+-------------------------------------+----------------+---+---+
| * |   |                                     |                |   |   |
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| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
|   | * | **Here are some important things to |                | * |   |
|   | * | keep in mind about these            |                | * |   |
|   | I | benefits:**                         |                | I |   |
|   | * |                                     |                | * |   |
|   | * | -   Please remember that all        |                | * |   |
|   |   |     benefits are subject to the     |                |   |   |
|   | * |     definitions, limitations, and   |                | * |   |
|   | * |     exclusions in this brochure and |                | * |   |
|   | M |     are payable only when we        |                | M |   |
|   | * |     determine they are medically    |                | * |   |
|   | * |     necessary.                      |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Plan physicians must provide or |                | * |   |
|   | * |     arrange your care.              |                | * |   |
|   | P |                                     |                | P |   |
|   | * | -   We have no calendar year        |                | * |   |
|   | * |     deductible.                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Be sure to read Section 4,      |                | * |   |
|   | * |     *Your costs for covered         |                | * |   |
|   | O |     services,* for valuable         |                | O |   |
|   | * |     information about how cost      |                | * |   |
|   | * |     sharing works. Also read        |                | * |   |
|   |   |     Section 9 about coordinating    |                |   |   |
|   | * |     benefits with other coverage,   |                | * |   |
|   | * |     including with Medicare.        |                | * |   |
|   | R |                                     |                | R |   |
|   | * | -   The amounts listed below are    |                | * |   |
|   | * |     for the charges billed by a     |                | * |   |
|   |   |     physician or other health care  |                |   |   |
|   | * |     professional for your surgical  |                | * |   |
|   | * |     care. Look in Section 5(c) for  |                | * |   |
|   | T |     charges associated with the     |                | T |   |
|   | * |     facility (i.e. hospital,        |                | * |   |
|   | * |     surgical center, etc.).         |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   YOUR PLAN PROVIDER MUST GET     |                | * |   |
|   | * |     PRIOR AUTHORIZATION OF SOME     |                | * |   |
|   | A |     SURGICAL PROCEDURES. Please     |                | A |   |
|   | * |     refer to the prior              |                | * |   |
|   | * |     authorization information shown |                | * |   |
|   |   |     in Section 3 to be sure which   |                |   |   |
|   | * |     services require prior          |                | * |   |
|   | * |     authorization and identify      |                | * |   |
|   | N |     which surgeries require prior   |                | N |   |
|   | * |     authorization.                  |                | * |   |
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+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | > *All         |   |   |
|   |   |                                     | > charges*     |   |   |
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|   |   |                                     |                |   |   |
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| o |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
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| a |   |                                     |                |   |   |
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| e |   |                                     |                |   |   |
| . |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+

+---------------------------------------------+------------------------+
| > **Reconstructive surgery**                | > **You pay**          |
+---------------------------------------------+------------------------+
| -   Surgery to correct a functional defect  | > Nothing              |
|                                             |                        |
| -   Surgery to correct a condition caused   |                        |
|     by injury or illness if:                |                        |
|                                             |                        |
| > the condition produced a major effect   |                        |
| > on the member's appearance and            |                        |
| >                                           |                        |
| > the condition can reasonably be         |                        |
| > expected to be corrected by such surgery  |                        |
|                                             |                        |
| -   Surgery to correct a condition that     |                        |
|     existed at or from birth and is a       |                        |
|     significant deviation from the common   |                        |
|     form or norm. Examples of congenital    |                        |
|     anomalies are: protruding ear           |                        |
|     deformities; cleft lip; cleft palate;   |                        |
|     birth marks; webbed fingers; and webbed |                        |
|     toes.                                   |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   All stages of breast reconstruction     |                        |
|     surgery following a mastectomy, such    |                        |
|     as:                                     |                        |
|                                             |                        |
| > surgery to produce a symmetrical        |                        |
| > appearance on the other breast;           |                        |
| >                                           |                        |
| > treatment of any physical               |                        |
| > complications, such as lymphedemas;       |                        |
| >                                           |                        |
| > breast prostheses and surgical bras and |                        |
| > replacements (see Prosthetic devices)     |                        |
| >                                           |                        |
| > Note: If you need a mastectomy, you may   |                        |
| > choose to have the procedure performed on |                        |
| > an inpatient basis and remain in the      |                        |
| > hospital up to 48 hours after the         |                        |
| > procedure.                                |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Cosmetic surgery -- any surgical       |                        |
|     procedure (or any portion of a          |                        |
|     procedure) performed primarily to       |                        |
|     improve physical appearance through     |                        |
|     change in bodily form, except repair of |                        |
|     accidental injury*                      |                        |
|                                             |                        |
| -   *Surgeries related to sex               |                        |
|     transformation*                         |                        |
+---------------------------------------------+------------------------+
| > **Oral and maxillofacial surgery**        |                        |
+---------------------------------------------+------------------------+
| > Oral surgical procedures, with the prior  | > Nothing              |
| > approval of Plan Medical Director, such   |                        |
| > as:                                       |                        |
|                                             |                        |
| -   Reduction of fractures of the jaws or   |                        |
|     facial bones;                           |                        |
|                                             |                        |
| -   Surgical correction of cleft lip, cleft |                        |
|     palate or severe functional             |                        |
|     malocclusion;                           |                        |
|                                             |                        |
| -   Removal of stones from salivary ducts;  |                        |
|                                             |                        |
| -   Excision of leukoplakia or              |                        |
|     malignancies;                           |                        |
|                                             |                        |
| -   Excision of cysts and incision of       |                        |
|     abscesses when done as independent      |                        |
|     procedures; and                         |                        |
|                                             |                        |
| -   Other surgical procedures that do not   |                        |
|     involve the teeth or their supporting   |                        |
|     structures.                             |                        |
|                                             |                        |
| -   TMJ treatment and services (non-dental) |                        |
+---------------------------------------------+------------------------+
| > *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)*                         |                        |
+---------------------------------------------+------------------------+
| > **Organ/tissue transplants**              | > **You pay**          |
+---------------------------------------------+------------------------+
| > Limited to:                               | > Nothing              |
|                                             |                        |
| -   Cornea                                  |                        |
|                                             |                        |
| -   Heart                                   |                        |
|                                             |                        |
| -   Heart/lung                              |                        |
|                                             |                        |
| -   Kidney                                  |                        |
|                                             |                        |
| -   Kidney/Pancreas                         |                        |
|                                             |                        |
| -   Pancreas                                |                        |
|                                             |                        |
| -   Lung                                    |                        |
|                                             |                        |
| -   Liver                                   |                        |
|                                             |                        |
| -   Allogeneic (donor) bone marrow/stem     |                        |
|     cell transplants                        |                        |
|                                             |                        |
| -   Autologous bone marrow transplants      |                        |
|     (autologous stem cell and peripheral    |                        |
|     stem cell support) for the following    |                        |
|     conditions: acute lymphocytic or        |                        |
|     non-lymphocytic leukemia; advanced      |                        |
|     Hodgkin\'s lymphoma; advanced           |                        |
|     non-Hodgkin\'s lymphoma; advanced       |                        |
|     neuroblastoma; breast cancer; multiple  |                        |
|     myeloma; epithelial ovarian cancer; and |                        |
|     testicular, mediastinal,                |                        |
|     retroperitoneal and ovarian germ cell   |                        |
|     tumors                                  |                        |
|                                             |                        |
| -   Intestinal transplants (small           |                        |
|     intestine) and the small intestine with |                        |
|     the liver or small intestine with       |                        |
|     multiple organs such as the liver,      |                        |
|     stomach and pancreas                    |                        |
|                                             |                        |
| -   National Transplant Program (NTP)       |                        |
|     please see Section 5(g), Special        |                        |
|     Features                                |                        |
|                                             |                        |
| > Limited Benefits -- Treatment for breast  |                        |
| > cancer, multiple myeloma, epithelial      |                        |
| > ovarian cancer may be provided in an NCI- |                        |
| > or NIH-approved clinical trial at a       |                        |
| > Plan-designated center of excellence and  |                        |
| > if approved by the Plan's medical         |                        |
| > director in accordance with the Plan's    |                        |
| > protocols.                                |                        |
| >                                           |                        |
| > Note: We cover related medical and        |                        |
| > hospital expenses of the donor when we    |                        |
| > cover the recipient.                      |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Donor screening tests and donor search |                        |
|     expenses, except those performed for    |                        |
|     the actual donor*                       |                        |
|                                             |                        |
| -   *Implants of artificial organs*         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Transplants not listed as covered*     |                        |
+---------------------------------------------+------------------------+
| > **Anesthesia**                            |                        |
+---------------------------------------------+------------------------+
| > Professional services provided in --      | > Nothing              |
|                                             |                        |
| -   Hospital (inpatient)                    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Hospital outpatient department          |                        |
|                                             |                        |
| -   Skilled nursing facility                |                        |
|                                             |                        |
| -   Ambulatory surgical center              |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Office                                  |                        |
+---------------------------------------------+------------------------+

+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   |             |   |     |
|  * |   |                                   |             |   |     |
| *S |   |                                   |             |   |     |
| ec |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  5 |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| (c |   |                                   |             |   |     |
| ). |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| Se |   |                                   |             |   |     |
| rv |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| pr |   |                                   |             |   |     |
| ov |   |                                   |             |   |     |
| id |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| by |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| sp |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| or |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  o |   |                                   |             |   |     |
| th |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  f |   |                                   |             |   |     |
| ac |   |                                   |             |   |     |
| il |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| y, |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| mb |   |                                   |             |   |     |
| ul |   |                                   |             |   |     |
| an |   |                                   |             |   |     |
| ce |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| rv |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| ** |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
|    | * | > **Here are some important       |             | * |     |
|    | * | > things to remember about these  |             | * |     |
|    | I | > benefits:**                     |             | I |     |
|    | * |                                   |             | * |     |
|    | * | -   Please remember that all      |             | * |     |
|    |   |     benefits are subject to the   |             |   |     |
|    | * |     definitions, limitations, and |             | * |     |
|    | * |     exclusions in this brochure   |             | * |     |
|    | M |     and are payable only when we  |             | M |     |
|    | * |     determine they are medically  |             | * |     |
|    | * |     necessary.                    |             | * |     |
|    |   |                                   |             |   |     |
|    | * | -   Plan physicians must provide  |             | * |     |
|    | * |     or arrange your care and you  |             | * |     |
|    | P |     must be hospitalized in a     |             | P |     |
|    | * |     Plan facility.                |             | * |     |
|    | * |                                   |             | * |     |
|    |   | -   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  |             | * |     |
|    | * |     covered in Sections 5(a) or   |             | * |     |
|    | A |     (b).                          |             | A |     |
|    | * |                                   |             | * |     |
|    | * | -   **YOUR PRIMARY CARE PHYSICIAN |             | * |     |
|    |   |     MUST OBTAIN OUR PRIOR         |             |   |     |
|    | * |     AUTHORIZATION FOR HOSPITAL    |             | * |     |
|    | * |     STAYS, EXCEPT FOR             |             | * |     |
|    | N |     EMERGENCIES.** Please refer   |             | N |     |
|    | * |     to Section 3 to be sure which |             | * |     |
|    | * |     services require Prior        |             | * |     |
|    |   |     Authorization.                |             |   |     |
|    | * |                                   |             | * |     |
|    | * |                                   |             | * |     |
|    | T |                                   |             | T |     |
|    | * |                                   |             | * |     |
|    | * |                                   |             | * |     |
+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   | **You pay** |   |     |
|  * |   |                                   |             |   |     |
| *B |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| ef |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  D |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| cr |   |                                   |             |   |     |
| ip |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| ** |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| #  |   |                                   | ########    |   |     |
| ## |   |                                   |             |   |     |
| ## |   |                                   |             |   |     |
| ## |   |                                   |             |   |     |
| #  |   |                                   |             |   |     |
| In |   |                                   |             |   |     |
| pa |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| t  |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| sp |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   | > \$250 per |   |     |
| Ro |   |                                   | > admission |   |     |
| om |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| bo |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| d, |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| su |   |                                   |             |   |     |
| ch |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| as |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  w |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| d, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| mi |   |                                   |             |   |     |
| pr |   |                                   |             |   |     |
| iv |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| e, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| or |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  i |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ve |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| cc |   |                                   |             |   |     |
| om |   |                                   |             |   |     |
| mo |   |                                   |             |   |     |
| da |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| s; |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  g |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  n |   |                                   |             |   |     |
| ur |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| e; |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  m |   |                                   |             |   |     |
| ea |   |                                   |             |   |     |
| ls |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
| pe |   |                                   |             |   |     |
| ci |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| di |   |                                   |             |   |     |
| et |   |                                   |             |   |     |
| s. |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  N |   |                                   |             |   |     |
| ot |   |                                   |             |   |     |
| e: |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| If |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  y |   |                                   |             |   |     |
| ou |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  r |   |                                   |             |   |     |
| eq |   |                                   |             |   |     |
| ue |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  p |   |                                   |             |   |     |
| ri |   |                                   |             |   |     |
| va |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ro |   |                                   |             |   |     |
| om |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| is |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  n |   |                                   |             |   |     |
| ot |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  m |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| ly |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ne |   |                                   |             |   |     |
| ce |   |                                   |             |   |     |
| ss |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| y, |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  y |   |                                   |             |   |     |
| ou |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  p |   |                                   |             |   |     |
| ay |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| he |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ad |   |                                   |             |   |     |
| di |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ch |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| ge |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| bo |   |                                   |             |   |     |
| ve |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| he |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
| em |   |                                   |             |   |     |
| ip |   |                                   |             |   |     |
| ri |   |                                   |             |   |     |
| va |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ro |   |                                   |             |   |     |
| om |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  r |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| e. |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| #  |   |                                   | > Nothing   |   |     |
| ## |   |                                   |             |   |     |
| #  |   |                                   |             |   |     |
| Ot |   |                                   |             |   |     |
| he |   |                                   |             |   |     |
| r  |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| sp |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| vi |   |                                   |             |   |     |
| ce |   |                                   |             |   |     |
| s  |   |                                   |             |   |     |
| an |   |                                   |             |   |     |
| d  |   |                                   |             |   |     |
| su |   |                                   |             |   |     |
| pp |   |                                   |             |   |     |
| li |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| ,  |   |                                   |             |   |     |
| su |   |                                   |             |   |     |
| ch |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| s: |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| Op |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| in |   |                                   |             |   |     |
| g, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  r |   |                                   |             |   |     |
| ec |   |                                   |             |   |     |
| ov |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| y, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| ma |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| rn |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| y, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  o |   |                                   |             |   |     |
| th |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| me |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  r |   |                                   |             |   |     |
| oo |   |                                   |             |   |     |
| ms |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| Pr |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| cr |   |                                   |             |   |     |
| ib |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  d |   |                                   |             |   |     |
| ru |   |                                   |             |   |     |
| gs |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  m |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| in |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| Di |   |                                   |             |   |     |
| ag |   |                                   |             |   |     |
| no |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| la |   |                                   |             |   |     |
| bo |   |                                   |             |   |     |
| ra |   |                                   |             |   |     |
| to |   |                                   |             |   |     |
| ry |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| ts |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| X- |   |                                   |             |   |     |
| ra |   |                                   |             |   |     |
| ys |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| Ad |   |                                   |             |   |     |
| mi |   |                                   |             |   |     |
| ni |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
| ra |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| of |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| bl |   |                                   |             |   |     |
| oo |   |                                   |             |   |     |
| d, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
| lo |   |                                   |             |   |     |
| od |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| pr |   |                                   |             |   |     |
| od |   |                                   |             |   |     |
| uc |   |                                   |             |   |     |
| ts |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  o |   |                                   |             |   |     |
| th |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
| io |   |                                   |             |   |     |
| lo |   |                                   |             |   |     |
| gi |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| ls |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  B |   |                                   |             |   |     |
| lo |   |                                   |             |   |     |
| od |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| or |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
| lo |   |                                   |             |   |     |
| od |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| pl |   |                                   |             |   |     |
| as |   |                                   |             |   |     |
| ma |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| Dr |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| sp |   |                                   |             |   |     |
| li |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| ri |   |                                   |             |   |     |
| le |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| tr |   |                                   |             |   |     |
| ay |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| rv |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  M |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| su |   |                                   |             |   |     |
| pp |   |                                   |             |   |     |
| li |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| eq |   |                                   |             |   |     |
| ui |   |                                   |             |   |     |
| pm |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| t, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  i |   |                                   |             |   |     |
| nc |   |                                   |             |   |     |
| lu |   |                                   |             |   |     |
| di |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| ox |   |                                   |             |   |     |
| yg |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| An |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| th |   |                                   |             |   |     |
| et |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| an |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| th |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| ia |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| rv |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   | > *All      |   |     |
| *N |   |                                   | > charges*  |   |     |
| ot |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| ov |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| :* |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| *C |   |                                   |             |   |     |
| us |   |                                   |             |   |     |
| to |   |                                   |             |   |     |
| di |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| e* |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| *N |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| -c |   |                                   |             |   |     |
| ov |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  f |   |                                   |             |   |     |
| ac |   |                                   |             |   |     |
| il |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| ie |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| su |   |                                   |             |   |     |
| ch |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| as |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  n |   |                                   |             |   |     |
| ur |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| me |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| sc |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| ol |   |                                   |             |   |     |
| s* |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  * |   |                                   |             |   |     |
| Pe |   |                                   |             |   |     |
| rs |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| om |   |                                   |             |   |     |
| fo |   |                                   |             |   |     |
| rt |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| em |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| su |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| le |   |                                   |             |   |     |
| ph |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| e, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| el |   |                                   |             |   |     |
| ev |   |                                   |             |   |     |
| is |   |                                   |             |   |     |
| io |   |                                   |             |   |     |
| n, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| rb |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| er |   |                                   |             |   |     |
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| ce |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| ue |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  m |   |                                   |             |   |     |
| ea |   |                                   |             |   |     |
| ls |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| s* |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| *P |   |                                   |             |   |     |
| ri |   |                                   |             |   |     |
| va |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  n |   |                                   |             |   |     |
| ur |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| e* |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| ## |   |                                   | ####        |   |     |
| ## |   |                                   | **You pay** |   |     |
|  * |   |                                   |             |   |     |
| *O |   |                                   |             |   |     |
| ut |   |                                   |             |   |     |
| pa |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| t  |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| sp |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|  o |   |                                   |             |   |     |
| r  |   |                                   |             |   |     |
| am |   |                                   |             |   |     |
| bu |   |                                   |             |   |     |
| la |   |                                   |             |   |     |
| to |   |                                   |             |   |     |
| ry |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
| ur |   |                                   |             |   |     |
| gi |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| l  |   |                                   |             |   |     |
| ce |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| ** |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| -  |   |                                   | > \$125 per |   |     |
|    |   |                                   | > facility  |   |     |
| Op |   |                                   | > use       |   |     |
| er |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| in |   |                                   |             |   |     |
| g, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  r |   |                                   |             |   |     |
| ec |   |                                   |             |   |     |
| ov |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| y, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  o |   |                                   |             |   |     |
| th |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| me |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  r |   |                                   |             |   |     |
| oo |   |                                   |             |   |     |
| ms |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| #  |   |                                   |             |   |     |
| ## |   |                                   |             |   |     |
| #  |   |                                   |             |   |     |
| Pr |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| cr |   |                                   |             |   |     |
| ib |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
|  d |   |                                   |             |   |     |
| ru |   |                                   |             |   |     |
| gs |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|  m |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| in |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| Di |   |                                   |             |   |     |
| ag |   |                                   |             |   |     |
| no |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| bo |   |                                   |             |   |     |
| ra |   |                                   |             |   |     |
| to |   |                                   |             |   |     |
| ry |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  X |   |                                   |             |   |     |
| -r |   |                                   |             |   |     |
| ay |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  p |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| lo |   |                                   |             |   |     |
| gy |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| rv |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| Ad |   |                                   |             |   |     |
| mi |   |                                   |             |   |     |
| ni |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
| ra |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| of |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| bl |   |                                   |             |   |     |
| oo |   |                                   |             |   |     |
| d, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
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| od |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| pr |   |                                   |             |   |     |
| od |   |                                   |             |   |     |
| uc |   |                                   |             |   |     |
| ts |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  o |   |                                   |             |   |     |
| th |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
| io |   |                                   |             |   |     |
| lo |   |                                   |             |   |     |
| gi |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| ls |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  B |   |                                   |             |   |     |
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| od |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
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| od |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| pl |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
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| e- |   |                                   |             |   |     |
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| rg |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
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| ng |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| Dr |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| ay |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| rv |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  M |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
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| pl |   |                                   |             |   |     |
| ie |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  i |   |                                   |             |   |     |
| nc |   |                                   |             |   |     |
| lu |   |                                   |             |   |     |
| di |   |                                   |             |   |     |
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|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| yg |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
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| ne |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
| he |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| cs |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| an |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| th |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| ia |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| rv |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  N |   |                                   |             |   |     |
| ot |   |                                   |             |   |     |
| e: |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
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| >  |   |                                   |             |   |     |
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| al |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| rv |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| su |   |                                   |             |   |     |
| pp |   |                                   |             |   |     |
| li |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  r |   |                                   |             |   |     |
| el |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| to |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| de |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| pr |   |                                   |             |   |     |
| oc |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| ur |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| wh |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ne |   |                                   |             |   |     |
| ce |   |                                   |             |   |     |
| ss |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| by |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| no |   |                                   |             |   |     |
| n- |   |                                   |             |   |     |
| de |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ph |   |                                   |             |   |     |
| ys |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  i |   |                                   |             |   |     |
| mp |   |                                   |             |   |     |
| ai |   |                                   |             |   |     |
| rm |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| t. |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| We |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| do |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  n |   |                                   |             |   |     |
| ot |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| ov |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| he |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| de |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  p |   |                                   |             |   |     |
| ro |   |                                   |             |   |     |
| ce |   |                                   |             |   |     |
| du |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
| s. |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| #  |   |                                   | > *All      |   |     |
|  * |   |                                   | > charges*  |   |     |
| No |   |                                   |             |   |     |
| t  |   |                                   |             |   |     |
| co |   |                                   |             |   |     |
| ve |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
| d: |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
| lo |   |                                   |             |   |     |
| od |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
| lo |   |                                   |             |   |     |
| od |   |                                   |             |   |     |
|  d |   |                                   |             |   |     |
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| at |   |                                   |             |   |     |
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|  n |   |                                   |             |   |     |
| ot |   |                                   |             |   |     |
|  r |   |                                   |             |   |     |
| ep |   |                                   |             |   |     |
| la |   |                                   |             |   |     |
| ce |   |                                   |             |   |     |
| d  |   |                                   |             |   |     |
| by |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| he |   |                                   |             |   |     |
|  m |   |                                   |             |   |     |
| em |   |                                   |             |   |     |
| be |   |                                   |             |   |     |
| r* |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| ## |   |                                   | ########    |   |     |
| ## |   |                                   |             |   |     |
| ## |   |                                   |             |   |     |
| ## |   |                                   |             |   |     |
|  E |   |                                   |             |   |     |
| xt |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| de |   |                                   |             |   |     |
| d  |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
|  b |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| ef |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| s/ |   |                                   |             |   |     |
| sk |   |                                   |             |   |     |
| il |   |                                   |             |   |     |
| le |   |                                   |             |   |     |
| d  |   |                                   |             |   |     |
| nu |   |                                   |             |   |     |
| rs |   |                                   |             |   |     |
| in |   |                                   |             |   |     |
| g  |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
|  f |   |                                   |             |   |     |
| ac |   |                                   |             |   |     |
| il |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| y  |   |                                   |             |   |     |
| be |   |                                   |             |   |     |
| ne |   |                                   |             |   |     |
| fi |   |                                   |             |   |     |
| ts |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   | > Nothing   |   |     |
|  C |   |                                   |             |   |     |
| ov |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  f |   |                                   |             |   |     |
| or |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| up |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| to |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| 60 |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| da |   |                                   |             |   |     |
| ys |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  p |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| le |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ye |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| wh |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  f |   |                                   |             |   |     |
| ul |   |                                   |             |   |     |
| l- |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| me |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
| ki |   |                                   |             |   |     |
| ll |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  n |   |                                   |             |   |     |
| ur |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| is |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ne |   |                                   |             |   |     |
| ce |   |                                   |             |   |     |
| ss |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| y, |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| fi |   |                                   |             |   |     |
| ne |   |                                   |             |   |     |
| me |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| in |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  s |   |                                   |             |   |     |
| ki |   |                                   |             |   |     |
| ll |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  n |   |                                   |             |   |     |
| ur |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| fa |   |                                   |             |   |     |
| ci |   |                                   |             |   |     |
| li |   |                                   |             |   |     |
| ty |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| is |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  m |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| ly |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| pp |   |                                   |             |   |     |
| ro |   |                                   |             |   |     |
| pr |   |                                   |             |   |     |
| ia |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| as |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| de |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| rm |   |                                   |             |   |     |
| in |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| by |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| Pl |   |                                   |             |   |     |
| an |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| do |   |                                   |             |   |     |
| ct |   |                                   |             |   |     |
| or |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| ap |   |                                   |             |   |     |
| pr |   |                                   |             |   |     |
| ov |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| by |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| he |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
|  P |   |                                   |             |   |     |
| la |   |                                   |             |   |     |
| n. |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  S |   |                                   |             |   |     |
| ki |   |                                   |             |   |     |
| ll |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  g |   |                                   |             |   |     |
| en |   |                                   |             |   |     |
| er |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  n |   |                                   |             |   |     |
| ur |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ng |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| se |   |                                   |             |   |     |
| rv |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| Ph |   |                                   |             |   |     |
| ys |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| ia |   |                                   |             |   |     |
| ns |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| vi |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ts |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  P |   |                                   |             |   |     |
| hy |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| ot |   |                                   |             |   |     |
| he |   |                                   |             |   |     |
| ra |   |                                   |             |   |     |
| py |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| X- |   |                                   |             |   |     |
| ra |   |                                   |             |   |     |
| ys |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| Ad |   |                                   |             |   |     |
| mi |   |                                   |             |   |     |
| ni |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
| ra |   |                                   |             |   |     |
| ti |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| of |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| dr |   |                                   |             |   |     |
| ug |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  m |   |                                   |             |   |     |
| ed |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| at |   |                                   |             |   |     |
| io |   |                                   |             |   |     |
| ns |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| fl |   |                                   |             |   |     |
| ui |   |                                   |             |   |     |
| ds |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+
| >  |   |                                   | > *All      |   |     |
|  N |   |                                   | > charges*  |   |     |
| ot |   |                                   |             |   |     |
| >  |   |                                   |             |   |     |
| co |   |                                   |             |   |     |
| ve |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
| d: |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| Pe |   |                                   |             |   |     |
| rs |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| om |   |                                   |             |   |     |
| fo |   |                                   |             |   |     |
| rt |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| it |   |                                   |             |   |     |
| em |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| su |   |                                   |             |   |     |
| ch |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| as |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| te |   |                                   |             |   |     |
| le |   |                                   |             |   |     |
| vi |   |                                   |             |   |     |
| si |   |                                   |             |   |     |
| on |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  a |   |                                   |             |   |     |
| nd |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  t |   |                                   |             |   |     |
| el |   |                                   |             |   |     |
| ep |   |                                   |             |   |     |
| ho |   |                                   |             |   |     |
| ne |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| -  |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  C |   |                                   |             |   |     |
| us |   |                                   |             |   |     |
| to |   |                                   |             |   |     |
| di |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  c |   |                                   |             |   |     |
| ar |   |                                   |             |   |     |
| e, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
| st |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| cu |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
| s, |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|  d |   |                                   |             |   |     |
| om |   |                                   |             |   |     |
| ic |   |                                   |             |   |     |
| il |   |                                   |             |   |     |
| ia |   |                                   |             |   |     |
| ry |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| or |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| co |   |                                   |             |   |     |
| nv |   |                                   |             |   |     |
| al |   |                                   |             |   |     |
| es |   |                                   |             |   |     |
| ce |   |                                   |             |   |     |
| nt |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
|    |   |                                   |             |   |     |
| ca |   |                                   |             |   |     |
| re |   |                                   |             |   |     |
+----+---+-----------------------------------+-------------+---+-----+

+---------------------------------------------+------------------------+
| #### **Hospice care**                       | #### **You pay**       |
+---------------------------------------------+------------------------+
| > Hospice care for a patient who as         | > Nothing              |
| > certified by a Plan doctor is in the      |                        |
| > terminal stages of illness and who has a  |                        |
| > life expectancy of six months or less.    |                        |
| >                                           |                        |
| > Hospice care services include:            |                        |
|                                             |                        |
| -   inpatient care                          |                        |
|                                             |                        |
| -   outpatient care                         |                        |
|                                             |                        |
| -   physician services                      |                        |
|                                             |                        |
| -   psychologist, social worker or family   |                        |
|     counselor services for individual or    |                        |
|     family counseling                       |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Independent nursing*                   |                        |
|                                             |                        |
| -   *homemaker services, including services |                        |
|     and supplies that are primarily to aid  |                        |
|     you or your dependent in daily living*  |                        |
|                                             |                        |
| -   *services of a person who is a member   |                        |
|     of your family who normally resides in  |                        |
|     your house*                             |                        |
|                                             |                        |
| -   *services or supplies not listed in the |                        |
|     Hospice Care Program*                   |                        |
|                                             |                        |
| -   *services for curative or               |                        |
|     life-prolonging procedures*             |                        |
|                                             |                        |
| -   *bereavement counseling*                |                        |
|                                             |                        |
| -   *services for respite care*             |                        |
|                                             |                        |
| -   *nutritional supplements,               |                        |
|     non-prescription drugs or substances,   |                        |
|     medical supplies, vitamins or minerals* |                        |
+---------------------------------------------+------------------------+
| ######## Ambulance                          | ########               |
+---------------------------------------------+------------------------+
| -   Local professional ambulance service    | > Nothing              |
|     when medically appropriate              |                        |
+---------------------------------------------+------------------------+

+---+---+----------------------------------------+------------+---+---+---+
| # |   |                                        |            |   |   |   |
| # |   |                                        |            |   |   |   |
| # |   |                                        |            |   |   |   |
| # |   |                                        |            |   |   |   |
| # |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| S |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
| i |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| 5 |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| ( |   |                                        |            |   |   |   |
| d |   |                                        |            |   |   |   |
| ) |   |                                        |            |   |   |   |
| . |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| E |   |                                        |            |   |   |   |
| m |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| g |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| y |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| v |   |                                        |            |   |   |   |
| i |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
| / |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| i |   |                                        |            |   |   |   |
| d |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
+---+---+----------------------------------------+------------+---+---+---+
|   | * | > **Here are some important things to  |            | * | # |   |
|   | * | > keep in mind about these benefits:** |            | * | # |   |
|   | I |                                        |            | I | # |   |
|   | * | -   Please remember that all benefits  |            | * | # |   |
|   | * |     are subject to the definitions,    |            | * | # |   |
|   |   |     limitations, and exclusions in     |            |   |   |   |
|   | * |     this brochure and are payable only |            | * |   |   |
|   | * |     when we determine they are         |            | * |   |   |
|   | M |     medically necessary.               |            | M |   |   |
|   | * |                                        |            | * |   |   |
|   | * | -   We have no calendar year           |            | * |   |   |
|   |   |     deductible.                        |            |   |   |   |
|   | * |                                        |            | * |   |   |
|   | * | -   Be sure to read Section 4, *Your   |            | * |   |   |
|   | P |     costs for covered services,* for   |            | P |   |   |
|   | * |     valuable information about how     |            | * |   |   |
|   | * |     cost sharing works. Also read      |            | * |   |   |
|   |   |     Section 9 about coordinating       |            |   |   |   |
|   | * |     benefits with other coverage,      |            | * |   |   |
|   | * |     including with Medicare.           |            | * |   |   |
|   | O |                                        |            | O |   |   |
|   | * | #####                                  |            | * |   |   |
|   | * |                                        |            | * |   |   |
|   |   |                                        |            |   |   |   |
|   | * |                                        |            | * |   |   |
|   | * |                                        |            | * |   |   |
|   | R |                                        |            | R |   |   |
|   | * |                                        |            | * |   |   |
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+---+---+----------------------------------------+------------+---+---+---+
| > |   |                                        | **You      |   |   |   |
|   |   |                                        | pay**      |   |   |   |
| * |   |                                        |            |   |   |   |
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| c |   |                                        |            |   |   |   |
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| p |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
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| n |   |                                        |            |   |   |   |
| * |   |                                        |            |   |   |   |
| * |   |                                        |            |   |   |   |
+---+---+----------------------------------------+------------+---+---+---+
| * |   |                                        |            |   |   |   |
| * |   |                                        |            |   |   |   |
| E |   |                                        |            |   |   |   |
| m |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| g |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| y |   |                                        |            |   |   |   |
| w |   |                                        |            |   |   |   |
| i |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
| h |   |                                        |            |   |   |   |
| i |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| u |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| v |   |                                        |            |   |   |   |
| i |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| * |   |                                        |            |   |   |   |
| * |   |                                        |            |   |   |   |
+---+---+----------------------------------------+------------+---+---+---+
| - |   |                                        | > \$15 per |   |   |   |
|   |   |                                        | > office   |   |   |   |
|   |   |                                        | > visit    |   |   |   |
|   |   |                                        |            |   |   |   |
| E |   |                                        |            |   |   |   |
| m |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| g |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| y |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| P |   |                                        |            |   |   |   |
| l |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| d |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| ' |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| f |   |                                        |            |   |   |   |
| f |   |                                        |            |   |   |   |
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| c |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
+---+---+----------------------------------------+------------+---+---+---+
| - |   |                                        | > \$25 per |   |   |   |
|   |   |                                        | > visit.   |   |   |   |
|   |   |                                        | > Urgent   |   |   |   |
|   |   |                                        | > care     |   |   |   |
| E |   |                                        | >          |   |   |   |
| m |   |                                        |  copayment |   |   |   |
| e |   |                                        | > waived   |   |   |   |
| r |   |                                        | > if       |   |   |   |
| g |   |                                        | > admitted |   |   |   |
| e |   |                                        | > to       |   |   |   |
| n |   |                                        | > hospital |   |   |   |
| c |   |                                        |            |   |   |   |
| y |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
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|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
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| t |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| u |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| g |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
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| r |   |                                        |            |   |   |   |
+---+---+----------------------------------------+------------+---+---+---+
| - |   |                                        | > \$50 per |   |   |   |
|   |   |                                        | > visit.   |   |   |   |
|   |   |                                        | >          |   |   |   |
|   |   |                                        |  Emergency |   |   |   |
| E |   |                                        | > care     |   |   |   |
| m |   |                                        | >          |   |   |   |
| e |   |                                        |  copayment |   |   |   |
| r |   |                                        | > waived   |   |   |   |
| g |   |                                        | > if       |   |   |   |
| e |   |                                        | > admitted |   |   |   |
| n |   |                                        | > to       |   |   |   |
| c |   |                                        | > hospital |   |   |   |
| y |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
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| c |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
| \ |   |                                        |            |   |   |   |
| ' |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| v |   |                                        |            |   |   |   |
| i |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
+---+---+----------------------------------------+------------+---+---+---+
| * |   |                                        | > *All     |   |   |   |
| N |   |                                        | > charges* |   |   |   |
| o |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| v |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| d |   |                                        |            |   |   |   |
| : |   |                                        |            |   |   |   |
| E |   |                                        |            |   |   |   |
| l |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
| i |   |                                        |            |   |   |   |
| v |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| - |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| m |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| g |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| y |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| * |   |                                        |            |   |   |   |
+---+---+----------------------------------------+------------+---+---+---+
| # |   |                                        |            |   |   |   |
| # |   |                                        |            |   |   |   |
| # |   |                                        |            |   |   |   |
| # |   |                                        |            |   |   |   |
| # |   |                                        |            |   |   |   |
| # |   |                                        |            |   |   |   |
| # |   |                                        |            |   |   |   |
| # |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| E |   |                                        |            |   |   |   |
| m |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| g |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| y |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| u |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
| i |   |                                        |            |   |   |   |
| d |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| u |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| v |   |                                        |            |   |   |   |
| i |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
+---+---+----------------------------------------+------------+---+---+---+
| - |   |                                        | > \$15 per |   |   |   |
|   |   |                                        | > office   |   |   |   |
|   |   |                                        | > visit    |   |   |   |
|   |   |                                        |            |   |   |   |
| E |   |                                        |            |   |   |   |
| m |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| g |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| y |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| d |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| ' |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| o |   |                                        |            |   |   |   |
| f |   |                                        |            |   |   |   |
| f |   |                                        |            |   |   |   |
| i |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
+---+---+----------------------------------------+------------+---+---+---+
| - |   |                                        | > \$25 per |   |   |   |
|   |   |                                        | > visit.   |   |   |   |
|   |   |                                        | > Urgent   |   |   |   |
|   |   |                                        | > care     |   |   |   |
| E |   |                                        | >          |   |   |   |
| m |   |                                        |  copayment |   |   |   |
| e |   |                                        | > waived   |   |   |   |
| r |   |                                        | > if       |   |   |   |
| g |   |                                        | > admitted |   |   |   |
| e |   |                                        | > to       |   |   |   |
| n |   |                                        | > hospital |   |   |   |
| c |   |                                        |            |   |   |   |
| y |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| u |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| g |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
| t |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
+---+---+----------------------------------------+------------+---+---+---+
| - |   |                                        | > \$50 per |   |   |   |
|   |   |                                        | > visit.   |   |   |   |
|   |   |                                        | >          |   |   |   |
|   |   |                                        |  Emergency |   |   |   |
| E |   |                                        | > care     |   |   |   |
| m |   |                                        | >          |   |   |   |
| e |   |                                        |  copayment |   |   |   |
| r |   |                                        | > waived   |   |   |   |
| g |   |                                        | > if       |   |   |   |
| e |   |                                        | > admitted |   |   |   |
| n |   |                                        | > to       |   |   |   |
| c |   |                                        | > hospital |   |   |   |
| y |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| c |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| r |   |                                        |            |   |   |   |
| e |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
| a |   |                                        |            |   |   |   |
| s |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
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| a |   |                                        |            |   |   |   |
| n |   |                                        |            |   |   |   |
|   |   |                                        |            |   |   |   |
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| d |   |                                        |            |   |   |   |
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| \ |   |                                        |            |   |   |   |
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+---+---+----------------------------------------+------------+---+---+---+
| > |   |                                        | > *All     |   |   |   |
|   |   |                                        | > charges* |   |   |   |
| * |   |                                        |            |   |   |   |
| N |   |                                        |            |   |   |   |
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| b |   |                                        |               |   |   |   |
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| s |   |                                        |               |   |   |   |
| e |   |                                        |               |   |   |   |
| b |   |                                        |               |   |   |   |
| e |   |                                        |               |   |   |   |
| n |   |                                        |               |   |   |   |
| e |   |                                        |               |   |   |   |
| f |   |                                        |               |   |   |   |
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| t |   |                                        |               |   |   |   |
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| * |   |                                        |               |   |   |   |
| * |   |                                        |               |   |   |   |
+---+---+----------------------------------------+---------------+---+---+---+
|   | * | > When you get our approval for        |               | * |   |   |
|   | * | > services and follow a treatment plan |               | * |   |   |
|   | I | > we approve, cost-sharing and         |               | I |   |   |
|   | * | > limitations for Plan mental health   |               | * |   |   |
|   | * | > and substance abuse benefits will be |               | * |   |   |
|   |   | > no greater than for similar benefits |               |   |   |   |
|   | * | > for other illnesses and conditions.  |               | * |   |   |
|   | * | >                                      |               | * |   |   |
|   | M | > **Here are some important things to  |               | M |   |   |
|   | * | > keep in mind about these benefits:** |               | * |   |   |
|   | * |                                        |               | * |   |   |
|   |   | -   Please remember that all benefits  |               |   |   |   |
|   | * |     are subject to the definitions,    |               | * |   |   |
|   | * |     limitations, and exclusions in     |               | * |   |   |
|   | P |     this brochure and are payable only |               | P |   |   |
|   | * |     when we determine they are         |               | * |   |   |
|   | * |     medially necessary.                |               | * |   |   |
|   |   |                                        |               |   |   |   |
|   | * | -   We have no calendar year           |               | * |   |   |
|   | * |     deductible.                        |               | * |   |   |
|   | O |                                        |               | O |   |   |
|   | * | -   Be sure to read Section 4, *Your   |               | * |   |   |
|   | * |     costs for covered services,* for   |               | * |   |   |
|   |   |     valuable information about how     |               |   |   |   |
|   | * |     cost sharing works. Also read      |               | * |   |   |
|   | * |     Section 9 about coordinating       |               | * |   |   |
|   | R |     benefits with other coverage,      |               | R |   |   |
|   | * |     including with Medicare.           |               | * |   |   |
|   | * |                                        |               | * |   |   |
|   |   | -   **YOU MUST GET PREAUTHORIZATION OF |               |   |   |   |
|   | * |     THESE SERVICES.** See the          |               | * |   |   |
|   | * |     instructions after the benefits    |               | * |   |   |
|   | T |     description below.                 |               | T |   |   |
|   | * |                                        |               | * |   |   |
|   | * |                                        |               | * |   |   |
|   |   |                                        |               |   |   |   |
|   | * |                                        |               | * |   |   |
|   | * |                                        |               | * |   |   |
|   | A |                                        |               | A |   |   |
|   | * |                                        |               | * |   |   |
|   | * |                                        |               | * |   |   |
|   |   |                                        |               |   |   |   |
|   | * |                                        |               | * |   |   |
|   | * |                                        |               | * |   |   |
|   | N |                                        |               | N |   |   |
|   | * |                                        |               | * |   |   |
|   | * |                                        |               | * |   |   |
|   |   |                                        |               |   |   |   |
|   | * |                                        |               | * |   |   |
|   | * |                                        |               | * |   |   |
|   | T |                                        |               | T |   |   |
|   | * |                                        |               | * |   |   |
|   | * |                                        |               | * |   |   |
+---+---+----------------------------------------+---------------+---+---+---+
| > |   |                                        | > **You pay** |   |   |   |
|   |   |                                        |               |   |   |   |
| * |   |                                        |               |   |   |   |
| * |   |                                        |               |   |   |   |
| B |   |                                        |               |   |   |   |
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|   |   |                                        |               |   |   |   |
| D |   |                                        |               |   |   |   |
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| s |   |                                        |               |   |   |   |
| c |   |                                        |               |   |   |   |
| r |   |                                        |               |   |   |   |
| i |   |                                        |               |   |   |   |
| p |   |                                        |               |   |   |   |
| t |   |                                        |               |   |   |   |
| i |   |                                        |               |   |   |   |
| o |   |                                        |               |   |   |   |
| n |   |                                        |               |   |   |   |
| * |   |                                        |               |   |   |   |
| * |   |                                        |               |   |   |   |
+---+---+----------------------------------------+---------------+---+---+---+
| # |   |                                        |               |   |   |   |
| # |   |                                        |               |   |   |   |
| # |   |                                        |               |   |   |   |
|   |   |                                        |               |   |   |   |
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|   |   |                                        | > sharing     |   |   |   |
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| - |   |                                        | > \$25 per    |   |   |   |
|   |   |                                        | > office      |   |   |   |
|   |   |                                        | > visit       |   |   |   |
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+---+---+----------------------------------------+---------------+---+---+---+
| - |   |                                        | > Nothing     |   |   |   |
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+---+---+----------------------------------------+---------------+---+---+---+
| - |   |                                        | > Your cost   |   |   |   |
|   |   |                                        | > sharing     |   |   |   |
|   |   |                                        | > res         |   |   |   |
|   |   |                                        | ponsibilities |   |   |   |
| S |   |                                        | > are no      |   |   |   |
| e |   |                                        | > greater     |   |   |   |
| r |   |                                        | > than for    |   |   |   |
| v |   |                                        | > other       |   |   |   |
| i |   |                                        | > illness or  |   |   |   |
| c |   |                                        | > conditions. |   |   |   |
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| . |   |                                        |               |   |   |   |
+---+---+----------------------------------------+---------------+---+---+---+
| # |   |                                        |               |   |   |   |
| # |   |                                        |               |   |   |   |
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|   |   |                                        |               |   |   |   |
| t |   |                                        |               |   |   |   |
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| a |   |                                        |               |   |   |   |
| t |   |                                        |               |   |   |   |
| m |   |                                        |               |   |   |   |
| e |   |                                        |               |   |   |   |
| n |   |                                        |               |   |   |   |
| t |   |                                        |               |   |   |   |
|   |   |                                        |               |   |   |   |
| p |   |                                        |               |   |   |   |
| l |   |                                        |               |   |   |   |
| a |   |                                        |               |   |   |   |
| n |   |                                        |               |   |   |   |
| . |   |                                        |               |   |   |   |
+---+---+----------------------------------------+---------------+---+---+---+

+-----+---+-------------------------------------------------+---+-------+
| **S |   |                                                 |   |       |
| ect |   |                                                 |   |       |
| ion |   |                                                 |   |       |
| 5   |   |                                                 |   |       |
| (   |   |                                                 |   |       |
| f). |   |                                                 |   |       |
| Pre |   |                                                 |   |       |
| scr |   |                                                 |   |       |
| ipt |   |                                                 |   |       |
| ion |   |                                                 |   |       |
| d   |   |                                                 |   |       |
| rug |   |                                                 |   |       |
| b   |   |                                                 |   |       |
| ene |   |                                                 |   |       |
| fit |   |                                                 |   |       |
| s** |   |                                                 |   |       |
+-----+---+-------------------------------------------------+---+-------+
|     | * | **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             | * |       |
|     | M |     definitions, limitations and exclusions in  | M |       |
|     | * |     this brochure and are payable only when we  | * |       |
|     | * |     determine they are medically necessary.     | * |       |
|     |   |                                                 |   |       |
|     | * | -   We have no calendar year deductible.        | * |       |
|     | * |                                                 | * |       |
|     | P | -   Be sure to read Section 4, *Your costs for  | P |       |
|     | * |     covered services*, for valuable information | * |       |
|     | * |     about how cost sharing works. Also read     | * |       |
|     |   |     Section 9 about coordinating benefits with  |   |       |
|     | * |     other coverage, including with Medicare.    | * |       |
|     | * |                                                 | * |       |
|     | O |                                                 | O |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     |   |                                                 |   |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     | R |                                                 | R |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     |   |                                                 |   |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     | T |                                                 | T |       |
|     | * |                                                 | * |       |
|     | * |                                                 | * |       |
|     |   |                                                 |   |       |
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+-----+---+-------------------------------------------------+---+-------+
|     | * |                                                 |   |       |
|     | P |                                                 |   |       |
|     | r |                                                 |   |       |
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|     | * |                                                 |   |       |
+-----+---+-------------------------------------------------+---+-------+

*.*

+---------------------------------------------+------------------------+
| > **Benefit Description**                   | **You pay**            |
+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      |                        |
+---------------------------------------------+------------------------+
| > We cover the following medications and    | > **[Retail            |
| > supplies prescribed by a Plan physician   | > P                    |
| > and obtained from a Plan pharmacy or      | harmacy]{.underline}** |
| > through our mail order program:           | >                      |
|                                             | > \$7 per generic      |
| -   Drugs and medicine that by Federal law  | > formulary drug       |
|     of the United States require a          | >                      |
|     physician's prescription for their      | > \$15 per name brand  |
|     purchase, except those listed as *Not   | > formulary drug with  |
|     covered*.                               | > no generic           |
|                                             | > equivalent           |
| -   Oral and injectable contraceptive drugs | >                      |
|     and contraceptive devices;              | > \$35 per name brand  |
|     contraceptive diaphragms.               | > formulary drug with  |
|                                             | > generic equivalent   |
| -   Insulin, glucose test trips, and other  | > OR per non-formulary |
|     prescription diabetic supplies.         | > drug                 |
|                                             | >                      |
| -   Disposable needles and syringes needed  | > **[Mail Order        |
|     to inject covered prescribed            | > (Maintenance         |
|     medication.                             | > medications          |
|                                             | > only)]{.underline}** |
| -   Oral fertility medications.             | >                      |
|                                             | > \$16 per generic     |
| ```{=html}                                  | > formulary drug       |
| <!-- -->                                    | >                      |
| ```                                         | > \$40 per name brand  |
| -   Intravenous fluids and medication for   | > formulary drug with  |
|     home use, implantable drugs, and some   | > no generic           |
|     injectable drugs are covered under      | > equivalent           |
|     Medical and Surgical Benefits.          | >                      |
|                                             | > \$100 per name brand |
| ```{=html}                                  | > formulary drug with  |
| <!-- -->                                    | > generic equivalent   |
| ```                                         | > OR per non-formulary |
| -   Drugs to treat sexual dysfunction are   | > drug                 |
|     limited. Contact the Plan for dose      | >                      |
|     limits and prior authorization.         | > Note: If there is no |
|                                             | > generic equivalent   |
| -   Oral agent for controlling blood sugar  | > available, you will  |
|                                             | > still have to pay    |
|                                             | > the brand name copay |
+---------------------------------------------+------------------------+
| -   Implanted time-release medications,     | > \$100 one-time copay |
|     such as Norplant. There is no charge    | > per prescription     |
|     when the device is implanted during a   |                        |
|     covered hospitalization. There will be  |                        |
|     no refund of any portion of this copay  |                        |
|     if the implanted time-release           |                        |
|     medication is removed before the end of |                        |
|     its expected life.                      |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Drugs and supplies for cosmetic        |                        |
|     purposes*                               |                        |
|                                             |                        |
| -   *Vitamins (except for prenatal          |                        |
|     vitamins), nutrients and food           |                        |
|     supplements even if a physician         |                        |
|     prescribes or administers them*         |                        |
|                                             |                        |
| -   *Non-prescription medicines, over the   |                        |
|     counter drugs*                          |                        |
|                                             |                        |
| -   *Drugs obtained from a non-Plan         |                        |
|     pharmacy except for out-of-area         |                        |
|     emergencies*                            |                        |
|                                             |                        |
| -   *Medical supplies such as dressings and |                        |
|     antiseptics*                            |                        |
|                                             |                        |
| -   *Drugs to enhance athletic performance* |                        |
|                                             |                        |
| -   *Smoking cessation drugs and            |                        |
|     medications, including nicotine         |                        |
|     patches*                                |                        |
|                                             |                        |
| -   *Diet pills or appetite suppressants    |                        |
|     (except when used in the treatment of   |                        |
|     morbid obesity)*                        |                        |
|                                             |                        |
| -   *Replacement of drugs due to loss or    |                        |
|     theft*                                  |                        |
|                                             |                        |
| -   *Prescriptions more than one year from  |                        |
|     the original date of issue*             |                        |
|                                             |                        |
| -   *Injectable fertility drugs (see        |                        |
|     Infertility benefit under Medical and   |                        |
|     Surgical Benefits for limited           |                        |
|     coverage)*                              |                        |
+---------------------------------------------+------------------------+

+----------------------+-----------------------------------------------+
| > Section 5 (g).     |                                               |
| > Special features   |                                               |
+======================+===============================================+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| > **Flexible         | > Under the flexible benefits option, we      |
| > benefits option**  | > determine the most effective way to provide |
|                      | > services.                                   |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| > **24 hour nurse    | > For any of your health concerns, 24 hours a |
| > line**             | > day, 7 days a week, you may call            |
|                      | > 1-800-366-3401 and talk with a registered   |
|                      | > nurse who will discuss treatment options    |
|                      | > and answer your health questions.           |
+----------------------+-----------------------------------------------+
| > **Services for     | > Certified Languages International is a      |
| > deaf and hearing   | > company that is contracted by Lovelace      |
| > impaired**         | > Health Plan to Supply interpreters for      |
|                      | > patients and providers in any language      |
|                      | > including sign language, either by phone or |
|                      | > in person if certified employee             |
|                      | > interpreters are not available.             |
|                      | >                                             |
|                      | > Deaf/Hearing impaired individuals may       |
|                      | > access the member services department by    |
|                      | > calling their state relay line.             |
+----------------------+-----------------------------------------------+
| > **Centers of       | > Lovelace Health Plan members have access to |
| > Excellence**       | > the Lifesource Organ Transplant Network ®   |
|                      | > which is an organization of participating   |
|                      | > hospitals which provides organ transplant   |
|                      | > services. As part of the rigorous           |
|                      | > credentialing program, each hospital's      |
|                      | > transplant program is evaluated for patient |
|                      | > outcome, as well as waiting period, housing |
|                      | > arrangements, "patient friendly"            |
|                      | > environment and the availability of         |
|                      | > transportation, before it is included in    |
|                      | > the Lifesource Organ Transplant Network ®.  |
+----------------------+-----------------------------------------------+
| > **Travel           | > We cover you for emergency services any     |
| > benefit/services   | > where in the world                          |
| > overseas**         |                                               |
+----------------------+-----------------------------------------------+

+---+---+--------------------------------------+----------+---+--------+
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| S |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
| c |   |                                      |          |   |        |
| t |   |                                      |          |   |        |
| i |   |                                      |          |   |        |
| o |   |                                      |          |   |        |
| n |   |                                      |          |   |        |
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| 5 |   |                                      |          |   |        |
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| ( |   |                                      |          |   |        |
| h |   |                                      |          |   |        |
| ) |   |                                      |          |   |        |
| . |   |                                      |          |   |        |
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| D |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
| n |   |                                      |          |   |        |
| t |   |                                      |          |   |        |
| a |   |                                      |          |   |        |
| l |   |                                      |          |   |        |
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| b |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
| n |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
| f |   |                                      |          |   |        |
| i |   |                                      |          |   |        |
| t |   |                                      |          |   |        |
| s |   |                                      |          |   |        |
+---+---+--------------------------------------+----------+---+--------+
|   | * | Here are some important things to    |          | * |        |
|   | * | keep in mind about these benefits:   |          | * |        |
|   | I |                                      |          | I |        |
|   | * | -   Please remember that all         |          | * |        |
|   | * |     benefits are subject to the      |          | * |        |
|   |   |     definitions, limitations, and    |          |   |        |
|   | * |     exclusions in this brochure and  |          | * |        |
|   | * |     are payable only when we         |          | * |        |
|   | M |     determine they are medically     |          | M |        |
|   | * |     necessary.                       |          | * |        |
|   | * |                                      |          | * |        |
|   |   | -   Plan dentists must provide or    |          |   |        |
|   | * |     arrange your care.               |          | * |        |
|   | * |                                      |          | * |        |
|   | P | -   We have no calendar year         |          | P |        |
|   | * |     deductible.                      |          | * |        |
|   | * |                                      |          | * |        |
|   |   | -   We cover hospitalization for     |          |   |        |
|   | * |     dental procedures only when      |          | * |        |
|   | * |     prior authorized by our Medical  |          | * |        |
|   | O |     Director and a non-dental        |          | O |        |
|   | * |     physical impairment exists which |          | * |        |
|   | * |     makes hospitalization necessary  |          | * |        |
|   |   |     to safeguard the health of the   |          |   |        |
|   | * |     patient. See Section 5(c) for    |          | * |        |
|   | * |     inpatient hospital benefits. We  |          | * |        |
|   | R |     do not cover the dental          |          | R |        |
|   | * |     procedure unless it is described |          | * |        |
|   | * |     below.                           |          | * |        |
|   |   |                                      |          |   |        |
|   | * | -   Be sure to read Section 4, *Your |          | * |        |
|   | * |     costs for covered services*, for |          | * |        |
|   | T |     valuable information about how   |          | T |        |
|   | * |     cost sharing works. Also read    |          | * |        |
|   | * |     Section 9 about coordinating     |          | * |        |
|   |   |     benefits with other coverage,    |          |   |        |
|   | * |     including with Medicare.         |          | * |        |
|   | * |                                      |          | * |        |
|   | A |                                      |          | A |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   |   |                                      |          |   |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   | N |                                      |          | N |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   |   |                                      |          |   |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
|   | T |                                      |          | T |        |
|   | * |                                      |          | * |        |
|   | * |                                      |          | * |        |
+---+---+--------------------------------------+----------+---+--------+
| # |   |                                      | > **You  |   |        |
| # |   |                                      | > pay**  |   |        |
| # |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
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| t |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
+---+---+--------------------------------------+----------+---+--------+
| > |   |                                      | > \$15   |   |        |
|   |   |                                      | > per    |   |        |
| W |   |                                      | > office |   |        |
| e |   |                                      | > visit  |   |        |
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| . |   |                                      |          |   |        |
+---+---+--------------------------------------+----------+---+--------+
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
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| t |   |                                      |          |   |        |
| a |   |                                      |          |   |        |
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| s |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
| * |   |                                      |          |   |        |
+---+---+--------------------------------------+----------+---+--------+
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| W |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
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| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
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| t |   |                                      |          |   |        |
| a |   |                                      |          |   |        |
| l |   |                                      |          |   |        |
| > |   |                                      |          |   |        |
|   |   |                                      |          |   |        |
| b |   |                                      |          |   |        |
| e |   |                                      |          |   |        |
| n |   |                                      |          |   |        |
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| f |   |                                      |          |   |        |
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| t |   |                                      |          |   |        |
| s |   |                                      |          |   |        |
| . |   |                                      |          |   |        |
+---+---+--------------------------------------+----------+---+--------+

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

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

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

**Dental Source Dental Plan**

**URGENT NOTE TO MEMBERS CONSIDERING ENROLLINGIN THIS DENTALPLAN:**

**Before** you choose this non-FEHB Dental Benefit, please read our list
of participating dentists. To obtain a copy of the list of participating
dentists, call the Dental Member Services Department at (505) 237-1501.
Our dental network has a limited number of dentists. Our dental provider
list shows the number of dental providers we have and the county their
office is located in. The following is the list of the counties the
majority of our dentists are located in, including the percentage of our
participating dentists in each county.

#####  Percentage of our 

#####  participating

##### [County]{.underline} [dentists in each County]{.underline}

> Bernalillo County 62%
>
> El Paso County 17%
>
> Sandoval County 5%
>
> Santa Fe County 13%
>
> San Juan County 3%

Dental Source Dental Plan is a discount referral dental plan available
to Lovelace Health Systems, Inc. members enrolled through the FEHB
Program. Members select a personal dentist from a list of participating
dentists throughout the state of New Mexico.

**Dental Source Dental Plan** has no deductibles, no claim forms, no
waiting periods, no maximums, and no pre-existing exclusions. The plan
includes:

-   Preventive & diagnostic services

-   Restoratives/endontics/orthodontia

-   Save as much as 20% to 60% off many dental procedures

-   Simply pay the member fees listed on your schedule directly to the
    dental office

-   Select your dentist from a list of participating dentists

It is easy to enroll. Complete your enrollment/authorization form and
send it with the correct payment to Dental Source in the self addressed
return envelope. You may pay the entire annual premium by check, money
order, Master Card, Discover or Visa. Member \$48.88, Member plus one
dependent \$97.60, or family \$148.88.

Or you may select the monthly bank draft. Monthly premiums would be:
Member \$4.75; Member plus one \$8.68; Family \$13.25.

There are no limits on the number of visits or amount of dental care you
receive per year. For any requested dental office changes, or questions
you may have, you may call the Dental Member Services Department at
(505) 237-1501. If received before the 23^rd^ of the month, the transfer
will take effect the 1^st^ of the following month. You can also change
your provider office, address telephone number or request additional ID
cards on the internet by visiting their web page at
www.Dentalsource.com.

**Benefits on this page are not part of the FEHB contract*.***

+-----------------------------------------------------------------------+
| > 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 *What Services Require Our Prior Approval*
> on page 12.**
>
> We do not cover the following:

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

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

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

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

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

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

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

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

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

**Medical, hospital** In most cases, providers and facilities file
claims for you. Physicians

**and drug benefits** must file on the form HCFA-1500, Health Insurance
Claim Form. Facilities will file on the UB-92 form. For claims questions
and assistance, call us at (505 )262-7363 Albuquerque area or
1-800-808-7363 statewide.

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

-   Covered member's name and ID number;

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

-   Dates you received the services or supplies;

-   Diagnosis;

-   Type of each service or supply;

-   The charge for each service or supply;

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

-   Receipts, if you paid for your services.

> **Submit your claims to: Please refer to your ID card for the address
> to mail any claims.**

**Deadline for filing** Send us all of the documents for your claim as
soon as possible. You must

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

**When we need more** Please reply promptly when we ask for additional
information. We may

**information** delay processing or deny your claim if you do not
respond.

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

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

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

+----+-------------------------------------------+---------------------+
| ** | **Description**                           |                     |
| St |                                           |                     |
| ep |                                           |                     |
| ** |                                           |                     |
+----+-------------------------------------------+---------------------+
| *  | Ask us in writing to reconsider our       |                     |
| *1 | 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: Lovelace  |                     |
|    |     Health Plan, Altura Office Complex,   |                     |
|    |     4101 Indian School Road, NE,          |                     |
|    |     Albuquerque, NM 87110; and            |                     |
|    |                                           |                     |
|    | (c) Include a statement about why you     |                     |
|    |     believe our initial decision was      |                     |
|    |     wrong, based on specific benefit      |                     |
|    |     provisions in this brochure; and      |                     |
|    |                                           |                     |
|    | (d) Include copies of documents that      |                     |
|    |     support your claim, such as           |                     |
|    |     physicians\' letters, operative       |                     |
|    |     reports, bills, medical records, and  |                     |
|    |     explanation of benefits (EOB) forms.  |                     |
+----+-------------------------------------------+---------------------+
| *  | We have 30 days from the date we receive  |                     |
| *2 | 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.               |                     |
+----+-------------------------------------------+---------------------+
| *  | You or your provider must send the        |                     |
| *3 | 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.   |                     |
+----+-------------------------------------------+---------------------+
| *  | If you do not agree with our decision,    |                     |
| *4 | 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  |                     |
|    | Program, Health Insurance Group 3 1900 E  |                     |
|    | Street, NW, Washington, D.C. 20415-3630.  |                     |
+----+-------------------------------------------+---------------------+
|    | 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.                    |                     |
+----+-------------------------------------------+---------------------+
| *  |                                           |                     |
| *T |                                           |                     |
| he |                                           |                     |
| di |                                           |                     |
| sp |                                           |                     |
| ut |                                           |                     |
| ed |                                           |                     |
| cl |                                           |                     |
| ai |                                           |                     |
| ms |                                           |                     |
| p  |                                           |                     |
| ro |                                           |                     |
| ce |                                           |                     |
| ss |                                           |                     |
| (  |                                           |                     |
| co |                                           |                     |
| nt |                                           |                     |
| in |                                           |                     |
| ue |                                           |                     |
| d) |                                           |                     |
| ** |                                           |                     |
+----+-------------------------------------------+---------------------+
|    | 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       |                     |
| *5 | request and will use the 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 prior               |                     |
|    | authorization. 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 (505) 262-7363
    Albuquerque area or 1-800-808-7363 statewide 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

```{=html}
<!-- -->
```
-   You may call OPM\'s Health Insurance Group 3 at (202)-606-0737
    between 8 a.m. and 5 p.m. eastern time.

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

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

**When you have other health** You must tell us if you or a covered
family member have coverage

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

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

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

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

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

-   People 65 years of age and older.

-   Some people with disabilities, under 65 years of age.

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

Medicare has two parts:

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

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

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

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

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

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

> When you are enrolled in Original Medicare along with this plan, you
> still need to follow the rules in this brochure for us to cover your
> care. Your care must continue to be authorized by your Plan PCP, or
> recertified as required.

**We will not waive any of our copayments or coinsurance.**

-   **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. Please note, if your Plan
    physician does not participate in Medicare, you will have to file a
    claim with Medicare.

-   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

> (505 ) 262-7363 Albuquerque area or 1-800-808-7363 statewide. You may
> also visit our website at
> [www.Lovelacehealthplan.com](http://www.lovelace.com/) . In this case
> we do not waive any out-of-pocket costs.
>
> **We do not waive any costs if the Original Medicare Plan is your
> primary payer.**
>
> **(Primary payer chart begins on next page)**

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

+---------------------------------------------------+------+-----------+
| > **Primary Payer Chart**                         |      |           |
+---------------------------------------------------+------+-----------+
| **A. When you - or your covered spouse - are age  | *    |           |
| 65 or over and have Medicare and you...**         | *The |           |
|                                                   | pri  |           |
|                                                   | mary |           |
|                                                   | p    |           |
|                                                   | ayer |           |
|                                                   | for  |           |
|                                                   | the  |           |
|                                                   | in   |           |
|                                                   | divi |           |
|                                                   | dual |           |
|                                                   | with |           |
|                                                   | Medi |           |
|                                                   | care |           |
|                                                   | is.  |           |
|                                                   | ..** |           |
+---------------------------------------------------+------+-----------+
|                                                   | **Me | **This    |
|                                                   | dica | Plan**    |
|                                                   | re** |           |
+---------------------------------------------------+------+-----------+
| 1)  Are an active employee with the Federal       |      |          |
|     government and**...**                         |      |           |
|                                                   |      |           |
|     -   You have FEHB coverage on your own or     |      |           |
|         through your spouse who is also an active |      |           |
|         employee                                  |      |           |
+---------------------------------------------------+------+-----------+
| -   You have FEHB coverage through your spouse    |     |           |
|     who is an annuitant                           |      |           |
+---------------------------------------------------+------+-----------+
| 2)  Are an annuitant and**...**                   |     |           |
|                                                   |      |           |
|     -   You have FEHB coverage on your own or     |      |           |
|         through your spouse who is also an        |      |           |
|         annuitant                                 |      |           |
+---------------------------------------------------+------+-----------+
| -   You have FEHB coverage through your spouse    |      | >        |
|     who is an active employee                     |      |           |
+---------------------------------------------------+------+-----------+
| 3)  Are a reemployed annuitant with the Federal   | \*  |           |
|     government and your position is excluded from |      |           |
|     the FEHB (your employing office will know if  |      |           |
|     this is the case)                             |      |           |
+---------------------------------------------------+------+-----------+
| 4)  Are a reemployed annuitant with the Federal   |      | >        |
|     government and your position is not excluded  |      |           |
|     from the FEHB (your employing office will     |      |           |
|     know if this is the case) and**...**          |      |           |
|                                                   |      |           |
|     -   You have FEHB coverage on your own or     |      |           |
|         through your spouse who is also an active |      |           |
|         employee                                  |      |           |
+---------------------------------------------------+------+-----------+
| -   You have FEHB coverage through your spouse    |     |           |
|     who is an annuitant                           |      |           |
+---------------------------------------------------+------+-----------+
| 5)  Are a Federal judge who retired under title   | ##   |           |
|     28, U.S.C., or a Tax Court judge who retired  | #### |           |
|     under Section 7447 of title 26, U.S.C. (or if |  \* |           |
|     your covered spouse is this type of judge)    |      |           |
+---------------------------------------------------+------+-----------+
| 6)  Are enrolled in Part B only, regardless of    |     |  for     |
|     your employment status                        | for  | other     |
|                                                   | Part | services  |
|                                                   | B    |           |
|                                                   | serv |           |
|                                                   | ices |           |
+---------------------------------------------------+------+-----------+
| 7)  Are a former Federal employee receiving       |     |           |
|     Workers' Compensation and the Office of       | \*\* |           |
|     Workers' Compensation Programs has determined |      |           |
|     that you are unable to return to duty)        |      |           |
+---------------------------------------------------+------+-----------+

+---------------------------------------------------+------+-----------+
| **B. When you or a covered family member...**     |      |           |
+---------------------------------------------------+------+-----------+
| ###### Have Medicare solely b                     |      |          |
| ased on end stage renal disease (ESRD) and**...** |      |           |
|                                                   |      |           |
| ###### It is within the first                     |      |           |
| 30 months of eligibility for or entitlement to Me |      |           |
| dicare due to ESRD (30-month coordination period) |      |           |
+---------------------------------------------------+------+-----------+
| -   It is beyond the 30-month coordination period |     |           |
|     and you or a family member are still entitled |      |           |
|     to Medicare due to ESRD                       |      |           |
+---------------------------------------------------+------+-----------+
| 1)  Become eligible for Medicare due to ESRD      |      | for      |
|     while already a Medicare beneficiary          |      | 30-month  |
|     and**...**                                    |      | coo       |
|                                                   |      | rdination |
| -   This Plan was the primary payer before        |      | period    |
|     eligibility due to ESRD                       |      |           |
+---------------------------------------------------+------+-----------+
| -   Medicare was the primary payer before         |     |           |
|     eligibility due to ESRD                       |      |           |
+---------------------------------------------------+------+-----------+
| **C. When either you or your spouse are eligible  |      |           |
| for Medicare solely due to disability and you**   |      |           |
+---------------------------------------------------+------+-----------+
| 1)  Are an active employee with the Federal       |      |          |
|     government and**...**                         |      |           |
|                                                   |      |           |
|     -   You have FEHB coverage on your own or     |      |           |
|         through your spouse who is also an active |      |           |
|         employee                                  |      |           |
+---------------------------------------------------+------+-----------+
| -   You have FEHB coverage through your spouse    |     |           |
|     who is an annuitant                           |      |           |
+---------------------------------------------------+------+-----------+
| 2)  Are an annuitant and**...**                   |     | []{.mark} |
|                                                   |      |           |
|     -   You have FEHB coverage on your own or     |      |           |
|         through your spouse who is also an        |      |           |
|         annuitant                                 |      |           |
+---------------------------------------------------+------+-----------+
| -   You have FEHB coverage through your spouse    |      |          |
|     who is an active employee                     |      |           |
+---------------------------------------------------+------+-----------+
| **D. Are covered under the FEHB Spouse Equity     |     |           |
| provision as a former spouse**                    |      |           |
+---------------------------------------------------+------+-----------+

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

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

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

> If you enroll in a Medicare managed care plan, the following options
> are available to you:

**This Plan and our Medicare + Choice plan:** You may enroll in our
Medicare + Choice plan and also remain enrolled in our FEHB plan. In
this case, we do not waive any of our copayments, coinsurance, or
deductibles for your FEHB coverage.

**This Plan and another plan's Medicare + Choice plan:** You may enroll
in another plan's Medicare + Choice plan and also remain enrolled in our
FEHB plan. We will still provide benefits when your Medicare + Choice
plan is primary, even out of the managed care plan's network and/or
service area (if you use our Plan providers), but we will not waive any
of our copayments, coinsurance, or deductibles. If you enroll in a
Medicare + Choice plan, tell us. We will need to know whether you are in
the Original Medicare Plan or in a Medicare + Choice plan so we can
correctly coordinate benefits with Medicare.

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

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

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

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

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

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

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

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

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

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

**care**

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

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

**If you do not seek damages you must agree to let us try. This is
called subrogation. If you need more information, contact us for our
subrogation procedures.**

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

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

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

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care. See page 13.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 13.

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

**Custodial care** Custodial care is care you receive when you need help
performing activities of daily living \-- such as walking, grooming,
bathing, dressing, getting in an out of bed, toileting, eating,
preparing foods, or taking medications that can usually be
self-administered. Custodial care that lasts 90 days or more is
sometimes known as Long Term Care. We do not cover 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. We have no deductible.

+-------------------------+--------------------------------------------+
| **Experimental or       | Experimental, investigational and unproven |
| investigational         | services are medical, surgical,            |
| services**              | diagnostic, psychiatric, substance abuse   |
|                         | or other health care technologies,         |
|                         | supplies, treatments, procedures, drug     |
|                         | therapies or devices that are determined   |
|                         | by the Medical Director to be:             |
+-------------------------+--------------------------------------------+
|                         | -   not approved by the U.S. Food and Drug |
|                         |     Administration (FDA) to be lawfully    |
|                         |     marketed for the proposed use and not  |
|                         |     recognized for the treatment of the    |
|                         |     particular indication in one of the    |
|                         |     standard reference compendia (The      |
|                         |     United States Pharmacopoeia Drug       |
|                         |     Information, The American Medical      |
|                         |     Association Drug Evaluations; or the   |
|                         |     American Hospital Formulary Service    |
|                         |     Drug Information) or in medical        |
|                         |     literature. Medical literature means   |
|                         |     scientific studies published in a      |
|                         |     peer-reviewed national professional    |
|                         |     medical journal;                       |
+-------------------------+--------------------------------------------+
|                         | -   the subject of review or approval by   |
|                         |     an Institutional Review Board for the  |
|                         |     proposed use;                          |
+-------------------------+--------------------------------------------+
|                         | -   the subject of an ongoing clinical     |
|                         |     trial that meets the definition of a   |
|                         |     phase I, II or III Clinical Trial as   |
|                         |     set forth in the FDA regulations,      |
|                         |     regardless of whether the trial is     |
|                         |     subject to FDA oversight; or           |
+-------------------------+--------------------------------------------+
|                         | -   not demonstrated, through existing     |
|                         |     peer-reviewed literature to be safe    |
|                         |     and effective for treating or          |
|                         |     diagnosing the condition or illness    |
|                         |     for which its use is proposed.         |
+-------------------------+--------------------------------------------+

**Medical necessity** Medically necessary covered Service and Supplies
are those Service and

> Supplies that are determined by our Medical Director to be:

-   No more than required to meet your basic health needs; and

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-   consistent with the diagnosis of the condition for which they are
    required; and

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-   consistent in type, frequency and duration of treatment with
    scientifically based guidelines as determined by medical research;
    and

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-   required for purposes other than the comfort and convenience of the
    patient or his Physician; and

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-   rendered in the least intensive setting that is appropriate for the
    delivery of health care; and

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-   of demonstrated medical value.

**Us/We** Us and we refer to Lovelace Health Systems, Inc.

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

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

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

**Coverage information**

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

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

**Where you can get** See
[www.opm.gov/insure](http://www.opm.gov/insure). Also, your employing or
retirement office

**Information** can answer your questions, and give you *a* *Guide to
Federal Employees*

**about enrolling in the** *Health Benefits Plans,* brochures for other
plans, and other materials you

**FEHB Program** need to make an informed decision about your FEHB
coverage. These materials tell you:

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

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

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

**available for you** you, your spouse, and your 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 health benefits, nor will
we. Please tell us immediately when you add or remove family members
from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.

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

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

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

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

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

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

> As long as the court/administrative order is in effect, and you have
> at least one child identified in the order who is still eligible under
> the FEHB Program, you cannot cancel your enrollment, change to Self
> Only, or change to a plan that doesn\'t serve the area in which your
> children live, unless you provide documentation that you have other
> coverage for the children. If the court/administrative order is still
> in effect when you retire, and you have at least one child still
> eligible for FEHB coverage, you must continue your FEHB coverage into
> retirement (if eligible) and cannot cancel your coverage, change to
> Self Only, or change to a plan that doesn't serve the area in which
> your children live as long as the court/administrative order is in
> effect. Contact your employing office for further information.
>
> **When benefits and** The benefits in this brochure are effective on
> January 1. If you joined this
>
> **premiums start** Plan during Open Season, your coverage begins on
> the first day of your first pay period that starts on or after
> January 1. If you changed plans or plan options during Open Season and
> you receive care between January 1 and the effective date of coverage
> under your new plan or option, your claims will be paid according to
> the 2004 benefits of your old plan or option. However, if your old
> plan left the FEHB Program at the end of the year, you are covered
> under that plan's 2003 benefits until the effective date of your
> coverage with your new plan. Annuitants\' coverage and premiums begin
> on January 1. If you joined at any other time during the year, your
> employing office will tell you the effective date of coverage.
>
> **When you retire** When you retire, you can usually stay in the FEHB
> Program. Generally, you must have been enrolled in the FEHB Program
> for the last five years of your Federal service. If you do not meet
> this requirement, you may be eligible for other forms of coverage,
> such as Temporary Continuation of Coverage (TCC), or a conversion
> policy (a non-FEHB individual policy).

**When you lose benefits**

> **• When FEHB coverage ends** You will receive an additional 31 days
> of coverage, for no additional premium, when:
>
> Your enrollment ends, unless you cancel your enrollment, or
>
> You are a family member no longer eligible for coverage.

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

> **• Spouse equity** If you are divorced from a Federal employee or
> annuitant, you may not continue
>
> **coverage** to get benefits under your former spouse's enrollment.
> This is the case even when the court has ordered your former spouse to
> supply health coverage to you. But, you may be eligible for your own
> FEHB coverage under the spouse equity law or Temporary Continuation of
> Coverage (TCC). If you are recently divorced or are anticipating a
> divorce, contact your ex-spouse's employing or retirement office to
> get RI 70-5, the *Guide to Federal Employees Health Benefits Plans for
> Temporary Continuation of Coverage and Former Spouse Enrollees*, or
> other information about your coverage choices. You can also download
> the guide from OPM's website, www.opm.gov/insure.
>
> **• Temporary continuation** If you leave Federal service, or if you
> lose coverage because you no longer
>
> **of coverage (TCC)** qualify as a family member, you may be eligible
> for Temporary Continuation of Coverage (TCC). For example, you can
> receive TCC if you are not able to continue your FEHB enrollment after
> you retire, if you lose your job, if you are a covered dependent child
> and you turn 22 or marry, etc.

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

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

> **• Converting to** You may convert to a non-FEHB individual policy
> if:
>
> **individual coverage ** Your coverage under TCC or the spouse equity
> law ends (If you canceled your coverage or did not pay your premium,
> you cannot convert);
>
>  You decided not to receive coverage under TCC or the spouse equity
> law; or
>
>  You are not eligible for coverage under TCC or the spouse equity
> law.

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

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

**• Getting a Certificate of** The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) is a

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

> you can choose to participate in either, or both, of the flexible
> spending accounts. If you
>
> are not eligible for FEHB, you are not eligible to enroll for a Health
> Care FSA. However, almost all Federal employees are eligible to enroll
> for the Dependent Care FSA. The only exception is intermittent (also
> called when actually employed \[WAE\]) employees expected to work less
> than 180 days during the year.
>
> *Note:* FSAFEDS is the FSA Program established for all Executive
> Branch employees and Legislative Branch employees whose employers
> signed on. Under IRS law, FSAs are not available to annuitants. In
> addition, the U.S. Postal Service and the Judicial Branch, among
> others, are Federal agencies that have their own plans with slightly
> different rules, but the advantages of having an FSA are the same no
> matter what agency you work for.
>
> **How much should I** Plan carefully when deciding how much to
> contribute to an FSA. Because of the tax
>
> **contribute to my FSA?** benefits of an FSA, the IRS places strict
> guidelines on them. You need to estimate how
>
> much you want to allocate to an FSA because current IRS regulations
> require you forfeit any funds remaining in your account(s) at the end
> of the FSA plan year. This is referred to as the "use-it-or-lose-it"
> rule. You will have until April 29, 2004 to submit claims for your
> eligible expenses incurred during 2003 if you enrolled in FSAFEDS when
> it was initially offered. You will have until April 30, 2005 to submit
> claims for your eligible expenses incurred from January 1 through
> December 31, 2004 if you elect FSAFEDS during this Open Season.
>
> The **FSAFEDS Calculator** at
> [www.fsafeds.com](http://www.fsafeds.com/) will help you plan your FSA
> allocations and provide an estimate of your tax savings based on your
> individual situation.

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

> you and the Plan share costs, and medical services and supplies that
> are not covered by the Plan and for which you must pay. These
> out-of-pocket costs are summarized on page XX and detailed throughout
> this brochure. Your HCFSA will reimburse you for such costs when they
> are for tax deductible medical care for you and your dependents that
> is NOT covered by this FEHB Plan or any other coverage that you have.
>
> Under this Plan, typical out-of-pocket expenses include office visit
> copays, prescription drug copays and emergency care copays. Common but
> significant expenses not covered by the plan include glasses, laser
> vision surgery and hearing aids.\]
>
> The IRS governs expenses reimbursable by a HCFSA. See Publication 502
> for a comprehensive list of tax-deductible medical expenses.  **Note:
> While you will see insurance premiums listed in Publication 502, they
> are NOT a reimbursable expense for FSA purposes**.  Publication 502
> can be found on the IRS Web site at
> <http://www.irs.gov/pub/irs-pdf/p502.pdf>.  If you do not see your
> service or expense listed in Publication 502, please call a FSAFEDS
> Benefit Counselor at 1-877-FSAFEDS (372-3337), who will be able to
> answer your specific questions.
>
> **Tax savings with an FSA** An FSA lets you allot money for eligible
> expenses ***before*** your agency deducts taxes
>
> from your paycheck. This means the amount of income that your taxes
> are based on will be lower, so your tax liability will also be lower.
> Without an FSA, you would still pay for these expenses, but you would
> do so using money remaining in your paycheck after Federal (and often
> state and local) taxes are deducted. The following chart illustrates a
> typical tax savings example:

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

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

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

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

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

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

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

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

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

-   **Tax credits and** You *cannot* claim expenses on your Federal
    income tax return if you receive

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

> may help you decide whether to participate in FSAFEDS.

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

> the HCFSA at any time during the year for expenses up to the annual
> amount you\'ve
>
> elected to contribute.
>
> Only health care expenses exceeding 7.5% of your adjusted gross income
> are eligible to be deducted on your Federal income tax return. Using
> the example listed in the above chart, only health care expenses
> exceeding \$3,750 (7.5% of \$50,000) would be eligible to be deducted
> on your Federal income tax return. In addition, money set aside
> through a HCFSA is also exempt from FICA taxes. This exception is not
> available on your Federal income tax return.
>
> **Dependent care expenses** The DCFSA generally allows many families
> to save more than they would with the
>
> Federal tax credit for dependent care expenses. Note that you may only
> be reimbursed from the DCFSA up to your current account balance. If
> you file a claim for more than your current balance, it will be held
> until additional payroll allotments have been added to your account.
>
> Visit [www.fsafeds.com](http://www.fsafeds.com/) and download the
> Dependent Care Tax Credit Worksheet from the Quick Links box to help
> you determine what is best for your situation. You may also wish to
> consult a tax professional for more details.

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

> **to participate in FSAFEDS?** and 1.5% of the annual election for a
> DCFSA, most agencies have elected to pay these fees out of their share
> of employment tax savings. To be sure, check the FSAFEDS.com web site
> or call 1-877-FSAFEDS (372-3337). Also, remember that participating in
> FSAFEDS can cost you money if you don't spend your entire account
> balance by the end of the plan year and wind up forfeiting your end of
> year account balance, per the IRS "use-it-or-lose-it" rule.
>
> **Contact us To** find out more or to enroll, please visit the
> **FSAFEDS Web site** at
>
> [**www.fsafeds.com**](http://www.fsafeds.com/), or contact SHPS by
> email or by phone**.** SHPS Benefit Counselors are available from 9:00
> a.m. until 9:00 p.m. eastern time, Monday through Friday.

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

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

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

**The Federal Long Term Care Insurance Program**

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

Program:

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

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

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

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

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

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

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

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

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

**A**ccidental injury 36

Allergy tests 18

Alternative treatment 21

Allogenetic (donor) bone

marrow transplant 25

Ambulance 28

Anesthesia 25

Autologous bone marrow transplant 25

**B**iopsies 23

Blood and blood plasma 26

Breast cancer screening 16

Casts 26

Catastrophic protection out-of-pocket maximum 13

Changes for 2004 9

Chemotherapy 18

Chiropractic 21

Cholesterol tests 16

Claims 39

Coinsurance 13

Colorectal cancer screening 16

Contraceptive devices and drugs 17

Coordination of benefits 42

Covered charges 48

Covered providers 10

Crutches 20

**D**eductible 13

Definitions 48

Dental care 36

Diagnostic services 15

Disputed claims review 40

Donor expenses (transplants) 25

Dressings 27

Durable medical equipment (DME) 20

**E**ducational classes and

programs 22

Effective date of enrollment 50

Emergency 29

Experimental or investigational 48

Eyeglasses 19

**F**amily planning 17

Fecal occult blood test 16

**G**eneral Exclusions 38

**H**earing services 19

Home health services 21

Hospice care 28

Home nursing care 21

Hospital 26

**I**mmunizations 16

Infertility 17

Inhospital physician care 15

Inpatient Hospital Benefits 26

Insulin 34

**L**aboratory and pathological services 27

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

Mail Order Prescription Drugs 34

Mammograms 16

Maternity Benefits 17

Medicaid 47

Medically necessary 48

Medicare 42

Mental Conditions/Substance Abuse Benefits 31

Newborn care 17

Non-FEHB Benefits 37

Nurse

Licensed Practical Nurse 21

Registered Nurse 21, 35

Nursery charges 17

**O**bstetrical care 17

Occupational therapy 18

Office visits 15

Oral and maxillofacial surgery 24

Orthopedic devices 20

Ostomy and catheter supplies 21

Out-of-pocket expenses 13

Outpatient facility care 27

Oxygen 26, 27

**P**ap test 16

Physical examination............ 16

Physical therapy 18

Physician 15

Pre-admission testing 27

Prescription drugs 33

Preventive care, adult 16

Preventive care, children 16

Preventive services 16

Prior approval 12

Prior authorization 12

Prostate cancer screening 16

Prosthetic devices 20

Psychologist 31

Psychotherapy 31

**R**adiation therapy 18

Renal dialysis 18

Room and board 26

**S**econd surgical opinion 15

Skilled nursing facility care 27

Smoking cessation 34

Speech therapy 19

Splints 26

Sterilization procedures 17

Subrogation 47

Substance abuse 31

Surgery 23

-   Anesthesia 25

```{=html}
<!-- -->
```
-   Oral 24

-   Outpatient 27

-   Reconstructive 24

    Syringes 34

    **T**emporary continuation of coverage 51

    Transplants 25

Treatment therapies 18

**V**ision services 19

**W**ell child care 16

Wheelchairs 20

Workers' compensation 47

**X**-rays 15

  -----------------------------------------------------------------------
  **Summary of benefits for Lovelace Health Systems, Inc. - 2004**

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

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

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

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

+-------------------------------------+--------------------------+-----+
| **Benefits**                        | You Pay                  | **  |
|                                     |                          | Pag |
|                                     |                          | e** |
+=====================================+==========================+=====+
| Medical services provided by        | Office visit: \$15       | >   |
| physicians:                         | primary care;            |  15 |
|                                     |                          |     |
| -   Diagnostic and treatment        | \$25 specialist care     |     |
|     services provided in the office |                          |     |
+-------------------------------------+--------------------------+-----+
| Services provided by a hospital:    | \$250 per admission      | >   |
|                                     |                          |  26 |
| -   Inpatient                       | \$125 per facility use   | >   |
|                                     |                          | >   |
| -   Outpatient                      |                          |  27 |
+-------------------------------------+--------------------------+-----+
| Emergency benefits:                 | \$15 per office visit;   | >   |
|                                     | \$25 per urgent care     |  29 |
| -   In-area                         | visit copay; \$50 per    | >   |
|                                     | hospital emergency care  | >   |
| -   Out-of-area                     | visit copay              |  29 |
+-------------------------------------+--------------------------+-----+
| > Mental health and substance abuse | Regular cost sharing.    | >   |
| > treatment                         |                          |  31 |
+-------------------------------------+--------------------------+-----+
| Prescription drugs                  | **[Retail                | >   |
|                                     | Pharmacy]{.underline}**  |  33 |
|                                     |                          |     |
|                                     | \$7 per generic          |     |
|                                     | formulary; \$15 per name |     |
|                                     | brand formulary; \$35    |     |
|                                     | per name brand           |     |
|                                     | non-formulary.           |     |
|                                     |                          |     |
|                                     | **[Mail                  |     |
|                                     | Order]{.underline}**     |     |
|                                     |                          |     |
|                                     | **(Maintenance           |     |
|                                     | medications only)**      |     |
|                                     |                          |     |
|                                     | \$16 per generic         |     |
|                                     | formulary; \$40 per name |     |
|                                     | brand formulary drug;    |     |
|                                     | \$100 per name brand     |     |
|                                     | non-formulary.           |     |
|                                     |                          |     |
|                                     | Note: If there is no     |     |
|                                     | generic equivalent       |     |
|                                     | available, you will      |     |
|                                     | still have to pay the    |     |
|                                     | name brand copay.        |     |
+-------------------------------------+--------------------------+-----+
| Dental Care (Accidental dental      | \$15 office visit copay  | >   |
| injury only)                        |                          |  36 |
+-------------------------------------+--------------------------+-----+
| Vision Care                         | Eye exam, including      | >   |
|                                     | refractions every 24     |  19 |
|                                     | months; Office visit:    |     |
|                                     | \$15 primary care; \$25  |     |
|                                     | specialist care.         |     |
|                                     |                          |     |
|                                     | One pair of eyeglasses   |     |
|                                     | or one set of contact    |     |
|                                     | lenses every 24 months,  |     |
|                                     | subject to the following |     |
|                                     | maximum Plan payment     |     |
|                                     | every two years:         |     |
|                                     |                          |     |
|                                     | Single lenses-\$20;      |     |
|                                     | Bifocal lenses-\$30;     |     |
|                                     | Trifocal lenses-\$40;    |     |
|                                     | Contact lenses-\$75;     |     |
|                                     | Frames-\$30. You pay the |     |
|                                     | difference above amount  |     |
|                                     | shown for lenses and     |     |
|                                     | more costly frames.      |     |
+-------------------------------------+--------------------------+-----+
| > Special features: Flexible        |                          | >   |
| > benefits option; 24 hour nurse    |                          |  35 |
| > line; Services for deaf and       |                          |     |
| > hearing impaired; ; Centers of    |                          |     |
| > Excellence; Travel                |                          |     |
| > benefit/services overseas         |                          |     |
+-------------------------------------+--------------------------+-----+
| Protection against catastrophic     | Nothing after            | >   |
| costs                               | \$1,500/Self Only or     |  13 |
|                                     | \$3,000/Family           |     |
| (your catastrophic protection       | enrollment per year.     |     |
| out-of-pocket maximum)              | This copay maximum does  |     |
|                                     | not include Prescription |     |
|                                     | Drugs, Dental services,  |     |
|                                     | Mental Health/Substance  |     |
|                                     | Abuse services, External |     |
|                                     | Prosthetics or           |     |
|                                     | Infertility services.    |     |
+-------------------------------------+--------------------------+-----+

**2004 Rate Information for**

**Lovelace Health Systems, Inc.**

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

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

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

<table style="width:100%;">
<colgroup>
<col style="width: 22%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><strong>Non-Postal Premium</strong></td>
<td colspan="4"><strong>Postal Premium</strong></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"><strong>Biweekly</strong></td>
<td colspan="3"><strong>Monthly</strong></td>
<td colspan="4"><strong>Biweekly</strong></td>
</tr>
<tr class="odd">
<td colspan="2"><p><strong>Type of</strong></p>
<p><strong>Enrollment</strong></p></td>
<td colspan="2"><strong>Code</strong></td>
<td colspan="2"><p><strong>Gov’t</strong></p>
<p><strong>Share</strong></p></td>
<td><p><strong>Your</strong></p>
<p><strong>Share</strong></p></td>
<td colspan="2"><p><strong>Gov’t</strong></p>
<p><strong>Share</strong></p></td>
<td><p><strong>Your</strong></p>
<p><strong>Share</strong></p></td>
<td colspan="3"><p><strong>USPS</strong></p>
<p><strong>Share</strong></p></td>
<td><p><strong>Your</strong></p>
<p><strong>Share</strong></p></td>
</tr>
<tr class="even">
<td colspan="4"><strong>The State of New Mexico</strong></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Self Only</strong></td>
<td colspan="2"><strong>Q11</strong></td>
<td colspan="2"><strong>$115.43</strong></td>
<td colspan="2">$38.48</td>
<td><strong>$250.10</strong></td>
<td colspan="3"><strong>$83.37</strong></td>
<td><strong>$136.60</strong></td>
<td colspan="2"><strong>$17.31</strong></td>
</tr>
<tr class="even">
<td><strong>Self and Family</strong></td>
<td colspan="2"><strong>Q12</strong></td>
<td colspan="2"><strong>$277.09</strong></td>
<td colspan="2"><strong>$100.60</strong></td>
<td><strong>$600.36</strong></td>
<td colspan="3"><strong>$217.97</strong></td>
<td><strong>$327.12</strong></td>
<td colspan="2"><strong>$50.57</strong></td>
</tr>
</tbody>
</table>