![](media/image1.png){width="0.80625in" height="0.7875in"} **Heart of
America HMO**

**2004**

**A Health Maintenance Organization**

**Serving: North Central North Dakota**

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

**Enrollment codes for this Plan:**

**RU1 Self Only**

**RU2 Self and Family**

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height="0.8347222222222223in"}

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**RI 73-543**

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Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

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

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**Notice of the Office of Personnel Management\'s**

 

**Privacy Practices**

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND

######### DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW IT

CAREFULLY.

 

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

 

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

 

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

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

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

-   Where required by law.

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

 

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

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

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

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

 

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

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

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

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

 

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

 

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

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

-   Get a listing of those getting your personal medical information
    from OPM in the past 6 years.  The listing will not cover your
    personal medical information that was given to you or your personal
    representative, and 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
may also call 202-606-0191 and ask for OPM\'s FEHB Program privacy 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 notice by
mail within 60 days of the change.  The privacy practices listed in this
notice are effective April 14, 2003.

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  Table of Contents
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Introduction 4

Plain Language 4

Stop Health Care Fraud 4

Preventing medical mistakes 5

Section 1. Facts about this HMO plan 7

How we pay providers 7

Your Rights 7

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 10

• Specialty care 10

• 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...............................................................................24

(c) Services provided by a hospital or other facility, and ambulance
    services 27

(d) Emergency services/accidents 29

(e) Mental health and substance abuse benefits 31

(f) Prescription drug benefits 33

(g) Dental benefits 35

Section 6. General exclusions \-- things we don\'t cover 36

Section 7. Filing a claim for covered services 37

Section 8. The disputed claims process 38

Section 9. Coordinating benefits with other coverage 40

When you have other health coverage 40

> • What is Medicare? 40

-   Should I enroll in Medicare? 40

• Medicare + Choice 43

> • TRICARE/and CHAMPVA 43
>
> • Worker's Compensation 44
>
> • Medicaid 44
>
> • Other Government agencies 44
>
> • When others are responsible for injuries 44

Section 10. Definitions of terms we use in this brochure 45

Section 11. FEHB facts 47

Coverage information 47

• No pre-existing condition limitation 47

• Where you get information about enrolling in the FEHB Program 47

• Types of coverage available for you and your family 47

Children's Equity Act 48

• When benefits and premiums start 49

• When you retire 49

When you lose benefits 49

• When FEHB coverage ends 49

• Spouse equity coverage 49

• Temporary Continuation of Coverage (TCC) 49

• Converting to individual coverage 50

• Getting a Certificate of Group Health Plan Coverage 50

Two new Federal Programs complement FEHB benefits 51

The Federal Flexible Spending Account Program -- FSAFEDS 51 The Federal
Long Term Care Insurance Program 54

Index 56

Summary of benefits 57

Rates 58

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  Introduction

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This brochure describes the benefits of Heart of America HMO under our
contract (CS 2606) with the Office of Personnel Management, as
authorized by the Federal Employees Health Benefits law. The address for
Heart of America HMO administrative office is:

Heart of America HMO

810 South Main

Rugby, ND 58368

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 for 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 are summarized on page 9.
Rates are shown at the end of this brochure.

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  Plain Language

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

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

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

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

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

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  Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at 776-5848 or
    1-800-525-5661 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 Inspector General Fraud Hotline
>
> 1900 E. Street NW, Room 6400
>
> Washington DC, 20415

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

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

-   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 or with OPM if
    you are retired.

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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 FEHBP benefits or try
    to obtain services for someone who is not an eligible family member
    or who is no longer enrolled in the Plan.

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  Preventing Medical Mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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

    Want more information on patient safety?

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

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

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

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

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

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

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

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

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

When you receive services from Plan providers, you will not have to
submit claim forms or pay bills. You only pay the copayments,
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.

**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) lists the
specific types of information that we must make available to you. Some
of the required information is listed below.

-   We are Federally qualified

-   We have been in existence for 21 Years

-   We are a non-profit organization

If you want more information about us, call 701-776-5848 or
1-800-525-5661, or write to Heart of America HMO, 810 South Main. You
may also contact us by fax at 701-776-5425.

**Service Area**

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

All of Pierce, Rolette, Bottineau, McHenry, Towner, Ward, and Renville
counties in North Dakota and the portions of Benson, Wells, Sheridan,
McLean, Mountrail, and Burke Counties represented by the following zip
codes:

58310 58339 58365 58450 58718 58740 58762 58782

58313 58341 58366 58451 58754 58741 58763 58783

58316 58343 58367 58540 58722 58744 58768 58784

58317 58346 58368 58701 58723 58746 58769 58785

58318 58348 58369 58705 58725 58747 58770 58787

58320 58353 58384 58704 58731 58750 58772 58789

58324 58356 58385 58705 58733 58752 58773 58790

58325 58357 58386 58710 58734 58756 58775 58792

58329 58359 58418 58711 58735 58758 58776 58793

58331 58360 58422 58712 58736 58759 58778

58332 58362 58423 58713 58737 58760 58779

58337 58363 58438 58716 58739 58761 58781

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. 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.

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program - *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 51.

-   We added information regarding Preventing medical mistakes. See page
    5.

-   We added information regarding enrolling in Medicare. See page 40.

-   We revised the Medicare Primary Payer Chart. See page 42.

**Changes to this plan**

-   Your share of the non-Postal premium will increase by 1.5 % for Self
    Only or 5.6 % for Self and Family.

-   The maximum coinsurance for authorized services received from a
    non-plan specialist will increase from \$1000 to \$3000 per year.

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  Section 3. How you get care
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**Identification cards** We will send you an identification (ID) card
when you enroll. You should carry your ID card with you at all times.
You must show it whenever you receive services from a Plan provider, or
fill a prescription at a 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
701-776-5848.

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

• **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 list Plan providers in the provider directory, which we update
periodically. All doctors of the Johnson Clinic Professional Corporation
and Trinity Medical Group and affiliated clinics are available to HAHMO
members. The doctors of the Johnson Clinic, P.C. are available to
provide health care from offices located in Leeds, Towner, Maddock,
Dunseith and Rugby, North Dakota. The doctors of the Trinity Medical
Group are available to provide health care from offices located in
Minot, Garrison, Mohall, Velva, Newtown, Kenmare, Parshall and Westhope,
North Dakota. Your plan doctor will coordinate your health care needs
including referrals to specialists when necessary. Services of
specialists other than Johnson Clinic and Trinity Medical Group primary
care doctors are covered only when there has been a referral by the
member's primary care doctor with the following exception: a woman may
see her plan gynecologist for an annual routine examination without a
referral.

• **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.

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

**to get 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. Provider directories are
available at the time of enrollment or upon request by calling the Heart
of America HMO office at 701-776-5848 or 1-800-525-5661.

• **Primary care** Your primary care physician can be a family
practitioner, internist, pediatrician or an OB-GYN. 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, a woman may see her plan gynecologist for her
annual routine examination without a referral.

Here are other things you should know about specialty care:

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

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

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

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

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

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

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

• **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 701-776-5848 or
1-800-525-5661. If you are new to the FEHB Program, we will arrange for
you to receive care.

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

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

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

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

These provisions apply only to the hospital benefit of the hospitalized
person; we cover your other non-hospital care.

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

**Services requiring prior approval** Your physician must get our
approval before sending you to a hospital, referring you to a
specialist, or recommending follow-up care. Before giving approval, we
consider if the service is medically necessary, and if it follows
generally accepted medical practice.

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  Section 4. Your costs for covered services
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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 when you receive services.

Example: When you see your primary care physician you pay a copayment of
\$10 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 those services. Copayments do not count toward any deductible.

We have a \$600 per member calendar year deductible for prescription
drugs.

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

Example: In our Plan, you pay 20% of charges up to a maximum coinsurance
of \$500 per year for prosthetic devices that exceed \$25

**Your catastrophic protection**

**out-of-pocket maximum**

**for deductibles, coinsurance,**

**and copayments** The copayment and coinsurance maximum is 50% of your
annual premium per calendar year for services rendered by in network
providers. When the copayment and coinsurance maximum applicable to your
contract has been fulfilled, copayment and coinsurance will no longer be
applied to the following services:

-   Emergency room services

-   Outpatient hospital services

-   Inpatient hospital services

-   Outpatient mental health services

-   Outpatient chemical dependency services

-   Inpatient mental health services

-   Inpatient chemical dependency services

-   Durable equipment and prosthetic devices

-   Referral services provided by participating providers

+-----------------------------------------------------------------------+
| **Section 5. Benefits -- OVERVIEW**                                   |
|                                                                       |
| ***(See page*** ***9*** ***for how our benefits changed this year and |
| page 52 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 claims forms,
claims filing advice, or more information about our benefits, contact us
at 701-776-5848 or at 1-800-525-5661.

a.  Medical services and supplies provided by physicians and other
    health care professionals 15-23

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

b.  Surgical and anesthesia services provided by physicians and other
    health care professionals 24-26

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

(c) Services provided by a hospital or other facility, and ambulance
    services 27-28

+---------------------------------+------------------------------------+
| •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) Dental benefits 35

Summary of benefits 57

+---+---+-------------------------------------+----------------+---+----+
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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 are payable only when  |                | * |    |
|   | M | we determine they are medically     |                | M |    |
|   | * | necessary.                          |                | * |    |
|   | * |                                     |                | * |    |
|   |   |  Plan physicians must provide or   |                |   |    |
|   | * | arrange your care.                  |                | * |    |
|   | * |                                     |                | * |    |
|   | P | >  Be sure to read Section 4,      |                | P |    |
|   | * | > *Your costs for covered service,* |                | * |    |
|   | * | > for valuable information about    |                | * |    |
|   |   | > how cost sharing works. Also read |                |   |    |
|   | * | > Section 9 about coordinating      |                | * |    |
|   | * | > benefits with other coverage,     |                | * |    |
|   | O | > including with Medicare.          |                | O |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
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|   | * |                                     |                | * |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | **You pay**    |   |    |
|   |   |                                     |                |   |    |
| * |   |                                     | **After the    |   |    |
| * |   |                                     | calendar year  |   |    |
| B |   |                                     | d              |   |    |
| e |   |                                     | eductible...** |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| # |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > \$10 per     |   |    |
|   |   |                                     | > office       |   |    |
| P |   |                                     | > visit;       |   |    |
| r |   |                                     | >              |   |    |
| o |   |                                     | > No copayment |   |    |
| f |   |                                     | > for visits   |   |    |
| e |   |                                     | > to a plan    |   |    |
| s |   |                                     | > specialist   |   |    |
| s |   |                                     | >              |   |    |
| i |   |                                     | > See note     |   |    |
| o |   |                                     | > below for    |   |    |
| n |   |                                     | > authorized   |   |    |
| a |   |                                     | > non-Plan     |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | > Nothing      |   |    |
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+---+---+-------------------------------------+----------------+---+----+
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+---+---+-------------------------------------+----------------+---+----+

+---------------------------------------------+------------------------+
| # Lab, X-ray and other diagnostic tests     | **You Pay**            |
+---------------------------------------------+------------------------+
| > Laboratory tests, such as:                | > Nothing              |
| >                                           |                        |
| >  Blood tests                             |                        |
| >                                           |                        |
| >  Urinalysis                              |                        |
| >                                           |                        |
| >  Non-routine pap tests                   |                        |
| >                                           |                        |
| >  Pathology                               |                        |
| >                                           |                        |
| >  X-rays                                  |                        |
| >                                           |                        |
| >  Non-routine Mammograms                  |                        |
| >                                           |                        |
| >  Cat Scans/MRI                           |                        |
| >                                           |                        |
| >  Ultrasound                              |                        |
| >                                           |                        |
| >  Electrocardiogram and EEG               |                        |
+---------------------------------------------+------------------------+
| ##### Preventive care, adult                |                        |
+---------------------------------------------+------------------------+
| Routine screenings such as*:*               | > Nothing              |
|                                             |                        |
| >  Total Blood Cholesterol -- once every   |                        |
| > three years~~,~~                          |                        |
| >                                           |                        |
| >  Colorectal Cancer Screening, including  |                        |
| >                                           |                        |
| > \-\-\-- Fecal occult blood test -- yearly |                        |
| > after age 50                              |                        |
+---------------------------------------------+------------------------+
| \-\-\-- Sigmoidoscopy, screening -- every   |                        |
| five years starting at age 50               |                        |
+---------------------------------------------+------------------------+
| > Prostate Specific Antigen (PSA test) --   |                        |
| > one annually for men age 40 and older     |                        |
+---------------------------------------------+------------------------+
| > Routine pap test                          |                        |
| >                                           |                        |
| > Note: There is a \$10 copay for an office |                        |
| > visit with a pap test.                    |                        |
+---------------------------------------------+------------------------+
| > Routine mammogram --covered for women age |                        |
| > 35 and older, as follows:                 |                        |
| >                                           |                        |
| >  From age 35 through 39, one during this |                        |
| > five year period                          |                        |
| >                                           |                        |
| >  From age 40 through 64, one every       |                        |
| > calendar year                             |                        |
| >                                           |                        |
| >  At age 65 and older, one every two      |                        |
| > consecutive calendar years                |                        |
+---------------------------------------------+------------------------+
| > *Not covered: Physical exams required for | > *All charges*        |
| > obtaining or continuing employment or     |                        |
| > insurance, or travel..*                   |                        |
+---------------------------------------------+------------------------+
| > Routine immunizations, limited to:        | > Nothing              |
| >                                           |                        |
| >  Tetanus-diphtheria (Td) booster -- once |                        |
| > every 10 years, ages 19 and over (except  |                        |
| > as provided for under Childhood           |                        |
| > immunizations)                            |                        |
| >                                           |                        |
| >  Influenza vaccines, annually,           |                        |
|                                             |                        |
| -   Pneumococcal vaccines, age 65 and over  |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ##### Preventive care, children             | **You pay**            |
+---------------------------------------------+------------------------+
| >  Childhood immunizations recommended by  | > Nothing              |
| > the American Academy of Pediatrics        |                        |
+---------------------------------------------+------------------------+
|  Well-child care charges for routine       | > \$10 per office      |
| examinations, immunizations and care        | > visit                |
| (through age 22)                            |                        |
|                                             |                        |
|  Examinations, such as:                    |                        |
|                                             |                        |
| > \-\--Eye exams through age 17 to          |                        |
| > determine the need for vision correction. |                        |
| >                                           |                        |
| > \-\--Ear exams through age 17 to          |                        |
| > determine the need for hearing correction |                        |
| >                                           |                        |
| > \-\--Examinations done on the day of      |                        |
| > immunizations (through age 22)            |                        |
+---------------------------------------------+------------------------+
| ######## Maternity care                     |                        |
+---------------------------------------------+------------------------+
| > Complete maternity (obstetrical) care,    | > \$10 copay on first  |
| > such as:                                  | > prenatal visit only  |
| >                                           |                        |
| >  Prenatal care                           |                        |
| >                                           |                        |
| >  Delivery                                |                        |
| >                                           |                        |
| >  Postnatal care                          |                        |
| >                                           |                        |
| > Note: Here are some things to keep in     |                        |
| > mind:                                     |                        |
| >                                           |                        |
| >  You do not need to precertify your      |                        |
| > normal delivery; see page 11 for other    |                        |
| > circumstances, such as extended stays for |                        |
| > you or your baby.                         |                        |
| >                                           |                        |
| >  You may remain in the hospital up to 48 |                        |
| > hours after a regular delivery and 96     |                        |
| > hours after a cesarean delivery. We will  |                        |
| > extend your inpatient stay if medically   |                        |
| > necessary.                                |                        |
| >                                           |                        |
| >  We cover routine nursery care of the    |                        |
| > newborn child during the covered portion  |                        |
| > of the mother's maternity stay. We will   |                        |
| > cover other care of an infant who         |                        |
| > requires non-routine treatment only if we |                        |
| > cover the infant under a Self and Family  |                        |
| > enrollment.                               |                        |
| >                                           |                        |
| >  We pay hospitalization and surgeon      |                        |
| > services (delivery) the same as for       |                        |
| > illness and injury. See Hospital benefits |                        |
| > (Section 5c) and Surgery benefits         |                        |
| > (Section 5b)*.*                           |                        |
+---------------------------------------------+------------------------+
| > *Not covered: Routine sonograms to        | > *All charges*        |
| > determine fetal age, size or sex*         |                        |
+---------------------------------------------+------------------------+
| ######## Family planning                    | **You pay**            |
+---------------------------------------------+------------------------+
| > A broad range of voluntary family         | > \$10 per visit       |
| > planning services, limited to:            |                        |
| >                                           |                        |
| >  Voluntary sterilization (See surgical   |                        |
| > procedures, Section 5 (b))                |                        |
| >                                           |                        |
| >  Surgically implanted contraceptives     |                        |
| > (such as Norplant)                        |                        |
| >                                           |                        |
| >  Injectable contraceptive drugs (such as |                        |
| > Depo provera)                             |                        |
| >                                           |                        |
| >  Intrauterine devices (IUDs)             |                        |
| >                                           |                        |
| >  Diaphragms                              |                        |
| >                                           |                        |
| > NOTE: We cover oral contraceptives under  |                        |
| > the prescription drug benefit.            |                        |
| >                                           |                        |
| > For covered medications and accessories,  |                        |
| > you pay 50% of charges after a \$600      |                        |
| > deductible.                               |                        |
+---------------------------------------------+------------------------+
| > *Not covered: reversal of voluntary       | > *All charges*        |
| > surgical sterilization, genetic           |                        |
| > counseling,*                              |                        |
+---------------------------------------------+------------------------+
| ######## Infertility services               |                        |
+---------------------------------------------+------------------------+
| > Diagnosis and treatment of infertility,   | > \$10 per visit       |
| > such as:                                  |                        |
| >                                           |                        |
| >  Artificial insemination:                |                        |
| >                                           |                        |
| > *\-\--intrauterine insemina­tion (IUI)*    |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Intracervical insemination (ICI)*      |                        |
|                                             |                        |
| -   *Intravaginal insemination (IVI)*       |                        |
|                                             |                        |
| >  *Assisted reproductive technology (ART) |                        |
| > procedures, such as:*                     |                        |
| >                                           |                        |
| > *\--in vitro fertilization*               |                        |
| >                                           |                        |
| > *\--embryo transfer, gamete GIFT and      |                        |
| > zygote*                                   |                        |
| >                                           |                        |
| > *\--zygote transfer*                      |                        |
| >                                           |                        |
| >  *Services and supplies related to       |                        |
| > excluded ART procedures*                  |                        |
| >                                           |                        |
| >  *Fertility drugs*                       |                        |
| >                                           |                        |
| >  *Cost of donor sperm*                   |                        |
| >                                           |                        |
| >  *Cost of donor egg*                     |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Allergy care**                          |                        |
+---------------------------------------------+------------------------+
| > Testing and treatment                     | > \$10 per visit       |
| >                                           |                        |
| > Allergy injection                         |                        |
+---------------------------------------------+------------------------+
| > Allergy serum                             | > Nothing              |
+---------------------------------------------+------------------------+
| > *Not covered: provocative food testing    | > *All charges*        |
| > and sublingual allergy desensitization*   |                        |
+---------------------------------------------+------------------------+
| ######## Treatment therapies                | **You pay**            |
+---------------------------------------------+------------------------+
| >  Chemotherapy and radiation therapy      | > \$10 per office      |
| >                                           | > visit                |
| > Note: High dose chemotherapy in           |                        |
| > association with autologous bone marrow   |                        |
| > transplants are limited to those          |                        |
| > transplants listed under Organ/Tissue     |                        |
| > Transplants on page 26.                   |                        |
| >                                           |                        |
| >  Respiratory and inhalation therapy      |                        |
| >                                           |                        |
| >  Dialysis -- hemodialysis and peritoneal |                        |
| > dialysis                                  |                        |
| >                                           |                        |
| >  Intravenous (IV)/Infusion Therapy --    |                        |
| > Home IV and antibiotic therapy            |                        |
| >                                           |                        |
| >  Growth hormone therapy (GHT)            |                        |
| >                                           |                        |
| > Note: We cover growth hormone under the   |                        |
| > prescription drug benefit.                |                        |
| >                                           |                        |
| > Note: -- We will only cover GHT when we   |                        |
| > preauthorize the treatment. Call your     |                        |
| > plan physician to get a referral for      |                        |
| > preauthorization. We will ask you to      |                        |
| > submit information that establishes that  |                        |
| > the GHT is medically necessary. Ask us to |                        |
| > authorize GHT before you begin treatment; |                        |
| > otherwise, we will only cover GHT         |                        |
| > services from the date you submit the     |                        |
| > information. If you do not ask or if we   |                        |
| > determine GHT is not medically necessary, |                        |
| > we will not cover the GHT or related      |                        |
| > services and supplies. See *Services      |                        |
| > requiring our prior approval* in Section  |                        |
| > 3.                                        |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Physical and occupational therapies**   | **You pay**            |
+---------------------------------------------+------------------------+
| >  Up to two consecutive months per        | > \$10 per outpatient  |
| > condition for the services of each of the | > visit                |
| > following:                                | >                      |
| >                                           | > Nothing per visit    |
| > qualified physical therapists; and      | > during covered       |
| >                                           | > inpatient admission  |
| > occupational therapists.                |                        |
| >                                           |                        |
| > Note: We only cover therapy to restore    |                        |
| > bodily function when there has been a     |                        |
| > total or partial loss of bodily function  |                        |
| > due to illness or injury.                 |                        |
| >                                           |                        |
| >  We Cover cardiac rehabilitation         |                        |
| > following a heart transplant, bypass      |                        |
| > surgery or a myocardial infarction, for   |                        |
| > up to three (3) sessions per week up to   |                        |
| > three (3) months. Any sessions beyond     |                        |
| > three (3) months require authorization by |                        |
| > HAHMO Medical Director.                   |                        |
| >                                           |                        |
| >  We cover long-term rehabilitative       |                        |
| > therapy (physical and occupational) after |                        |
| > the short-term therapy benefit has been   |                        |
| > exhausted. Benefits are provided for one  |                        |
| > supervisory physical therapy visit per    |                        |
| > month and one supervisory occupational    |                        |
| > therapy visit per month.                  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| >  *exercise programs*                     |                        |
+---------------------------------------------+------------------------+
| > **Speech therapy**                        |                        |
+---------------------------------------------+------------------------+
| >  Up to two consecutive months per        | > \$10 per outpatient  |
| > condition.                                | > visit                |
|                                             | >                      |
| NOTE: We cover speech therapy in all        | > Nothing per visit    |
| situations where it is medically necessary. | > during covered       |
|                                             | > inpatient admission  |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Hearing services (testing, treatment,   | **You pay**            |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| >  Hearing testing for children through    | > Nothing              |
| > age 17 (see *Preventive care, children*)  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| >  *all other hearing testing*             |                        |
| >                                           |                        |
| >  *hearing aids, testing and examinations |                        |
| > for them*                                 |                        |
+---------------------------------------------+------------------------+
| > **Vision services (testing, treatment,    |                        |
| > and supplies)**                           |                        |
+---------------------------------------------+------------------------+
| >  Eye exam to determine the need for      | > Nothing              |
| > vision correction for children through    |                        |
| > age 17 (see *Preventive care, children*   |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| >  *Eyeglasses or contact lenses and,      |                        |
| > after age 17, examinations for them*      |                        |
| >                                           |                        |
| >  *Eye exercises and orthoptics*          |                        |
| >                                           |                        |
| >  *Radial keratotomy and other refractive |                        |
| > surgery*                                  |                        |
+---------------------------------------------+------------------------+
| ######## Foot care                          |                        |
+---------------------------------------------+------------------------+
| > Routine foot care when you are under      | > Nothing              |
| > active treatment for a metabolic or       |                        |
| > peripheral vascular disease, such as      |                        |
| > diabetes.                                 |                        |
| >                                           |                        |
| > See orthopedic and prosthetic devices for |                        |
| > information on podiatric shoe inserts.    |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| >  *Cutting, trimming or removal of corns, |                        |
| > calluses, or the free edge of toenails,   |                        |
| > and similar routine treatment of          |                        |
| > conditions of the foot, except as stated  |                        |
| > above*                                    |                        |
| >                                           |                        |
| >  *Treatment of weak, strained or flat    |                        |
| > feet or bunions or spurs; and of any      |                        |
| > instability, imbalance or subluxation of  |                        |
| > the foot (unless the treatment is by open |                        |
| > cutting surgery)*                         |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Orthopedic and prosthetic devices**     | **You pay**            |
+---------------------------------------------+------------------------+
| >  Artificial limbs, lenses following      | > 20% coinsurance on   |
| > cataract surgery                          | > items that exceed    |
| >                                           | > \$25 up to a maximum |
| >  Externally worn breast prostheses and   | > coinsurance of \$500 |
| > surgical bras, including necessary        | > per contract per     |
| > replacements, following a mastectomy      | > calendar year.       |
| >                                           |                        |
| >  Internal prosthetic devices, such as    |                        |
| > artificial joints, pacemakers and         |                        |
| > cochlear implants and surgically          |                        |
| > implanted breast implant or TRAM-flap     |                        |
| > procedure following mastectomy. Note: See |                        |
| > 5(b) for coverage of the surgery to       |                        |
| > insert the device.                        |                        |
| >                                           |                        |
| >  Corrective orthopedic appliances for    |                        |
| > non-dental treatment of temporomandibular |                        |
| > joint (TMJ) pain dysfunction syndrome.    |                        |
| >                                           |                        |
| > Note: There is a maximum benefit of       |                        |
| > \$3,500 per member per calendar year for  |                        |
| > orthopedic and prosthetic devices and     |                        |
| > durable equipment combined.               |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| >  *Orthopedic and corrective shoes*       |                        |
| >                                           |                        |
| >  *arch supports*                         |                        |
| >                                           |                        |
| >  *foot orthotics*                        |                        |
| >                                           |                        |
| >  *heel pads and heel cups*               |                        |
| >                                           |                        |
| >  *lumbosacral supports*                  |                        |
| >                                           |                        |
| >  *corsets, trusses, and other supportive |                        |
| > devices*                                  |                        |
+---------------------------------------------+------------------------+
| ######## Durable medical equipment (DME)    | **You pay**            |
+---------------------------------------------+------------------------+
| > Rental or purchase, at our option,        | > 20% coinsurance on   |
| > including repair and adjustment, of       | > items which exceed   |
| > durable medical equipment prescribed by   | > \$25 up to a maximum |
| > your Plan physician, such as oxygen and   | > coinsurance of \$500 |
| > dialysis equipment. Under this benefit,   | > per contract per     |
| > we also cover:                            | > calendar year.       |
| >                                           |                        |
| >  hospital beds                           |                        |
| >                                           |                        |
| >  wheelchairs                             |                        |
| >                                           |                        |
| >  crutches                                |                        |
| >                                           |                        |
| >  walkers                                 |                        |
| >                                           |                        |
| >  blood glucose monitors                  |                        |
| >                                           |                        |
| >  insulin pumps                           |                        |
| >                                           |                        |
| > Note: There is a maximum benefit of       |                        |
| > \$3,500 per member per calendar year for  |                        |
| > orthopedic and prosthetic devices and     |                        |
| > durable equipment combined.               |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| >  *Motorized wheel chairs*                |                        |
+---------------------------------------------+------------------------+
| ######## Home health services               | ######## You Pay       |
+---------------------------------------------+------------------------+
| >  Home health care ordered by a Plan      | > Nothing              |
| > physician and provided by a registered    |                        |
| > nurse (R.N.), licensed practical nurse    |                        |
| > (L.P.N.), licensed vocational nurse       |                        |
| > (L.V.N.), or home health aide.            |                        |
|                                             |                        |
| -   Services include oxygen therapy,        |                        |
|     intravenous therapy and medications.    |                        |
+---------------------------------------------+------------------------+
| > Not covered:                              | > *All charges*        |
| >                                           |                        |
| >  *nursing care requested by, or for the  |                        |
| > convenience of, the patient or the        |                        |
| > patient's family;*                        |                        |
| >                                           |                        |
| >  *home care primarily for personal       |                        |
| > assistance that does not include a        |                        |
| > medical component and is not diagnostic,  |                        |
| > therapeutic, or rehabilitative.*          |                        |
+---------------------------------------------+------------------------+
| ######## Chiropractic                       |                        |
+---------------------------------------------+------------------------+
| >  Manipulation of the spine and           | > \$10 per visit       |
| > extremities                               |                        |
| >                                           |                        |
| >  Adjunctive procedures such as           |                        |
| > ultrasound, electrical muscle             |                        |
| > stimulation, vibratory therapy, and cold  |                        |
| > pack application                          |                        |
+---------------------------------------------+------------------------+
| ######## Alternative treatments             | ########               |
+---------------------------------------------+------------------------+
| ## No benefit for services such as:         | > *All charges*        |
|                                             |                        |
| ##  naturopathic services                  |                        |
|                                             |                        |
| ##  hypnotherapy                           |                        |
|                                             |                        |
| ##  biofeedback                            |                        |
|                                             |                        |
| ##  acupuncture                            |                        |
+---------------------------------------------+------------------------+
| #### **Educational classes and programs**   |                        |
+---------------------------------------------+------------------------+
| > Coverage is limited to:                   | > \$10 per visit       |
| >                                           |                        |
| >  Diabetes self-management which          |                        |
| > includes: individual instruction by       |                        |
| > primary care physician, diabetic course   |                        |
| > up to five days, diabetic camps for       |                        |
| > children up to age 16 and dietary         |                        |
| > instruction by a dietician                |                        |
| >                                           |                        |
| > Smoking Cessation -- up to \$100 for one  |                        |
| > smoking cessation program per member per  |                        |
| > lifetime, including all related expenses  |                        |
| > such as drugs                             |                        |
+---------------------------------------------+------------------------+

+---+---+-------------------------------------+----------------+---+---+
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| s |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
|   | * | > **Here are some important things  |                | * |   |
|   | * | > to keep in mind about these       |                | * |   |
|   | I | > benefits:**                       |                | I |   |
|   | * | >                                   |                | * |   |
|   | * | >  Please remember that all        |                | * |   |
|   |   | > benefits are subject to the       |                |   |   |
|   | * | > definitions, limitations, and     |                | * |   |
|   | * | > exclusions in this brochure and   |                | * |   |
|   | M | > are payable only when we          |                | M |   |
|   | * | > determine they are medically      |                | * |   |
|   | * | > necessary.                        |                | * |   |
|   |   | >                                   |                |   |   |
|   | * | >  Plan physicians must provide or |                | * |   |
|   | * | > arrange your care.                |                | * |   |
|   | P | >                                   |                | P |   |
|   | * | >  Be sure to read Section 4,      |                | * |   |
|   | * | > *Your costs for covered           |                | * |   |
|   |   | > services,* for valuable           |                |   |   |
|   | * | > information about how cost        |                | * |   |
|   | * | > sharing works. Also read Section  |                | * |   |
|   | O | > 9 about coordinating benefits     |                | O |   |
|   | * | > with other coverage, including    |                | * |   |
|   | * | > with Medicare.                    |                | * |   |
|   |   | >                                   |                |   |   |
|   | * | >  The amounts listed below are    |                | * |   |
|   | * | > for the charges billed by a       |                | * |   |
|   | R | > physician or other health care    |                | R |   |
|   | * | > professional for your surgical    |                | * |   |
|   | * | > care. Look in Section 5 (c) for   |                | * |   |
|   |   | > charges associated with the       |                |   |   |
|   | * | > facility (i.e. hospital, surgical |                | * |   |
|   | * | > center, etc.)                     |                | * |   |
|   | T |                                     |                | T |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | A |                                     |                | A |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | N |                                     |                | N |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | T |                                     |                | T |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | **You pay**    |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| B |   |                                     |                |   |   |
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| f |   |                                     |                |   |   |
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| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| D |   |                                     |                |   |   |
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| s |   |                                     |                |   |   |
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| r |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
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| n |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| S |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
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| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | > \$10 per     |   |   |
|   |   |                                     | > office visit |   |   |
| A |   |                                     | >              |   |   |
| > |   |                                     | > (nothing for |   |   |
|   |   |                                     | > hospital     |   |   |
| c |   |                                     | > visits)      |   |   |
| o |   |                                     | >              |   |   |
| m |   |                                     | > See not      |   |   |
| p |   |                                     | > below for    |   |   |
| r |   |                                     | > authorized   |   |   |
| e |   |                                     | > non-Plan     |   |   |
| h |   |                                     | > specialist   |   |   |
| e |   |                                     | > visits       |   |   |
| n |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
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| > |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
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| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
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| t |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
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| a |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
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| e |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
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| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| d |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| f |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| h |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| f |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| ; |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| F |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| 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.                                     |                        |
+---------------------------------------------+------------------------+
| >  All stages of breast reconstruction     | > Nothing              |
| > surgery following a mastectomy, such as:  |                        |
| >                                           |                        |
| > \-\--surgery to produce a symmetrical     |                        |
| > appearance on the other breast;           |                        |
| >                                           |                        |
| > \-\--treatment of any physical            |                        |
| > complications, such as lymphedemas;       |                        |
| >                                           |                        |
| > \-\--breast prostheses and surgical bras  |                        |
| > and replacements (see Prosthetic devices) |                        |
| >                                           |                        |
| > Note: If you need a mastectomy, you may   |                        |
| > choose to have the procedure performed on |                        |
| > an inpatient basis and remain in the      |                        |
| > hospital up to 48 hours after the         |                        |
| > procedure.                                |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| >  *Cosmetic surgery -- any surgical       |                        |
| > procedure (or any portion of a procedure) |                        |
| > performed primarily to improve physical   |                        |
| > appearance through change in bodily form, |                        |
| > except repair of accidental injury*       |                        |
| >                                           |                        |
| >  *Surgeries related to sex               |                        |
| > transformation*                           |                        |
+---------------------------------------------+------------------------+
| > **Oral and maxillofacial surgery**        |                        |
+---------------------------------------------+------------------------+
| > Oral surgical procedures, limited to:     | > Nothing              |
| >                                           |                        |
| >  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.                               |                        |
+---------------------------------------------+------------------------+
| > *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                                   |                        |
| >                                           |                        |
| >  Kidney                                  |                        |
| >                                           |                        |
| >  Liver                                   |                        |
| >                                           |                        |
| >  Allogeneic (donor) bone marrow          |                        |
| > transplants                               |                        |
| >                                           |                        |
| >  Autologous bone marrow transplants      |                        |
| > (autologous stem cell and peripheral stem |                        |
| > cell support) for the following           |                        |
| > conditions: acute lymphocytic or          |                        |
| > non-lymphocytic leukemia; advanced        |                        |
| > Hodgkin\'s lymphoma; advanced             |                        |
| > non-Hodgkin\'s lymphoma; advanced         |                        |
| > neuroblastoma; breast cancer; multiple    |                        |
| > myeloma; epithelial ovarian cancer; and   |                        |
| > testicular, mediastinal, retroperitoneal  |                        |
| > and ovarian germ cell tumors              |                        |
| >                                           |                        |
| >  Intestinal transplants (small           |                        |
| > intestine)                                |                        |
| >                                           |                        |
| > Limited Benefits - Treatment for breast   |                        |
| > cancer, multiple myeloma, and epithelial  |                        |
| > ovarian cancer is subject to approval by  |                        |
| > the Plan's medical director in accordance |                        |
| > with the Plan's protocols.                |                        |
| >                                           |                        |
| > Note: We cover related medical and        |                        |
| > hospital expenses of the donor when we    |                        |
| > cover the recipient.                      |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| >  *Donor screening tests and donor search |                        |
| > expenses, except those performed for the  |                        |
| > actual donor*                             |                        |
| >                                           |                        |
| >  *Implants of artificial organs*         |                        |
| >                                           |                        |
| >  *Transplants not listed as covered*     |                        |
+---------------------------------------------+------------------------+
| > **Anesthesia**                            | > **You pay**          |
+---------------------------------------------+------------------------+
| > Professional services provided in --      | > Nothing              |
| >                                           |                        |
| >  Hospital (inpatient)                    |                        |
| >                                           |                        |
| >  Hospital outpatient department          |                        |
| >                                           |                        |
| >  Skilled nursing facility                |                        |
| >                                           |                        |
| >  Ambulatory surgical center              |                        |
| >                                           |                        |
| >  Office                                  |                        |
+---------------------------------------------+------------------------+

+---+---+---+----+---+---------------------------------+-------------+---+----+
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   |  * |   |                                 |             |   |    |
|   |   |   | *S |   |                                 |             |   |    |
|   |   |   | ec |   |                                 |             |   |    |
|   |   |   | ti |   |                                 |             |   |    |
|   |   |   | on |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   |  5 |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   | (c |   |                                 |             |   |    |
|   |   |   | ). |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   | Se |   |                                 |             |   |    |
|   |   |   | rv |   |                                 |             |   |    |
|   |   |   | ic |   |                                 |             |   |    |
|   |   |   | es |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   | pr |   |                                 |             |   |    |
|   |   |   | ov |   |                                 |             |   |    |
|   |   |   | id |   |                                 |             |   |    |
|   |   |   | ed |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   | by |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   |  a |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   | ho |   |                                 |             |   |    |
|   |   |   | sp |   |                                 |             |   |    |
|   |   |   | it |   |                                 |             |   |    |
|   |   |   | al |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   | or |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   |  o |   |                                 |             |   |    |
|   |   |   | th |   |                                 |             |   |    |
|   |   |   | er |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   |  f |   |                                 |             |   |    |
|   |   |   | ac |   |                                 |             |   |    |
|   |   |   | il |   |                                 |             |   |    |
|   |   |   | it |   |                                 |             |   |    |
|   |   |   | y, |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   |  a |   |                                 |             |   |    |
|   |   |   | nd |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   |  a |   |                                 |             |   |    |
|   |   |   | mb |   |                                 |             |   |    |
|   |   |   | ul |   |                                 |             |   |    |
|   |   |   | an |   |                                 |             |   |    |
|   |   |   | ce |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   | se |   |                                 |             |   |    |
|   |   |   | rv |   |                                 |             |   |    |
|   |   |   | ic |   |                                 |             |   |    |
|   |   |   | es |   |                                 |             |   |    |
|   |   |   | ** |   |                                 |             |   |    |
+---+---+---+----+---+---------------------------------+-------------+---+----+
|   |   |   |    | * | > **Here are some important     |             | * |    |
|   |   |   |    | * | > things to remember about      |             | * |    |
|   |   |   |    | I | > these benefits:**             |             | I |    |
|   |   |   |    | * | >                               |             | * |    |
|   |   |   |    | * | >  Please remember that all    |             | * |    |
|   |   |   |    |   | > benefits are subject to the   |             |   |    |
|   |   |   |    | * | > definitions, limitations, and |             | * |    |
|   |   |   |    | * | > exclusions in this brochure   |             | * |    |
|   |   |   |    | M | > and are payable only when we  |             | M |    |
|   |   |   |    | * | > determine they are medically  |             | * |    |
|   |   |   |    | * | > necessary.                    |             | * |    |
|   |   |   |    |   | >                               |             |   |    |
|   |   |   |    | * | >  Plan physicians must        |             | * |    |
|   |   |   |    | * | > provide or arrange your care  |             | * |    |
|   |   |   |    | P | > and you must be hospitalized  |             | P |    |
|   |   |   |    | * | > in a Plan facility.           |             | * |    |
|   |   |   |    | * | >                               |             | * |    |
|   |   |   |    |   | >  Be sure to read Section 4,  |             |   |    |
|   |   |   |    | * | > *Your costs for covered       |             | * |    |
|   |   |   |    | * | > services,* for valuable       |             | * |    |
|   |   |   |    | O | > information about how cost    |             | O |    |
|   |   |   |    | * | > sharing works. Also read      |             | * |    |
|   |   |   |    | * | > Section 9 about coordinating  |             | * |    |
|   |   |   |    |   | > benefits with other coverage, |             |   |    |
|   |   |   |    | * | > including with Medicare.      |             | * |    |
|   |   |   |    | * | >                               |             | * |    |
|   |   |   |    | R | >  The amounts listed below    |             | R |    |
|   |   |   |    | * | > are for the charges billed by |             | * |    |
|   |   |   |    | * | > the facility (i.e., hospital  |             | * |    |
|   |   |   |    |   | > or surgical center) or        |             |   |    |
|   |   |   |    | * | > ambulance service for your    |             | * |    |
|   |   |   |    | * | > surgery or care. Any costs    |             | * |    |
|   |   |   |    | T | > associated with the           |             | T |    |
|   |   |   |    | * | > professional charge (i.e.,    |             | * |    |
|   |   |   |    | * | > physicians, etc.) are covered |             | * |    |
|   |   |   |    |   | > in Section 5(a) or (b).       |             |   |    |
|   |   |   |    | * |                                 |             | * |    |
|   |   |   |    | * |                                 |             | * |    |
|   |   |   |    | A |                                 |             | A |    |
|   |   |   |    | * |                                 |             | * |    |
|   |   |   |    | * |                                 |             | * |    |
|   |   |   |    |   |                                 |             |   |    |
|   |   |   |    | * |                                 |             | * |    |
|   |   |   |    | * |                                 |             | * |    |
|   |   |   |    | N |                                 |             | N |    |
|   |   |   |    | * |                                 |             | * |    |
|   |   |   |    | * |                                 |             | * |    |
|   |   |   |    |   |                                 |             |   |    |
|   |   |   |    | * |                                 |             | * |    |
|   |   |   |    | * |                                 |             | * |    |
|   |   |   |    | T |                                 |             | T |    |
|   |   |   |    | * |                                 |             | * |    |
|   |   |   |    | * |                                 |             | * |    |
+---+---+---+----+---+---------------------------------+-------------+---+----+
|   |   |   | >  |   |                                 | **You pay** |   |    |
|   |   |   |  * |   |                                 |             |   |    |
|   |   |   | *B |   |                                 |             |   |    |
|   |   |   | en |   |                                 |             |   |    |
|   |   |   | ef |   |                                 |             |   |    |
|   |   |   | it |   |                                 |             |   |    |
|   |   |   | >  |   |                                 |             |   |    |
|   |   |   |  D |   |                                 |             |   |    |
|   |   |   | es |   |                                 |             |   |    |
|   |   |   | cr |   |                                 |             |   |    |
|   |   |   | ip |   |                                 |             |   |    |
|   |   |   | ti |   |                                 |             |   |    |
|   |   |   | on |   |                                 |             |   |    |
|   |   |   | ** |   |                                 |             |   |    |
+---+---+---+----+---+---------------------------------+-------------+---+----+
|   |   |   | #  |   |                                 | ########    |   |    |
|   |   |   | ## |   |                                 |             |   |    |
|   |   |   | ## |   |                                 |             |   |    |
|   |   |   | ## |   |                                 |             |   |    |
|   |   |   | #  |   |                                 |             |   |    |
|   |   |   | In |   |                                 |             |   |    |
|   |   |   | pa |   |                                 |             |   |    |
|   |   |   | ti |   |                                 |             |   |    |
|   |   |   | en |   |                                 |             |   |    |
|   |   |   | t  |   |                                 |             |   |    |
|   |   |   | ho |   |                                 |             |   |    |
|   |   |   | sp |   |                                 |             |   |    |
|   |   |   | it |   |                                 |             |   |    |
|   |   |   | al |   |                                 |             |   |    |
+---+---+---+----+---+---------------------------------+-------------+---+----+
|   |   | > |    |   |                                 | > Nothing   |   |    |
|   |   |   |    |   |                                 |             |   |    |
|   |   | R |    |   |                                 |             |   |    |
|   |   | o |    |   |                                 |             |   |    |
|   |   | o |    |   |                                 |             |   |    |
|   |   | m |    |   |                                 |             |   |    |
|   |   | > |    |   |                                 |             |   |    |
|   |   |   |    |   |                                 |             |   |    |
|   |   | a |    |   |                                 |             |   |    |
|   |   | n |    |   |                                 |             |   |    |
|   |   | d |    |   |                                 |             |   |    |
|   |   | > |    |   |                                 |             |   |    |
|   |   |   |    |   |                                 |             |   |    |
|   |   | b |    |   |                                 |             |   |    |
|   |   | o |    |   |                                 |             |   |    |
|   |   | a |    |   |                                 |             |   |    |
|   |   | r |    |   |                                 |             |   |    |
|   |   | d |    |   |                                 |             |   |    |
|   |   | , |    |   |                                 |             |   |    |
|   |   | > |    |   |                                 |             |   |    |
|   |   |   |    |   |                                 |             |   |    |
|   |   | s |    |   |                                 |             |   |    |
|   |   | u |    |   |                                 |             |   |    |
|   |   | c |    |   |                                 |             |   |    |
|   |   | h |    |   |                                 |             |   |    |
|   |   | > |    |   |                                 |             |   |    |
|   |   |   |    |   |                                 |             |   |    |
|   |   | a |    |   |                                 |             |   |    |
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|   | . |   |    |   |                                 |             |   |    |
+---+---+---+----+---+---------------------------------+-------------+---+----+
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+---+---+---+----+---+---------------------------------+-------------+---+----+
|   | # |   |    |   |                                 |             |   |    |
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+---+---+---+----+---+---------------------------------+-------------+---+----+
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|   | c |   |    |   |                                 |             |   |    |
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|   | a |   |    |   |                                 |             |   |    |
|   | p |   |    |   |                                 |             |   |    |
|   | p |   |    |   |                                 |             |   |    |
|   | r |   |    |   |                                 |             |   |    |
|   | o |   |    |   |                                 |             |   |    |
|   | p |   |    |   |                                 |             |   |    |
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+---+---+---+----+---+---------------------------------+-------------+---+----+

+---+---+------------------------------------------------------+---+---+
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
| # |   |                                                      |   |   |
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|   |   |                                                      |   |   |
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| c |   |                                                      |   |   |
| t |   |                                                      |   |   |
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| . |   |                                                      |   |   |
|   |   |                                                      |   |   |
| E |   |                                                      |   |   |
| m |   |                                                      |   |   |
| e |   |                                                      |   |   |
| r |   |                                                      |   |   |
| g |   |                                                      |   |   |
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| n |   |                                                      |   |   |
| c |   |                                                      |   |   |
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| e |   |                                                      |   |   |
| r |   |                                                      |   |   |
| v |   |                                                      |   |   |
| i |   |                                                      |   |   |
| c |   |                                                      |   |   |
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| s |   |                                                      |   |   |
| / |   |                                                      |   |   |
| a |   |                                                      |   |   |
| c |   |                                                      |   |   |
| c |   |                                                      |   |   |
| i |   |                                                      |   |   |
| d |   |                                                      |   |   |
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| n |   |                                                      |   |   |
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| s |   |                                                      |   |   |
+---+---+------------------------------------------------------+---+---+
|   | * | > Here are some important things to keep in mind     | * | # |
|   | * | > about these benefits:                              | * | # |
|   | I | >                                                    | I | # |
|   | * | >  Please remember that all benefits are subject to | * | # |
|   | * | > the definitions, limitations, and exclusions in    | * | # |
|   |   | > this brochure.                                     |   |   |
|   | * | >                                                    | * |   |
|   | * | >  Be sure to read Section 4, *Your costs for       | * |   |
|   | M | > covered service,* for valuable information about   | M |   |
|   | * | > how cost sharing works. Also read Section 9 about  | * |   |
|   | * | > coordinating benefits with other coverage,         | * |   |
|   |   | > including with Medicare.                           |   |   |
|   | * |                                                      | * |   |
|   | * | #####                                                | * |   |
|   | P |                                                      | P |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
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|   | * |                                                      | * |   |
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|   |   |                                                      |   |   |
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|   |   |                                                      |   |   |
|   | * |                                                      | * |   |
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|   | A |                                                      | A |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
|   |   |                                                      |   |   |
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|   | * |                                                      | * |   |
|   | T |                                                      | T |   |
|   | * |                                                      | * |   |
|   | * |                                                      | * |   |
+---+---+------------------------------------------------------+---+---+
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| d |   |                                                      |   |   |
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| d |   |                                                      |   |   |
| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| b |   |                                                      |   |   |
| y |   |                                                      |   |   |
| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| P |   |                                                      |   |   |
| l |   |                                                      |   |   |
| a |   |                                                      |   |   |
| n |   |                                                      |   |   |
| > |   |                                                      |   |   |
|   |   |                                                      |   |   |
| p |   |                                                      |   |   |
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| v |   |                                                      |   |   |
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| s |   |                                                      |   |   |
| . |   |                                                      |   |   |
+---+---+------------------------------------------------------+---+---+

+-------------------------------------------------+--------------------+
| > **Benefit Description**                       | **You pay**        |
+-------------------------------------------------+--------------------+
| > **Emergency within our service area**         |                    |
+-------------------------------------------------+--------------------+
| >  Emergency care at a doctor\'s office        | Nothing            |
| >                                               |                    |
| >  Emergency care at an urgent care center     |                    |
+-------------------------------------------------+--------------------+
| >  Emergency care at a hospital, including     | > \$30 per visit   |
| > doctors\' services.                           |                    |
| >                                               |                    |
| > Note: If emergency results in admission, we   |                    |
| > waive the copayment.                          |                    |
+-------------------------------------------------+--------------------+
| > *Not covered: Elective care or non-emergency  | > *All charges*    |
| > care*                                         |                    |
+-------------------------------------------------+--------------------+
| ######## Emergency outside our service area     |                    |
+-------------------------------------------------+--------------------+
| >  Emergency care at a doctor\'s office        | Nothing            |
| >                                               |                    |
| >  Emergency care at an urgent care center     |                    |
+-------------------------------------------------+--------------------+
| >  Emergency care at a hospital, including     | > \$30 per visit   |
| > doctors\' services.                           |                    |
| >                                               |                    |
| > Note: If emergency results in admission, we   |                    |
| > waive the copayment.                          |                    |
+-------------------------------------------------+--------------------+
| > *Not covered:*                                | > *All charges*    |
| >                                               |                    |
| >  *Elective care or non-emergency care*       |                    |
| >                                               |                    |
| >  *Emergency care provided outside the        |                    |
| > service area if the need for care could have  |                    |
| > been foreseen before leaving the service      |                    |
| > area*                                         |                    |
| >                                               |                    |
| >  *Medical and hospital costs resulting from  |                    |
| > a normal full-term delivery of a baby outside |                    |
| > the service area*                             |                    |
|                                                 |                    |
| ########                                        |                    |
+-------------------------------------------------+--------------------+
| > **Ambulance**                                 |                    |
+-------------------------------------------------+--------------------+
| > Professional ambulance service when medically | Nothing            |
| > appropriate. We cover air ambulance when      |                    |
| > medically appropriate.                        |                    |
| >                                               |                    |
| > See 5(c) for non-emergency service.           |                    |
+-------------------------------------------------+--------------------+

+---+---+-----------------------------------------+----------------+---+---+
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| S |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| c |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| o |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| 5 |   |                                         |                |   |   |
| ( |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| ) |   |                                         |                |   |   |
| . |   |                                         |                |   |   |
| M |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| l |   |                                         |                |   |   |
| h |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| l |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| h |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| d |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| u |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| c |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| u |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| f |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+
|   | * | > 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:**  |                | * |   |
|   | * | >                                       |                | * |   |
|   |   | >  All benefits are subject to the     |                |   |   |
|   | * | > definitions, limitations, and         |                | * |   |
|   | * | > exclusions in this brochure.          |                | * |   |
|   | P | >                                       |                | P |   |
|   | * | >  Be sure to read Section 4, *Your    |                | * |   |
|   | * | > costs for covered services* for       |                | * |   |
|   |   | > valuable information about how cost   |                |   |   |
|   | * | > sharing works. Also read Section 9    |                | * |   |
|   | * | > about coordinating benefits with      |                | * |   |
|   | O | > other coverage, including with        |                | O |   |
|   | * | > Medicare.                             |                | * |   |
|   | * | >                                       |                | * |   |
|   |   | >  **YOU MUST GET PREAUTHORIZATION OF  |                |   |   |
|   | * | > THESE SERVICES.** See the             |                | * |   |
|   | * | > instructions after the benefits       |                | * |   |
|   | R | > description below.                    |                | R |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   |   |                                         |                |   |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   | T |                                         |                | T |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   |   |                                         |                |   |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   | A |                                         |                | A |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   |   |                                         |                |   |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   | N |                                         |                | N |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   |   |                                         |                |   |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
|   | T |                                         |                | T |   |
|   | * |                                         |                | * |   |
|   | * |                                         |                | * |   |
+---+---+-----------------------------------------+----------------+---+---+
| > |   |                                         | **You pay**    |   |   |
|   |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| B |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| f |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| > |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| D |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| c |   |                                         |                |   |   |
| r |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| p |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| o |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+
| # |   |                                         | ###            |   |   |
| # |   |                                         |                |   |   |
| # |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| M |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| l |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| h |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| l |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| h |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| d |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| u |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| c |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| u |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| b |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| f |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
| * |   |                                         |                |   |   |
+---+---+-----------------------------------------+----------------+---+---+
| > |   |                                         | > Your cost    |   |   |
|   |   |                                         | > sharing      |   |   |
| A |   |                                         | > re           |   |   |
| l |   |                                         | sponsibilities |   |   |
| l |   |                                         | > are no       |   |   |
| > |   |                                         | > greater than |   |   |
|   |   |                                         | > for other    |   |   |
| d |   |                                         | > illness or   |   |   |
| i |   |                                         | > conditions.  |   |   |
| a |   |                                         |                |   |   |
| g |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| o |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| c |   |                                         |                |   |   |
| > |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| d |   |                                         |                |   |   |
| > |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| r |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| m |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| t |   |                                         |                |   |   |
| > |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| s |   |                                         |                |   |   |
| e |   |                                         |                |   |   |
| r |   |                                         |                |   |   |
| v |   |                                         |                |   |   |
| i |   |                                         |                |   |   |
| c |   |                                         |                |   |   |
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| s |   |                                         |                |   |   |
| > |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
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| m |   |                                         |                |   |   |
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| d |   |                                         |                |   |   |
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|   |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| > |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| P |   |                                         |                |   |   |
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| a |   |                                         |                |   |   |
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|   |   |                                         |                |   |   |
| p |   |                                         |                |   |   |
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| v |   |                                         |                |   |   |
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| d |   |                                         |                |   |   |
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| r |   |                                         |                |   |   |
| > |   |                                         |                |   |   |
|   |   |                                         |                |   |   |
| a |   |                                         |                |   |   |
| n |   |                                         |                |   |   |
| d |   |                                         |                |   |   |
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| 3 |   |                                         |                |   |   |
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+---+---+-----------------------------------------+----------------+---+---+

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

+---------------------------------------------+---+----------------------+
| ### **Mental health an                      | # |                      |
| d substance abuse benefits** *(Continued)*  | # |                      |
|                                             | # |                      |
|                                             |   |                      |
|                                             | * |                      |
|                                             | * |                      |
|                                             | Y |                      |
|                                             | o |                      |
|                                             | u |                      |
|                                             |   |                      |
|                                             | p |                      |
|                                             | a |                      |
|                                             | y |                      |
|                                             | * |                      |
|                                             | * |                      |
+---------------------------------------------+---+----------------------+
| >  Diagnostic tests                        |   |                      |
+---------------------------------------------+---+----------------------+
| >  Services provided by a hospital or      | > |                      |
| > other facility                            |   |                      |
| >                                           | N |                      |
| >  Services in approved alternative care   | o |                      |
| > settings such as partial hospitalization, | t |                      |
| > residential treatment (under 21 years of  | h |                      |
| > age) and full-day hospitalization.        | i |                      |
| >                                           | n |                      |
| > Note: When you receive authorized         | g |                      |
| > services from a non-Plan facility, you    |   |                      |
| > pay 20% of charges up to a maximum        |   |                      |
| > coinsurance of \$3000 per year            |   |                      |
+---------------------------------------------+---+----------------------+
| ##                                          | > |                      |
| Not covered: Services we have not approved. |   |                      |
|                                             | A |                      |
| ## Note: OPM wil                            | l |                      |
| l base its review of disputes about treatme | l |                      |
| nt plans on the treatment plan\'s clinical  | > |                      |
| appropriateness. OPM will generally not ord |   |                      |
| er us to pay or provide one clinically appr | c |                      |
| opriate treatment plan in favor of another. | h |                      |
|                                             | a |                      |
|                                             | r |                      |
|                                             | g |                      |
|                                             | e |                      |
|                                             | s |                      |
|                                             | . |                      |
+---------------------------------------------+---+----------------------+
| **Preauthorization** To be eligible to      |   |                      |
| receive these benefits you must follow your |   |                      |
| treatment plan and all the following        |   |                      |
| authorization processes:                    |   |                      |
|                                             |   |                      |
| Inpatient service and outpatient therapy    |   |                      |
| services must be directed by your primary   |   |                      |
| care physician and approved by the HAHMO    |   |                      |
| Medical Director. Available providers for   |   |                      |
| Mental Health and Substance Abuse Benefits  |   |                      |
| are listed on your Provider Directory that  |   |                      |
| you receive when you enroll or you may call |   |                      |
| the HAHMO office at 701-776-5848 or         |   |                      |
| 1-800-525-5661 to obtain one.               |   |                      |
+---------------------------------------------+---+----------------------+

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

+-----+---+--------------------------------+------------------+---+----+
| **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   |                  | * |    |
|     | I | these benefits:**              |                  | I |    |
|     | * |                                |                  | * |    |
|     | * |  We cover prescribed drugs    |                  | * |    |
|     |   | and medications, as described  |                  |   |    |
|     | * | in the chart beginning on the  |                  | * |    |
|     | * | next page.                     |                  | * |    |
|     | M |                                |                  | M |    |
|     | * |  All benefits are subject to  |                  | * |    |
|     | * | the definitions, limitations   |                  | * |    |
|     |   | and exclusions in this         |                  |   |    |
|     | * | brochure and are payable only  |                  | * |    |
|     | * | when we determine they are     |                  | * |    |
|     | P | medically necessary.           |                  | P |    |
|     | * |                                |                  | * |    |
|     | * |  The calendar year deductible |                  | * |    |
|     |   | is: \$600 per member. The      |                  |   |    |
|     | * | calendar year deductible       |                  | * |    |
|     | * | applies to almost all benefits |                  | * |    |
|     | O | in this Section.               |                  | O |    |
|     | * |                                |                  | * |    |
|     | * |  Be sure to read Section 4,   |                  | * |    |
|     |   | *Your costs for covered        |                  |   |    |
|     | * | services* for valuable         |                  | * |    |
|     | * | information about how cost     |                  | * |    |
|     | R | sharing works. Also read       |                  | R |    |
|     | * | Section 9 about coordinating   |                  | * |    |
|     | * | benefits with other coverage,  |                  | * |    |
|     |   | including with Medicare.       |                  |   |    |
|     | * |                                |                  | * |    |
|     | * | **There are important features |                  | * |    |
|     | T | you should be aware of.**      |                  | T |    |
|     | * | These include:                 |                  | * |    |
|     | * |                                |                  | * |    |
|     |   |  **Who can write your         |                  |   |    |
|     | * | prescription.** A licensed     |                  | * |    |
|     | * | physician must write the       |                  | * |    |
|     | A | prescription                   |                  | A |    |
|     | * |                                |                  | * |    |
|     | * |  **Where you can obtain       |                  | * |    |
|     |   | them.** You may fill the       |                  |   |    |
|     | * | prescription at any pharmacy.  |                  | * |    |
|     | * | We do not have a network       |                  | * |    |
|     | N | pharmacy.                      |                  | N |    |
|     | * |                                |                  | * |    |
|     | * |  **Why use generic drugs.**   |                  | * |    |
|     |   | To reduce your out-of-pocket   |                  |   |    |
|     | * | expenses! A generic drug is    |                  | * |    |
|     | * | the chemical equivalent of a   |                  | * |    |
|     | T | corresponding brand name drug. |                  | T |    |
|     | * | Generic drugs are less         |                  | * |    |
|     | * | expensive than brand name      |                  | * |    |
|     |   | drugs; therefore, you may      |                  |   |    |
|     |   | reduce your out-of-pocket      |                  |   |    |
|     |   | costs by choosing to use a     |                  |   |    |
|     |   | generic drug.                  |                  |   |    |
|     |   |                                |                  |   |    |
|     |   |  **When you have to file a    |                  |   |    |
|     |   | claim.** See Section seven (7) |                  |   |    |
|     |   | -- Filing a claim for covered  |                  |   |    |
|     |   | services.                      |                  |   |    |
|     |   |                                |                  |   |    |
|     |   | -   Plan members called to     |                  |   |    |
|     |   |     active military duty (or   |                  |   |    |
|     |   |     members in time of         |                  |   |    |
|     |   |     national emergency) who    |                  |   |    |
|     |   |     need to obtain prescribed  |                  |   |    |
|     |   |     medications should call    |                  |   |    |
|     |   |     our Member Services        |                  |   |    |
|     |   |     Department at              |                  |   |    |
|     |   |     800-525-5661.              |                  |   |    |
+-----+---+--------------------------------+------------------+---+----+
| >   |   |                                | **You pay**      |   |    |
| **B |   |                                |                  |   |    |
| ene |   |                                | **After the      |   |    |
| fit |   |                                | calendar year    |   |    |
| > D |   |                                | deductible**     |   |    |
| esc |   |                                |                  |   |    |
| rip |   |                                |                  |   |    |
| tio |   |                                |                  |   |    |
| n** |   |                                |                  |   |    |
+-----+---+--------------------------------+------------------+---+----+
| >   |   |                                |                  |   |    |
| **C |   |                                |                  |   |    |
| ove |   |                                |                  |   |    |
| red |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  me |   |                                |                  |   |    |
| dic |   |                                |                  |   |    |
| ati |   |                                |                  |   |    |
| ons |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| and |   |                                |                  |   |    |
| > s |   |                                |                  |   |    |
| upp |   |                                |                  |   |    |
| lie |   |                                |                  |   |    |
| s** |   |                                |                  |   |    |
+-----+---+--------------------------------+------------------+---+----+
| >   |   |                                | > 50% of charges |   |    |
|  We |   |                                | > per            |   |    |
| >   |   |                                | > prescription   |   |    |
|  co |   |                                | > unit or        |   |    |
| ver |   |                                | > refill, after  |   |    |
| >   |   |                                | > you meet your  |   |    |
| the |   |                                | > \$600 per      |   |    |
| >   |   |                                | > member         |   |    |
| fol |   |                                | > deductible.    |   |    |
| low |   |                                |                  |   |    |
| ing |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  me |   |                                |                  |   |    |
| dic |   |                                |                  |   |    |
| ati |   |                                |                  |   |    |
| ons |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| and |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  su |   |                                |                  |   |    |
| ppl |   |                                |                  |   |    |
| ies |   |                                |                  |   |    |
| > p |   |                                |                  |   |    |
| res |   |                                |                  |   |    |
| cri |   |                                |                  |   |    |
| bed |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  by |   |                                |                  |   |    |
| > a |   |                                |                  |   |    |
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| lan |   |                                |                  |   |    |
| > p |   |                                |                  |   |    |
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| an: |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
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| >   |   |                                |                  |   |    |
|  Dr |   |                                |                  |   |    |
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| >   |   |                                |                  |   |    |
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| lud |   |                                |                  |   |    |
| ing |   |                                |                  |   |    |
| > i |   |                                |                  |   |    |
| nsu |   |                                |                  |   |    |
| lin |   |                                |                  |   |    |
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| syr |   |                                |                  |   |    |
| ing |   |                                |                  |   |    |
| es, |   |                                |                  |   |    |
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|  ne |   |                                |                  |   |    |
| edl |   |                                |                  |   |    |
| es, |   |                                |                  |   |    |
| > g |   |                                |                  |   |    |
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| ose |   |                                |                  |   |    |
| > t |   |                                |                  |   |    |
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| pe, |   |                                |                  |   |    |
| > B |   |                                |                  |   |    |
| ene |   |                                |                  |   |    |
| dic |   |                                |                  |   |    |
| t's |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
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| lut |   |                                |                  |   |    |
| ion |   |                                |                  |   |    |
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|  or |   |                                |                  |   |    |
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|  eq |   |                                |                  |   |    |
| uiv |   |                                |                  |   |    |
| ale |   |                                |                  |   |    |
| nt, |   |                                |                  |   |    |
| > g |   |                                |                  |   |    |
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| >   |   |                                |                  |   |    |
|  mo |   |                                |                  |   |    |
| nit |   |                                |                  |   |    |
| ors |   |                                |                  |   |    |
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| > a |   |                                |                  |   |    |
| cet |   |                                |                  |   |    |
| one |   |                                |                  |   |    |
| > t |   |                                |                  |   |    |
| est |   |                                |                  |   |    |
| > t |   |                                |                  |   |    |
| abl |   |                                |                  |   |    |
| ets |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| >  |   |                                |                  |   |    |
| > I |   |                                |                  |   |    |
| nsu |   |                                |                  |   |    |
| lin |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| >  |   |                                |                  |   |    |
| > D |   |                                |                  |   |    |
| isp |   |                                |                  |   |    |
| osa |   |                                |                  |   |    |
| ble |   |                                |                  |   |    |
| > n |   |                                |                  |   |    |
| eed |   |                                |                  |   |    |
| les |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| and |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  sy |   |                                |                  |   |    |
| rin |   |                                |                  |   |    |
| ges |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| for |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| the |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  ad |   |                                |                  |   |    |
| min |   |                                |                  |   |    |
| ist |   |                                |                  |   |    |
| rat |   |                                |                  |   |    |
| ion |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  of |   |                                |                  |   |    |
| > c |   |                                |                  |   |    |
| ove |   |                                |                  |   |    |
| red |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  me |   |                                |                  |   |    |
| dic |   |                                |                  |   |    |
| ati |   |                                |                  |   |    |
| ons |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| >  |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  Dr |   |                                |                  |   |    |
| ugs |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| for |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| sex |   |                                |                  |   |    |
| ual |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  dy |   |                                |                  |   |    |
| sfu |   |                                |                  |   |    |
| nct |   |                                |                  |   |    |
| ion |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| >  |   |                                |                  |   |    |
| > C |   |                                |                  |   |    |
| ont |   |                                |                  |   |    |
| rac |   |                                |                  |   |    |
| ept |   |                                |                  |   |    |
| ive |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  dr |   |                                |                  |   |    |
| ugs |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| and |   |                                |                  |   |    |
| > d |   |                                |                  |   |    |
| evi |   |                                |                  |   |    |
| ces |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| for |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  bi |   |                                |                  |   |    |
| rth |   |                                |                  |   |    |
| > c |   |                                |                  |   |    |
| ont |   |                                |                  |   |    |
| rol |   |                                |                  |   |    |
| > t |   |                                |                  |   |    |
| hat |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| are |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| FDA |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| app |   |                                |                  |   |    |
| rov |   |                                |                  |   |    |
| ed. |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  No |   |                                |                  |   |    |
| te: |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  We |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  co |   |                                |                  |   |    |
| ver |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  in |   |                                |                  |   |    |
| tra |   |                                |                  |   |    |
| ven |   |                                |                  |   |    |
| ous |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| flu |   |                                |                  |   |    |
| ids |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| and |   |                                |                  |   |    |
| > m |   |                                |                  |   |    |
| edi |   |                                |                  |   |    |
| cat |   |                                |                  |   |    |
| ion |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| for |   |                                |                  |   |    |
| > h |   |                                |                  |   |    |
| ome |   |                                |                  |   |    |
| > u |   |                                |                  |   |    |
| se, |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  im |   |                                |                  |   |    |
| pla |   |                                |                  |   |    |
| nta |   |                                |                  |   |    |
| ble |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| dru |   |                                |                  |   |    |
| gs, |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| and |   |                                |                  |   |    |
| > s |   |                                |                  |   |    |
| ome |   |                                |                  |   |    |
| > i |   |                                |                  |   |    |
| nje |   |                                |                  |   |    |
| cta |   |                                |                  |   |    |
| ble |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  dr |   |                                |                  |   |    |
| ugs |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  un |   |                                |                  |   |    |
| der |   |                                |                  |   |    |
| > M |   |                                |                  |   |    |
| edi |   |                                |                  |   |    |
| cal |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| and |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
|  Su |   |                                |                  |   |    |
| rgi |   |                                |                  |   |    |
| cal |   |                                |                  |   |    |
| >   |   |                                |                  |   |    |
| Ben |   |                                |                  |   |    |
| efi |   |                                |                  |   |    |
| ts. |   |                                |                  |   |    |
+-----+---+--------------------------------+------------------+---+----+

+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      | > **You pay**          |
| > *(continued)*                             |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All Charges*        |
| >                                           |                        |
| >  *Drugs and supplies for cosmetic        |                        |
| > purposes*                                 |                        |
| >                                           |                        |
| >  *Vitamins and nutritional substances    |                        |
| > that can be purchased without a           |                        |
| > prescription*                             |                        |
| >                                           |                        |
| >  *Nonprescription medicines*             |                        |
| >                                           |                        |
| >  *Medical supplies such as dressings and |                        |
| > antiseptics*                              |                        |
| >                                           |                        |
| >  *Drugs to enhance athletic performance* |                        |
| >                                           |                        |
| >  *Fertility drugs*                       |                        |
| >                                           |                        |
| >  *Smoking cessation drugs and            |                        |
| > medication*                               |                        |
+---------------------------------------------+------------------------+

+---+---+---------------------------------------+--------------+---+----+
| > |   |                                       |              |   |    |
|   |   |                                       |              |   |    |
| S |   |                                       |              |   |    |
| e |   |                                       |              |   |    |
| c |   |                                       |              |   |    |
| t |   |                                       |              |   |    |
| i |   |                                       |              |   |    |
| o |   |                                       |              |   |    |
| n |   |                                       |              |   |    |
| > |   |                                       |              |   |    |
|   |   |                                       |              |   |    |
| 5 |   |                                       |              |   |    |
| > |   |                                       |              |   |    |
|   |   |                                       |              |   |    |
| ( |   |                                       |              |   |    |
| g |   |                                       |              |   |    |
| ) |   |                                       |              |   |    |
| . |   |                                       |              |   |    |
| > |   |                                       |              |   |    |
|   |   |                                       |              |   |    |
| 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 |              | * |    |
|   | * | determine they are medically          |              | * |    |
|   | M | necessary.                            |              | M |    |
|   | * |                                       |              | * |    |
|   | * |  Plan dentists must provide or       |              | * |    |
|   |   | arrange your care.                    |              |   |    |
|   | * |                                       |              | * |    |
|   | * |  Be sure to read Section 4, Your     |              | * |    |
|   | P | costs for covered services for        |              | P |    |
|   | * | valuable information about how cost   |              | * |    |
|   | * | sharing works. Also read Section 9    |              | * |    |
|   |   | about coordinating benefits with      |              |   |    |
|   | * | other coverage, including with        |              | * |    |
|   | * | Medicare.                             |              | * |    |
|   | O |                                       |              | O |    |
|   | * |                                       |              | * |    |
|   | * |                                       |              | * |    |
|   |   |                                       |              |   |    |
|   | * |                                       |              | * |    |
|   | * |                                       |              | * |    |
|   | R |                                       |              | R |    |
|   | * |                                       |              | * |    |
|   | * |                                       |              | * |    |
|   |   |                                       |              |   |    |
|   | * |                                       |              | * |    |
|   | * |                                       |              | * |    |
|   | T |                                       |              | T |    |
|   | * |                                       |              | * |    |
|   | * |                                       |              | * |    |
|   |   |                                       |              |   |    |
|   | * |                                       |              | * |    |
|   | * |                                       |              | * |    |
|   | A |                                       |              | A |    |
|   | * |                                       |              | * |    |
|   | * |                                       |              | * |    |
|   |   |                                       |              |   |    |
|   | * |                                       |              | * |    |
|   | * |                                       |              | * |    |
|   | N |                                       |              | N |    |
|   | * |                                       |              | * |    |
|   | * |                                       |              | * |    |
|   |   |                                       |              |   |    |
|   | * |                                       |              | * |    |
|   | * |                                       |              | * |    |
|   | T |                                       |              | T |    |
|   | * |                                       |              | * |    |
|   | * |                                       |              | * |    |
+---+---+---------------------------------------+--------------+---+----+
| # |   |                                       | > **You      |   |    |
| # |   |                                       | > pay**      |   |    |
| # |   |                                       |              |   |    |
|   |   |                                       |              |   |    |
| * |   |                                       |              |   |    |
| * |   |                                       |              |   |    |
| A |   |                                       |              |   |    |
| c |   |                                       |              |   |    |
| c |   |                                       |              |   |    |
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| d |   |                                       |              |   |    |
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| t |   |                                       |              |   |    |
| a |   |                                       |              |   |    |
| l |   |                                       |              |   |    |
|   |   |                                       |              |   |    |
| i |   |                                       |              |   |    |
| n |   |                                       |              |   |    |
| j |   |                                       |              |   |    |
| u |   |                                       |              |   |    |
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| y |   |                                       |              |   |    |
|   |   |                                       |              |   |    |
| b |   |                                       |              |   |    |
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| i |   |                                       |              |   |    |
| t |   |                                       |              |   |    |
| * |   |                                       |              |   |    |
| * |   |                                       |              |   |    |
+---+---+---------------------------------------+--------------+---+----+
| > |   |                                       | Nothing      |   |    |
|   |   |                                       |              |   |    |
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|   |   |                                       |              |   |    |
| a |   |                                       |              |   |    |
| n |   |                                       |              |   |    |
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|   |   |                                       |              |   |    |
| a |   |                                       |              |   |    |
| c |   |                                       |              |   |    |
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| d |   |                                       |              |   |    |
| e |   |                                       |              |   |    |
| n |   |                                       |              |   |    |
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| a |   |                                       |              |   |    |
| l |   |                                       |              |   |    |
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|   |   |                                       |              |   |    |
| i |   |                                       |              |   |    |
| n |   |                                       |              |   |    |
| j |   |                                       |              |   |    |
| u |   |                                       |              |   |    |
| r |   |                                       |              |   |    |
| y |   |                                       |              |   |    |
| . |   |                                       |              |   |    |
+---+---+---------------------------------------+--------------+---+----+
| > |   |                                       |              |   |    |
|   |   |                                       |              |   |    |
| * |   |                                       |              |   |    |
| * |   |                                       |              |   |    |
| D |   |                                       |              |   |    |
| e |   |                                       |              |   |    |
| n |   |                                       |              |   |    |
| t |   |                                       |              |   |    |
| a |   |                                       |              |   |    |
| l |   |                                       |              |   |    |
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|   |   |                                       |              |   |    |
| b |   |                                       |              |   |    |
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| n |   |                                       |              |   |    |
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| f |   |                                       |              |   |    |
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| t |   |                                       |              |   |    |
| s |   |                                       |              |   |    |
| * |   |                                       |              |   |    |
| * |   |                                       |              |   |    |
+---+---+---------------------------------------+--------------+---+----+
| > |   |                                       |              |   |    |
|   |   |                                       |              |   |    |
| W |   |                                       |              |   |    |
| e |   |                                       |              |   |    |
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|   |   |                                       |              |   |    |
| o |   |                                       |              |   |    |
| t |   |                                       |              |   |    |
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| r |   |                                       |              |   |    |
| > |   |                                       |              |   |    |
|   |   |                                       |              |   |    |
| d |   |                                       |              |   |    |
| e |   |                                       |              |   |    |
| n |   |                                       |              |   |    |
| t |   |                                       |              |   |    |
| a |   |                                       |              |   |    |
| l |   |                                       |              |   |    |
| > |   |                                       |              |   |    |
|   |   |                                       |              |   |    |
| b |   |                                       |              |   |    |
| e |   |                                       |              |   |    |
| n |   |                                       |              |   |    |
| e |   |                                       |              |   |    |
| f |   |                                       |              |   |    |
| i |   |                                       |              |   |    |
| t |   |                                       |              |   |    |
| s |   |                                       |              |   |    |
| . |   |                                       |              |   |    |
+---+---+---------------------------------------+--------------+---+----+

+-----------------------------------------------------------------------+
| > 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 or condition.**
>
> We do not cover the following:

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

-   Services, drugs, or supplies you receive while you are not enrolled
    in 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,or coinsurance.

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

**Medical, hospital and drug benefits**

In most cases, providers and facilities file claims for you. Physicians
must file on the form HCFA-1500, Health Insurance Claim Form. Facilities
will file on the UB-92 form. For claims questions and assistance, call
us at 701-776-5848.

When you must file a claim \-- such as for out-of-area care \-- submit
it on the HCFA-1500 or a claim form that includes the information shown
below. Bills and receipts should be itemized and show:

-   Covered member's name and ID number;

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

-   Dates you received the services or supplies;

-   Diagnosis;

-   Type of each service or supply;

-   The charge for each service or supply;

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

-   Receipts, if you paid for your services.

> **Submit your claims to:** Heart of America HMO
>
> 810 South Main
>
> Rugby, ND 58368

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

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

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

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

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

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | \(a\) Write to us within 6 months from the date of our decision; |
| * | and                                                              |
| * |                                                                  |
|   | \(b\) Send your request to us at: Heart of America HMO, 810      |
|   | South Main, Rugby, ND 58368; and                                 |
|   |                                                                  |
|   | \(c\) Include a statement about why you believe our initial      |
|   | decision was wrong, based on specific benefit provisions in this |
|   | brochure; and                                                    |
|   |                                                                  |
|   | \(d\) Include copies of documents that support your claim, such  |
|   | as physicians\' letters, operative reports, bills, medical       |
|   | records, and explanation of benefits (EOB) forms.                |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | \(a\) Pay the claim (or 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 medical provider for more information. If  |
|   | we ask your provider, we will send you a copy of our             |
|   | request---go to step 3.                                          |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   |  90 days after the date of our letter upholding our initial     |
|   | decision; or                                                     |
|   |                                                                  |
|   |  120 days after you first wrote to us \-- if we did not answer  |
|   | that request in some way within 30 days; or                      |
|   |                                                                  |
|   |  120 days after we asked for additional information.            |
+---+------------------------------------------------------------------+
|   | Write to OPM at: Office of Personnel Management, Office of       |
|   | Insurance Programs, Health Benefits Contracts Division 3, 1900 E |
|   | Street, NW, Washington, DC 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.         |
|   |                                                                  |
|   | 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 provide a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | If you do not agree with OPM's decision, your only recourse is   |
|   | to sue. If you decide to sue, you must file the suit against OPM |
|   | in Federal court by December 31 of the third year after the year |
|   | in which you received the disputed services or supplies or from  |
|   | the year in which you were denied precertification or prior      |
|   | approval. This is the only deadline that may not be extended.    |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support their disputed claim decision. This           |
|   | information will become part of the court record.                |
+---+------------------------------------------------------------------+
|   | You may not sue until you have completed the disputed claims     |
|   | process. Further, Federal law governs your lawsuit, benefits,    |
|   | and payment of benefits. The Federal court will base its review  |
|   | on the record that was before OPM when OPM decided to uphold or  |
|   | overturn our decision. You may recover only the amount of        |
|   | benefits in dispute.                                             |
+---+------------------------------------------------------------------+

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

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at 701-776-5848 or
    1-800-525-5661 and we will expedite our review; or

```{=html}
<!-- -->
```
(a) We denied your initial request for care or preauthorization/prior
    approval, then:

> • If we expedite our review and maintain our denial, we will inform
> OPM so that they can give your claim expedited treatment too, or
>
> • You may call OPM\'s Health Benefits Contracts Division 3 at
> 202/606-0755 between 8 a.m. and 5 p.m. eastern time.

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

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

**When you have other health**

**coverage** You must tell us if you or a covered family member have
coverage under another group health plan or have automobile insurance
that pays medical 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 what the reasonable
charge for the benefit should be. After the primary plan pays, we will
pay what is left of the reasonable charge up to our regular benefit. We
will not pay more than our reasonable charge.

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

• People 65 years of age and older.

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

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

Medicare has two parts:

• Part A (Hospital Insurance). Most people do not have to pay for Part
A.

> If you or your spouse worked for at least 10 years in Medicare-covered
> employment, you should be able to qualify for premium-free Part A
> insurance. (Someone who was a Federal employee on January1, 1983 or
> since automatically qualifies.) Otherwise, if you are age 65 or older,
> you may be able to buy it. Contact 1-800-MEDICARE for more information

• Part B (Medical Insurance). Most people pay monthly for Part B.

> Generally, Part B premiums are withheld from your monthly Social
> Security check or your retirement check

**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**

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

When you are enrolled in Original Medicare along with this plan, you
still need to follow the rules in this brochure for us to cover your
care. Your care must continue to be directed by your Primary Care
Physician and referrals for specialty care must be approved by the HAHMO
Medical Director in order for us to pay our share.

> **Claims process when you have the Original Medicare Plan \--** You
> will probably never have to file a claim form when you have both our
> Plan and the Original 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 claims 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 claims, call us at 776-5854 or
    800-525-5661.

> We waive our copayment for visits to your primary care physician or
> authorized visits to a specialist. We waive our copayment for
> emergency room visits

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

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

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

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

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

.

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

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

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

**Suspended FEHB coverage to enroll in a Medicare + choice plan:** If
you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare + choice plan, eliminating your FEHB
premium. (OPM does not contribute to your Medicare + choice plan
premium.) For information on suspending your FEHB enrollment, contact
your retirement office. If you later want to re-enroll in the FEHB
Program, generally you may do so only at the next open season unless you
involuntarily lose coverage or move out of the Medicare + choice plans
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 or CHAMPVA
Health Benefits Advisor if you have questions about these programs.

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

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

> • you need because of a workplace-related disease 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 eligible care. You must use our providers.

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

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

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

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

**When others are responsible**

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

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

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

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

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

**Coinsurance** Coinsurance is the percentage of our reasonable charge
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 that HAHMO determines is
essential to assist the patient in meeting the activities of daily
living and is not primarily provided for therapeutic treatment of an
illness, disease, injury or condition. Care that exceeds 90 days may
also be classified as Long term care.

**Deductible** A deductible is a fixed amount of covered expenses you
must incur for certain covered services and supplies before we start
paying benefits for those services. See page 13.

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

**investigational services** investigational:

-   If the drug or device does not have required Food and Drug
    Administration (FDA) approval.

-   If reliable, (reports in respected medical and scientific
    literature) shows that the opinion of experts determine that further
    study is needed to decide how a drug, device or medical treatment or
    procedure compares with the standard method of treatment or
    diagnosis.

**Group health coverage** Health care coverage that a member is eligible
for because of employment by, membership in, or connection with, a
particular organization or group that provides payment for hospital,
medical, or other health care services or supplies.

**Medical necessity** Services, supplies or treatment rendered by a
hospital physician, skilled nursing facility, home health agency, or
other provider to treat an illness or injury which is:

-   Consistent with the symptoms or diagnosis of the condition, disease,
    ailment or injury;

-   Appropriate and accepted according to good medical practice
    standards;

-   Not primarily for the convenience of the member or the provider of
    care;

-   The most appropriate supply or level of service that can safely be
    provided to a member. When a member receives inpatient care, it
    further means that the member's medical symptoms or condition could
    not safely be treated on an outpatient basis.

**Plan allowance** Our Plan allowance is the amount we use to determine
our payment and your coinsurance for covered services. Plans determine
their allowance in different ways. We determine our allowance as
follows:

Our payment is based on usual, customary and reasonable charges. Usual,
Customary, and Reasonable means the usual charge made by a physician or
other supplier of services, medicines or supplies. The charge cannot
exceed the general level of charges made by other suppliers within the
area in which the charge is incurred for injury or sickness comparable
in severity and nature to the injury and sickness being treated.

**Us/We** Us and we refer to Heart of America HMO.

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

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

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

**Coverage information**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

**When you lose benefits**

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

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

You may be eligible for spouse equity coverage or Temporary Continuation
of Coverage.

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

**coverage** continue to get benefits under your former spouse's
enrollment. This is the case even 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 ww.opm.gov/insure.

**•Temporary continuation**

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

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

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

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

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

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

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

-   **What is an FSA?** It is a tax-favored benefit that allows you to
    set aside pre-tax money from

> your paychecks to pay for a variety of eligible expenses. *By using an
> FSA,* *you can reduce your taxes while paying for services you would
> have to pay for anyway, producing a discount that can be over 40%!!*

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

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

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

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

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

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

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

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-   **Enroll during Open Season** You **must make an election** to
    enroll in an FSA during the FEHB Open

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

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

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

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

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

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

> **contribute to my FSA?** Because of the tax **c**enefits 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

**pay** **for?** deductibles you must meet before the Plan provides
benefits, coinsurance

> or copayments that you pay when you and the Plan share costs, and
> medical services and supplies that are not covered by the Plan and for
> which you must pay. These out-of-pocket costs are summarized on page
> 13 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:coinsurance
> for services rendered by non-Plan specialists and facilities. A
> calendar year deductible apply to prescription drugs.
>
> 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

> **deductions** receive reimbursement for them from your HCFSA or
> DCFSA. Below are some guidelines that
>
> may help you decide whether to participate in FSAFEDS.

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

> reimbursed from the HCFSA at any time during the year for expenses up
> to the annual amount you\'ve elected to contribute.
>
> Only health care expenses exceeding 7.5% of your adjusted gross income
> are eligible to be deducted on your Federal income tax return. Using
> the example listed in the above chart, only health care expenses
> exceeding \$3,750 (7.5% of \$50,000) would be eligible to be deducted
> on your Federal income tax return. In addition, money set aside
> through a HCFSA is also exempt from FICA taxes. This 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

**to** **participate in FSAFEDS?** an HCFSA and 1.5% of the annual
election for a DCFSA, most agencies

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

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

> [**www.fsafeds.com**](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 does not
explain your benefit coverage.

**A**ccidental injury 35

Allergy tests 19

Alternative treatment 23

Ambulance 28

Anesthesia 26

Autologous bone marrow transplant 26

**B**iopsies 24

Birthing centers 17

Blood and blood plasma 27

Breast cancer screening 16

Casts 27

Catastrophic protection 13

Changes for 2004 9

Chemotherapy 19

Childbirth 17

Cholesterol tests 16

Claims 37-39

Coinsurance 13

Colorectal cancer screening 16

Congenital anomalies 24

Contraceptive devices and drugs 18

Coordination of benefits 40

Covered charges 57

Covered providers 10

Crutches 22

**D**eductible 13

Definitions 45

Dental care 35

Diagnostic services 15-16

Disputed claims review 38-39

Donor expenses (transplants) 26

Dressings 27

Durable medical equipment (DME) 22

**E**ducational classes and programs 23

Effective date of enrollment 47

Emergency 29-30

Experimental or investigational 36

Eyeglasses 21

**F**amily planning 18

Fecal occult blood test 16

**G**eneral Exclusions 36

**H**earing services 21

Home health services 23

Hospice care 28

Home nursing care 23

Hospital 12

**I**mmunizations 16-17

Infertility 18

Inhospital physician care 15

Inpatient Hospital Benefits 27

Insulin 22, 34

**L**aboratory and pathological services 15-16

**M**achine diagnostic tests 15-16

Magnetic Resonance Imagings (MRIs) 16

Mammograms 15

Maternity Benefits 17

Medicaid 44

Medically necessary 45

Medicare 40-41

Members 47

Mental Conditions/Substance Abuse Benefits 32

**N**eurological testing 16

Newborn care 17

Nursery charges 17

**O**bstetrical care 17

Occupational therapy 20

Office visits 15

Oral and maxillofacial surgery 25

Orthopedic devices 22

Ostomy and catheter supplies 22

Out-of-pocket expenses 13

Outpatient facility care 28

Oxygen 28

**P**ap test 16

Physical examination 16

Physical therapy 20

Physician 15

Preventive care, adult 16

Preventive care, children 17

Prescription drugs 33-34

Preventive services 16-17

Prior approval 12

Prostate cancer screening 16

Prosthetic devices 22

Psychologist 31

Psychotherapy 31-32

**R**adiation therapy 19

Rehabilitation therapies 20

Renal dialysis 19

Room and board 27

**S**econd surgical opinion 15

Skilled nursing facility care 28

Smoking cessation 23

Speech therapy 20

Splints 27

Sterilization procedures 18

Subrogation 44

Substance abuse 32

Surgery 24

-   Anesthesia 26

-   Oral 25

-   Outpatient 24-25

-   Reconstructive 25

Syringes 34

**T**emporary continuation of coverage 49

Transplants 26

Treatment therapies 19

**V**ision services 21

**W**ell child care 17

Wheelchairs 22

Workers' compensation 44

**X**-rays 16

  -----------------------------------------------------------------------
  **Summary of benefits for the Heart of America HMO -- 2004**

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

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

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

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

-   Below, an asterisk (\*) means the item is subject to the \$600
    calendar year deductible.

+-------------------------------------------+----------------------+---+
| **Benefits**                              | **You Pay**          | * |
|                                           |                      | * |
|                                           |                      | P |
|                                           |                      | a |
|                                           |                      | g |
|                                           |                      | e |
|                                           |                      | * |
|                                           |                      | * |
+-------------------------------------------+----------------------+---+
| Medical services provided by physicians:  | Office visit copay:  | > |
|                                           | \$10 primary care;   |   |
|  Diagnostic and treatment services       | \$ 0 specialist      | 1 |
| provided in the office                    |                      | 5 |
+-------------------------------------------+----------------------+---+
| Services provided by a hospital:          | > Nothing            | > |
|                                           |                      |   |
| >  Inpatient                             |                      | 2 |
| >                                         |                      | 7 |
| >  Outpatient                            |                      | > |
|                                           |                      | > |
|                                           |                      |   |
|                                           |                      | 2 |
|                                           |                      | 8 |
+-------------------------------------------+----------------------+---+
| Emergency benefits:                       | > \$30 copay for     | > |
|                                           | > each emergency     |   |
| >  In-area                               | > room visit.        | 3 |
| >                                         | >                    | 0 |
| >  Out-of-area                           | > \$30 copay for     | > |
|                                           | > each emergency     | > |
|                                           | > room visit.        |   |
|                                           |                      | 3 |
|                                           |                      | 0 |
+-------------------------------------------+----------------------+---+
| Mental health and substance abuse         | > Regular cost       | > |
| treatment                                 | > sharing.           |   |
|                                           |                      | 3 |
|                                           |                      | 1 |
+-------------------------------------------+----------------------+---+
| Prescription drugs                        | > *\*\$600           | > |
|                                           | > deductible and 50% |   |
|                                           | > of charges         | 3 |
|                                           | > thereafter.*       | 3 |
+-------------------------------------------+----------------------+---+
| Dental Care                               | > No benefit.        | > |
|                                           |                      |   |
| (Accidental injury benefit only)          |                      | 3 |
|                                           |                      | 5 |
+-------------------------------------------+----------------------+---+
| Vision Care                               | > No benefit.        |   |
+-------------------------------------------+----------------------+---+
| Protection against catastrophic costs     | Nothing after you    | > |
|                                           | have met the maximum |   |
| (Your out-of-pocket maximum)              | of 50% of your       | 1 |
|                                           | annual premium per   | 3 |
|                                           | calendar year.       |   |
|                                           |                      |   |
|                                           | Some costs do not    |   |
|                                           | count toward this    |   |
|                                           | protection           |   |
+-------------------------------------------+----------------------+---+

**2004 Rate Information for**

**Heart of America HMO Health Plan**

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

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

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

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

  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------
  **Self Only**   **RU1**   **\$88.82**    **\$29.60**   **\$192.44**   **\$**         **\$105.10**   **\$13.32**
                                                                        **64.14**                     

  **Self and      **RU2**   **\$228.26**   **\$76.08**   **\$494.55**   **\$164.85**   **\$270.10**   **\$34.24**
  Family**                                                                                            
  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------