NALC Health

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**Benefit Plan**

**<http://www.nalc.org/depart/hbp> 2004**

**A fee-for-service plan**

**with a preferred provider organization**

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**Sponsored and administered by the National Association of Letter
Carriers (NALC), AFL-CIO**

**Who may enroll in this Plan:**

-   A federal or postal employee or annuitant eligible to enroll in the
    Federal Employees Health Benefits Program;

-   A former spouse eligible for coverage under the Spouse Equity Law;
    or

-   An employee, former spouse, or child eligible for Temporary
    Continuation of Coverage (TCC).

> To enroll, you must be or become a member of the National Association
> of Letter Carriers.

**To become a member:**

-   If you are a Postal Service employee, you must be a dues-paying
    member of an NALC local branch.

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-   If you are a non-postal employee or annuitant, or a Spouse Equity or
    TCC enrollee, you become an associate member of NALC when you enroll
    in the NALC Health Benefit Plan.

![](media/image3.jpeg){width="1.3597222222222223in"
height="0.8145833333333333in"}**Membership dues:** NALC dues vary by
local branch. Associate members will be billed by the NALC for the \$36
annual membership fee, except where exempt by law.

**Enrollment codes for this Plan:**

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**321 Self Only**

**322 Self and Family**

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height="0.7256944444444444in"}

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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](http://www.usajobs.opm.gov/).

> Sincerely,
>
> ![](media/image9.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

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height="1.0354166666666667in"}

# ![](media/image11.png){width="1.1666666666666667in" height="0.9166666666666666in"}Notice of the United States

#  Office of Personnel Management's

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

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  Table of Contents
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Introduction............................................................................
4

Plain Language 4

Stop Health Care Fraud! 5

Preventing medical mistakes 6

Section 1. Facts about this fee-for-service plan 7

-   Notice of the NALC Health Benefit Plan's Privacy Practices 8

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

Section 3. How you get care 12

Identification cards 12

Where you get covered care 12

-   Covered providers 12

-   Covered facilities 12

What you must do to get covered care 13

How to get approval for 13

-   Your hospital stay (precertification) 13

-   Other services 14

Section 4. Your costs for covered services 15

-   Copayments 15

-   Deductible 15

-   Coinsurance 15

-   Differences between our allowance and the bill 15

Your catastrophic protection out-of-pocket maximum 16

When Government facilities bill us 16

If we overpay you 16

When you are age 65 or older and you do **not** have Medicare 17

When you have the Original Medicare Plan 18

Should I enroll in Medicare? 18

Section 5.
Benefits..................................................................
19

Overview 19

(a) Medical services and supplies provided by physicians and other
    health care professionals 20

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

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

(d) Emergency services/accidents 37

(e) Mental health and substance abuse benefits 39

(f) Prescription drug benefits 42

(g) Special features 44

-   Flexible benefits option

-   24-hour nurse line

-   24-hour help line for mental health and substance abuse

-   Services for deaf and hearing impaired

-   Disease management programs

-   Worldwide coverage

(h) Dental benefits 45

(i) Non-FEHB benefits available to Plan members 46

Section 6. General exclusions---things we don\'t cover 47

Section 7. Filing a claim for covered services 48

Section 8. The disputed claims process 49

Section 9. Coordinating benefits with other coverage 51

When you have other health coverage 51

What is Medicare? 51

-   Medicare + Choice 53

TRICARE and CHAMPVA 53

Workers' Compensation 53

Medicaid 54

When other Government agencies are responsible for your care 54

When others are responsible for injuries 54

Section 10. Definitions of terms we use in this brochure 55

Section 11. FEHB facts 57

Coverage information 57

-   No pre-existing condition limitation 57

-   Where you can get information about enrolling in the FEHB Program 57

-   Types of coverage available for you and your family 57

-   Children's Equity Act 57

-   When benefits and premiums start 58

-   When you retire 58

When you lose benefits 58

• When FEHB coverage ends 58

• Spouse equity coverage 58

• Temporary Continuation of Coverage (TCC) 59

• Converting to individual coverage 59

-   Getting a Certificate of Group Health Plan Coverage 59

Two new Federal Programs complement FEHB benefits 60

The Federal Flexible Spending Account Program -- *FSAFEDS* 60

The Federal Long Term Care Insurance Program 62

Index 63

Summary of benefits 65

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

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  Introduction

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This brochure describes the benefits of the **NALC Health Benefit Plan**
under our contract (CS 1067) with the United States Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits
law. The address for the NALC Health Benefit Plan administrative offices
is:

NALC Health Benefit Plan

20547 Waverly Court

Ashburn, VA 20149

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

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

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and changes are summarized on
page 11. Rates are shown at the end of this brochure.

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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 NALC
    Health Benefit Plan*.*

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

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

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

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  Stop Health Care Fraud!

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

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

**Protect Yourself From Fraud** - Here are some things you can do to
prevent fraud:

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

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at 703/729-4677
    or 1-888-636-NALC (6252) and explain the situation.

-   If we do not resolve the issue:

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

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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 age 22 or older (unless he/she is disabled and incapable
    of self support).

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

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

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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 health care providers and
    improve the quality of care you receive.

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

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

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

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

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

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  **Section 1. Facts about this fee-for-service plan**

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This Plan is a fee-for-service (FFS) plan. You can choose your own
physicians, hospitals, and other health care providers.

We reimburse you or your provider for your covered services, usually
based on a percentage of the amount we allow. The type and extent of
covered services, and the amount we allow, may be different from other
plans. Read brochures carefully.

**We also have Preferred Provider Organizations (PPO)**

Our fee-for-service plan offers services through a PPO. When you use our
PPO providers, you receive covered services at reduced cost. First
Health is solely responsible for the selection of PPO providers in your
area. Call\
1-800-622-6252 for the names of PPO providers and to verify their
continued participation, or call us at\
703/729-4677 or 1-888-636-NALC (6252) to request a PPO directory. You
can also go to our Web page, which you can reach through the FEHB Web
site, [www.opm.gov/insure](http://www.opm.gov/insure).

The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. Provider networks may
be more extensive in some areas than others. We cannot guarantee the
availability of every specialty in all areas. If no PPO provider is
available, or you do not use a PPO provider, the non-PPO benefits apply.

How we pay providers

When you use a PPO provider or facility, our Plan allowance is the
negotiated rate for the service. You are not responsible for charges
above the negotiated amount.

Non-PPO facilities and providers do not have special agreements with us.
Our payment is based on our allowance for covered services. You may be
responsible for amounts over the allowance.

We also obtain discounts from some non-PPO providers. When we obtain
discounts through negotiation with providers (PPO or non-PPO), we share
the savings with you.

**Your Rights**

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

-   The NALC Health Benefit Plan has been part of the FEHB Program since
    July 1960.

-   We are a not-for-profit employee organization sponsored health plan.

-   Our preferred provider organization (PPO) is The **First Health**
    Network.

-   Our network provider for mental health and substance abuse benefits
    is United Behavioral Health.

-   Our prescription drug retail network is the NALC CareSelect Network.

-   Our mail order prescription program is through CAREMARK.

If you want more information about us, call 703/729-4677 or
1-888-636-NALC (6252), or write to NALC Health Benefit Plan, 20547
Waverly Court, Ashburn, VA 20149. You may also visit our Web site at
[www.nalc.org/depart/hbp](http://www.nalc.org/depart/hbp).

**NOTICE OF THE NALC HEALTH BENEFIT PLAN'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.**

**I. Understanding Your Health Record/Information**

Each time you visit a physician, hospital, or other health care
provider, the details of your visit are recorded, and the record becomes
part of your individually identifiable health information. This
information---your symptoms, examination and test results, diagnosis,
and treatment---is protected health information, and we refer to it as
\"PHI.\" Health care providers may share PHI as they plan and coordinate
treatment, and health plans use PHI to determine benefits and process
claims.

**II. Our Privacy Practices**

Your protected health information allows us to provide prompt and
accurate consideration of your health claims. We store PHI through a
combination of paper and electronic means and limit its access to
individuals trained in the handling of protected health information.

In accordance with the requirements of the Privacy Rule of the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), we
safeguard any information you or your health care provider shares with
us.

**III. Uses and Disclosures of Protected Health Information**

Except for the purposes of treatment, payment, and health care
operations, or as otherwise described in this notice, we will disclose
your PHI only to you or your personal representative (someone who has
the legal right or authority to act for you).

We can use and disclose your PHI without individual authorization when
our use and disclosure is to carry out treatment, payment, and health
care operations.

-   Example (treatment): Based upon the PHI in your file, we may contact
    your physician and discuss possible drug interactions or duplicative
    therapy.

-   Example (payment): We disclose PHI when we ask your physician to
    clarify information or to provide additional information if your
    claim form is incomplete.

-   Examples (health care operations): We disclose PHI as part of our
    routine health care operations when we submit individual claims or
    files for audits. We may use and disclose your protected health
    information as part of our efforts to uncover instances of provider
    abuse and fraud. Or, we may combine the protected health information
    of many participants to help us decide on services for which we
    should provide coverage.

We also are permitted or required to disclose PHI without your written
permission (authorization) for other purposes:

-   To Business Associates: We contract with business associates to
    provide some services. Examples include, but are not limited to, our
    Preferred Provider Organization and Prescription Drug Program. When
    these services are contracted, we may disclose your PHI to our
    business associates so that they can perform the job we\'ve asked
    them to do in the consideration of your health claim. To protect
    your protected health information, however, we require our business
    associates to appropriately safeguard your information.

-   To Workers\' Compensation Offices: We may disclose your PHI to the
    extent authorized by, and to the extent necessary to comply with,
    laws relating to workers\' compensation or other similar programs
    established by law.

-   To Public Health Offices: As required by law, we may disclose your
    PHI to public health or legal authorities charged with preventing or
    controlling disease, injury, or disability.

-   To Health Oversight Agencies: We may disclose your PHI to a health
    oversight agency for activities authorized by law, such as audits,
    investigations, inspections, and legal actions. Oversight agencies
    seeking this information include government agencies that oversee
    the health care system, government benefit programs, other
    government regulatory programs, and civil rights laws.

-   For Health-Related Benefits and Services: We---or our business
    associates---may contact you or your health care provider to provide
    information about treatment alternatives or other health-related
    benefits and services that may be of interest to you.

-   For Food and Drug Administration Activities: We may disclose your
    PHI to a person or organization required by the Food and Drug
    Administration to track products or to report adverse effects,
    product defects or problems, or biological product deviations. Your
    protected health information may be used to enable product recalls,
    to make repairs or replacements, or to conduct post-marketing
    surveillance.

-   For Research Studies: We may disclose your PHI to researchers when
    an institutional review board that has established protocols to
    ensure the privacy of your protected health information, has
    approved their research.

-   For Military Activity and National Security: When the appropriate
    conditions apply, we may use or disclose protected health
    information of individuals who are Armed Forces personnel for
    activities deemed necessary by military command authorities; or to a
    foreign military authority if you are a member of that foreign
    military service. We may also disclose your protected health
    information to authorized federal officials conducting national
    security and intelligence activities, including protection of the
    President.

-   For Legal Proceedings: We may disclose your PHI in the course of a
    judicial or administrative proceeding; in response to an order of a
    court or administrative tribunal; or in response to a subpoena,
    discovery request, or other lawful process. Before we release PHI in
    response to a subpoena, discovery request, or other legal process
    not accompanied by a court order, we will require certain written
    assurances from the party seeking the PHI, consistent with the
    requirements of the HIPAA Privacy Regulations.

-   For Law Enforcement: We may disclose your PHI to a law enforcement
    official as part of certain law enforcement activities.

-   Regarding Inmates: If you are an inmate of a correctional
    institution or under the custody of a law enforcement official, we
    may release your PHI to the institution or law enforcement official,
    if the protected health information is necessary for the institution
    to provide you with health care, to protect the health and safety of
    you or others, or for the security of the correctional institution.

-   For Compliance Verification: We may disclose your PHI to the
    Secretary of the United States Department of Health and Human
    Services to investigate or determine our compliance with the federal
    regulations regarding privacy.

-   For Disaster Relief Purposes: We may disclose your protected health
    information to any authorized public or private entities assisting
    in disaster relief efforts.

Whether we use or disclose protected health information for treatment,
payment, or health care operations, or for another purpose, we limit our
use and disclosure to the minimum necessary information.

We must have your authorization to use or disclose your protected health
information for a purpose other than to carry out treatment, payment, or
health care operations, or the permitted uses and disclosures set forth
above, unless you cannot give an authorization because you are
incapacitated or there is an emergency situation.

-   Example: We would have to have your written authorization before we
    could provide your current physician PHI from a prior physician\'s
    bills, even if you wanted us to provide the information because the
    prior physician\'s records were unavailable.

You may revoke your authorization by writing to us, but your revocation
will not apply to actions we took before we received the revocation.
Send your request to our Privacy Official, at the address shown in
*VIII. How to Contact Us* below. We will not use or disclose protected
health information covered by an authorization once we receive your
revocation of the authorization.

If a use or disclosure for any purpose is prohibited or materially
limited by a federal law other than HIPAA that applies to this Plan, we
will meet the standards of the more stringent law.

**IV. Specific Uses of Protected Health Information**

Our plan is sponsored and administered by the National Association of
Letter Carriers (NALC), AFL-CIO. To be eligible for our health benefits,
you must be a member of the sponsoring organization. We provide NALC
access to our membership files so that they can ensure the membership
requirement has been met. We do not disclose claims-related information
to the NALC.

**V. Your Health Information Rights**

Although documents provided to the NALC Health Benefit Plan are our
property, the information belongs to you. With respect to protected
health information, you have these rights:

-   The right to see and get a copy of your protected health
    information. To request access to inspect and/or obtain a copy of
    your PHI, you must submit your request in writing to our Privacy
    Official, indicating the specific information you want. If you
    request a copy, we will impose a fee to cover the costs of copying
    and postage. We may decide to deny access to your protected health
    information. Depending on the circumstances, that decision to deny
    access may be reviewable by a licensed health professional that was
    not involved in the initial denial of access.

-   The right to request restrictions on certain uses and disclosures of
    your PHI. To request a restriction, write to our Privacy Official,
    indicating what information you want to limit; whether you want to
    limit use, disclosure, or both; and to whom you want the limits to
    apply. We are not required to agree to a restriction, but if we do,
    we will abide by our agreement, unless the restricted information is
    needed for emergency treatment.

-   The right to receive confidential communications of PHI. We will
    mail our explanation of benefits (EOB) statements and other
    payment-related materials to the enrollee. However, if you believe
    disclosure of your protected health information could result in harm
    to yourself or others, you have the right to request to receive
    confidential communications of PHI at an alternative address. Send
    your written request to our Privacy Official at the address listed
    at the end of this Notice. In the request, you must tell us (1) the
    address to which we should mail your PHI, and (2) that the
    disclosure of all or part of your PHI to an address other than the
    one you provided could endanger you or others. If we can accommodate
    your request, we will.

-   The right to receive an accounting of disclosures of PHI. You may
    request an accounting of the disclosures made by the Plan or its
    business associates including the names of persons and organizations
    that received your personal health information within six years (or
    less) of the date on which the accounting is requested, but not
    prior to April 14, 2003. Submit your request in writing to our
    Privacy Official.

> The listing will not cover disclosures made to carry out treatment,
> payment or health care operations; disclosures made to you or your
> personal representative regarding your own PHI; disclosures made to
> correctional institutions or for law enforcement purposes; or any
> information that you authorized us to release. The first request
> within a 12-month period will be free. For additional requests within
> the 12-month period, we will charge you for the costs of providing the
> accounting. We will notify you of the cost involved, and you may
> choose to withdraw or modify your request at that time, before any
> costs are incurred.

-   The right to amend the protected health information we have created,
    if you believe information is wrong or missing, and we agree. If you
    believe our information about you is incorrect, notify us in writing
    and we will investigate. Provide us the reason that supports your
    request. We will correct any errors we find.

> We may deny your request for an amendment if it does not include a
> reason to support your request. Additionally, we may deny your request
> if you ask us to amend information that 1) was not created by us,
> unless the person or entity that created the information is no longer
> available to make the amendment; 2) is not part of the health
> information kept by us; 3) is not part of the information which you
> would be permitted to inspect and copy; or 4) is accurate and
> complete.
>
> If we do not agree to the amendment, you may file a statement of
> disagreement with us, or you may request that we include your request
> for amendment along with the information, if and when we disclose your
> protected health information in the future. We may prepare a written
> rebuttal to your statement and will provide you with a copy of such
> rebuttal.
>
> If you have any questions about the right to access, or request
> correction of, information in your file, contact us.

-   The right to obtain a paper copy of our notice of privacy practices
    (Notice), upon request. Additionally, you may visit our web site at
    [www.nalc.org/depart/hbp]{.underline} to view or download the
    current notice.

**VI. Our Responsibilities to You**

We at the National Association of Letter Carriers Health Benefit Plan
are concerned about protecting the privacy of each of our member's
protected health information. We apply the same privacy rules for all
members -- current and former.

-   We are required by law to maintain the privacy of protected health
    information and to provide notice of our legal duties and privacy
    practices with respect to protected health information.

-   We are required to abide by the terms of our Notice.

-   We reserve the right to change the terms of our Notice and to make
    the new Notice provisions effective for all protected health
    information we maintain.

-   If we make a material revision to the content of this notice, we
    will provide each current member a new notice by mail, within 60
    days of the material revision.

**VII. To File a Complaint**

If you believe we have violated your privacy rights, you may file a
complaint with us or with the Secretary of the United States Department
of Health and Human Services. To file a complaint with us, write to our
Privacy Official at the address listed below. There will be no
retaliation for your filing a complaint.

**VIII. How to Contact Us**

If you have questions, you may call our Customer Service Department at
703/729-4677 or 1-888-636-NALC (6252), or you may write to our Privacy
Official. If you write to us, please provide a copy of your Member
identification card.

The address for our Privacy Official is:

Privacy Official

NALC Health Benefit Plan

20547 Waverly Court

Ashburn, VA 20149

**IX. Effective Date**

The terms of this Notice are in effect as of January 1, 2004.

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

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program -- *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 60.

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

-   We added information regarding enrolling in Medicare. See page 18.

-   We revised the Medicare Primary Payer Chart. See page 52.

**Changes to this Plan**

-   Your share of the NALC Postal premium will increase by 3.7% for Self
    Only or 0.9% for Self and Family.

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-   Your share of the non-Postal premium will increase by 6.7% for Self
    Only or 6.1% for Self and Family.

-   Your catastrophic protection out-of-pocket maximum is \$4000 per
    person or family for PPO providers and \$6000 per person or family
    for PPO and non-PPO providers combined. Previously, it was \$3000
    and \$3500. (Section 4)

-   We now cover osteoporosis screening for women with increased risk,
    age 60 and older. (Section 5(a))

-   We now cover an annual influenza vaccine for all adults. Previously,
    coverage was limited to age 65 and older. (Section 5(a))

-   Our coverage for a smoking cessation program no longer requires that
    the calendar year deductible be met before we consider the charges.
    (Section 5(a))

-   We changed the copayment for mail order prescription drugs and
    supplies. For a 60-day supply, you pay \$8 for generic drugs and
    \$24 for brand name; for a 90-day supply, you pay \$12 for generic
    drugs and \$35 for brand name. Previously, you paid \$7 for generic
    drugs and \$20 for brand name for a 60-day supply, and \$10 for
    generic and \$30 for brand name for a 90-day supply. (Section 5(f))

-   If you have Medicare, your mail order copayment for a 60-day supply
    is \$7 for generic drugs and \$20 for brand name. For a 90-day
    supply, you pay \$10 for generic drugs and \$30 for brand name.
    Previously, you paid \$5 for generic drugs and \$17 for brand for a
    60-day supply, and \$7.50 for generic and \$25 for brand name for a
    90-day supply. (Section 5(f))

-   Your coinsurance for non-network retail drugs and supplies is 50%.
    Previously, you paid 40%. (Section 5(f))

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

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

**Identification cards** We will send you an identification (ID) card
when you enroll. You should carry your ID card with you at all times.
You must show it whenever you receive services from a provider or fill a
prescription at an NALC CareSelect retail 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 want to obtain a
prescription at an NALC CareSelect retail pharmacy and have not received
your identification card, call us at 703/729-4677 or 1-888-636-NALC
(6252).

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
703/729-4677 or 1-888-636-NALC (6252), or write to us at 20547 Waverly
Court, Ashburn, VA 20149.

**Where you get covered care** You can get care from any "covered
provider" or "covered facility." How much we pay---and you pay---depends
on the type of covered provider or facility you use. If you use our
preferred providers, you will pay less.

**• Covered providers** We consider the following to be covered
providers when they perform services within the scope of their license
or certification:

-   A licensed doctor of medicine (M.D.) or osteopathy (D.O.); or, for
    specified services covered by the Plan, a licensed dentist (D.D.S.
    or D.M.D.), or podiatrist (D.P.M.).

-   A nurse anesthetist (C.R.N.A.).

-   A community mental health organization: A nonprofit organization or
    agency with a governing or advisory board representative of the
    community that provides comprehensive, consultative, and emergency
    services for treatment of mental conditions.

-   A qualified clinical psychologist, clinical social worker,
    optometrist, nurse midwife, nurse practitioner/clinical specialist,
    and nursing-school-administered clinic.

-   Other providers listed in Section 5. *Benefits*.

> Note: When we use the term "physician," it can mean any of the above
> providers.

**Medically underserved areas.** Note: We cover any licensed medical
practitioner for any covered service performed within the scope of that
license in states OPM determines are "medically underserved." For 2004,
the states are: Alabama, Idaho, Kentucky, Louisiana, Maine, Mississippi,
Missouri, Montana, New Mexico, North Dakota, South Carolina, South
Dakota, Texas, Utah, West Virginia and Wyoming.

> **• Covered facilities** Covered facilities include:

# **Birthing center:** A freestanding facility that provides comprehensive maternity care in a home-like atmosphere and is licensed or certified by the jurisdiction. 

# **Freestanding ambulatory facility:** An outpatient facility accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or that has Medicare certification.

-   **Hospice:** A facility that 1) provides care to the terminally
    > ill; 2) is licensed or certified by the jurisdiction in which it
    > operates; 3) is supervised by a staff of physicians (M.D. or D.O.)
    > with at least one such physician on call 24 hours a day; 4)
    > provides 24-hour-a-day nursing services under the direction of a
    > registered nurse (R.N.) and has a full-time administrator; and 5)
    > provides an ongoing quality assurance program.

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-   **Hospital:** An institution that is accredited as a hospital under
    > the hospital accreditation program of the Joint Commission on
    > Accreditation of Healthcare Organizations (JCAHO); or 2) any other
    > institution licensed as a hospital, operating under the
    > supervision of a staff of physicians with 24-hour-a-day registered
    > nursing service, and is primarily engaged in providing general
    > inpatient acute care and treatment of sick and injured persons
    > through medical, diagnostic and major surgical facilities. All
    > these facilities must be provided on its premises or under its
    > control.

> The term "hospital" does not include a convalescent home or extended
> care facility, or any institution or part thereof which a) is used
> principally as a convalescent facility, nursing home, or facility for
> the aged; b) furnishes primarily domiciliary or custodial care,
> including training in the routines of daily living; or c) is operated
> as a school or residential treatment facility.

-   **Skilled nursing facility (SNF):** A facility eligible for Medicare
    > payment, or a government facility not covered by Medicare, that
    > provides continuous non-custodial inpatient skilled nursing care
    > by a medical staff for post-hospital patients.

-   **Treatment facility:** A freestanding facility accredited by the
    Joint Commission on Accreditation of Healthcare Organizations
    (JCAHO) for treatment of substance abuse.

It depends on the kind of care you want to receive. You can go to any

provider you want, but we must approve some care in advance.

**Specialty care:** If you have a chronic or disabling condition and

-   lose access to your specialist because we drop out of the Federal
    Employees Health Benefits (FEHB) Program and you enroll in another
    FEHB Plan, or

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-   lose access to your PPO specialist because we terminate our contract
    with your specialist for other than cause,

you may be able to continue seeing your specialist and receiving any PPO
benefits 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**,** and any PPO benefits continue until
the end of your postpartum care, even if it is beyond the 90 days.

**Hospital care:** We pay for covered services from the effective date
of your enrollment. If you are in the hospital, however, when your
enrollment in our Plan begins, call our Customer Service department
immediately at 703/729-4677 or 1-888-636-NALC (6252)**.**

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;

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

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

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

### How to Get Approval for...

### 

**• Your hospital stay Precertification** is the process by which --
prior to your inpatient hospital admission -- we evaluate the medical
necessity of your proposed stay and the number of days required to treat
your condition. Unless we are misled by the information given to us, we
won't change our decision on medical necessity. Precertification is not
a guarantee of benefit payments.

In most cases, your physician or hospital will take care of
precertification. Because you are still responsible for ensuring that we
are asked to precertify your care, you should always ask your physician
or hospital whether they have contacted us.

**Warning:** We will reduce our benefits for the inpatient hospital stay
by \$500 if no one contacts us for precertification. In addition, if we
determine the stay is not medically necessary, we will not pay any
inpatient hospital benefits.

-   You, your representative, your physician, or your hospital must call
    us at 1-800-622-6252 prior to admission, unless your admission is
    related to a mental health and substance abuse condition. In that
    case call 1-877-468-1016.

-   If you have an emergency admission due to a condition that you
    reasonably believe puts your life in danger or could cause serious
    damage to bodily function, you, your representative, the physician,
    or the hospital must telephone us within two business days following
    the day of the emergency admission, even if you have been discharged
    from the hospital.

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-   Provide the following information:

>  Enrollee's name and Member identification number;
>
>  Patient's name, birth date, and phone number;
>
>  Reason for hospitalization, and proposed treatment or surgery;
>
>  Name and phone number of admitting physician;
>
>  Name of hospital or facility; and
>
>  Number of planned days of confinement.

-   We will tell the physician and/or hospital the number of approved
    inpatient days and send written confirmation of our decision to you,
    your physician, and the hospital.

Maternity care You do not need to precertify a maternity admission for a
routine delivery. However, if your medical condition requires you to
stay more than 48 hours after a vaginal delivery or 96 hours after a
cesarean section, then your physician or the hospital must contact us
for precertification of additional days. Further, if your baby stays
after you are discharged, then your physician or the hospital must
contact us within two business days for precertification of additional
days for your baby.

**If your hospital stay** If your hospital stay---including for
maternity care---needs to be

**needs to be extended:** extended, you, your representative, your
physician**,** or the hospital must ask us to approve the additional
days.

-   If no one contacted us, we will decide whether the hospital stay was
    medically necessary.

>  If we determine that the stay was medically necessary, we will pay
> the inpatient charges, but reduce benefits by \$500.
>
>  If we determine that it was not medically necessary for you to be an
> inpatient, we will not pay inpatient hospital benefits. We will pay
> only for covered medical supplies and services that are otherwise
> payable on an outpatient basis.

-   If we denied the precertification request, we will not pay inpatient
    hospital benefits. We will pay only for covered medical supplies and
    services that would be otherwise payable on an outpatient basis.

-   When we precertified the admission but you remained in the hospital
    beyond the number of days we approved, and you do not get the
    additional days precertified, then:

>  For the part of the admission that was medically necessary, we will
> pay inpatient benefits, but
>
>  For the part of the admission that was not medically necessary, we
> will pay only medical services and supplies otherwise payable on an
> outpatient basis and will not pay inpatient benefits.

**Exceptions:** You do not need precertification in these cases:

-   You are admitted to a hospital outside the United States.

-   You have another group health insuranceincluding Medicare Part
    Athat is the primary payer for the hospital stay.

    Note: If you exhaust your Medicare hospital benefits and do not want
    to use your Medicare lifetime reserve days, you **do** need to
    precertify with us by calling 1-800-622-6252.

**• Other services** Some other services require precertification, prior
authorization, or a referral.

-   Growth hormone therapy (GHT): We cover GHT only when we preauthorize
    the treatment. Call 1-888-636-NALC (6252) for preauthorization. See
    Section 5(a). *Treatment therapies.*

-   Some drugs, such as those for sexual dysfunction, require prior
    authorization. Call us at 1-888-636-NALC (6252) for information.

-   Organ/tissue transplants and donor expenses: The Plan participates
    in the **First Health** National Transplant Program. Before your
    initial evaluation as a potential candidate for a transplant
    procedure, you or your physician must contact First Health at
    1-800-622-6252 and speak to a Transplant Case Manager. See Section
    5(b). *Organ/tissue transplants*.

-   Mental health and substance abuse care: United Behavioral Health
    (UBH) provides the Plan's mental health and substance abuse
    benefits. Call 1-877-468-1016 for preauthorization. See Section
    5(e). *Mental health and substance abuse benefits*.

-   Durable medical equipment (DME): Although DME does not require prior
    authorization, you should call us at 1-888-636-NALC (6252) before
    you purchase or rent DME so we can give you information on
    discounted rates. See Section 5(a). *Durable medical equipment*.

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

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

This is what you will pay out-of-pocket for your covered care:

**• Copayments** A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc., when you receive services.
Copayments are not the same for all services. See Section 5. *Benefits*.

> Example: When you see your PPO physician you pay a \$20 copayment per
> office visit**,** and when you are admitted to a non-PPO hospital, you
> pay \$100 per admission.

**• Deductible** A deductible is a fixed amount of covered expenses you
must incur for certain covered services and supplies before we start
paying benefits for them. The family deductible is satisfied when the
combined covered expenses applied to the calendar year deductible for
family members total the amounts shown. Copayments do not count toward
any deductible.

-   The PPO calendar year deductible is \$250 per person (\$500 per
    family). If you use non-PPO providers, your calendar year deductible
    is increased to a maximum of \$300 per person (\$600 per family).
    Whether or not you use PPO providers**,** your deductible will not
    exceed \$300 per person (\$600 per family).

-   The calendar year drug deductible of \$25 per person or \$50 per
    family applies only to non-network benefits.

-   The calendar year deductible for in-network mental health and
    substance abuse benefits is \$250 per person (\$500 per family).

-   The calendar year deductible for out-of-network mental health and
    substance abuse inpatient and outpatient professional services is
    \$300 per person (\$600 per family).

-   The calendar year deductible for out-of-network substance abuse
    treatment in a treatment facility is \$300 per person.

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

**• Coinsurance** Coinsurance is the percentage of our allowance that
you must pay for your care. Coinsurance doesn't begin until you meet
your deductible.

Example: When you see a non-PPO physician, your coinsurance is 30% of
our allowance for office visits.

Note: If your provider routinely waives (does not require you to pay)
your copayments, deductibles, or coinsurance, the provider is misstating
the fee and may be violating the law. In this case, when we calculate
our share, we will reduce the provider's fee by the amount waived.

For example, if your physician ordinarily charges \$100 for a service
but routinely waives your 30% coinsurance, the actual charge is \$70. We
pay \$49 (70% of the actual charge of \$70).

Our "Plan allowance" is the amount we use to calculate our payment

for covered services. Fee-for-service plans arrive at their allowances
in

different ways, so their allowances vary. For more information about how
we determine our Plan allowance, see the definition of Plan allowance in
Section 10.

Often, the provider's bill is more than a fee-for-service plan's
allowance. Whether or not you have to pay the difference between our
allowance and the bill will depend on the provider you use.

-   **PPO providers** agree to limit what they will bill you. Because of
    that, when you use a preferred provider, your share of covered
    charges consists only of your copayment, deductible, and
    coinsurance. Here is an example about coinsurance: You see a PPO
    physician who charges \$150, but our allowance is \$100. If you have
    met your deductible, you are only responsible for your coinsurance.
    That is, you pay just 15% of our \$100 allowance (\$15). Because of
    the agreement, your PPO physician will not bill you for the \$50
    difference between our allowance and his/her bill.

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-   **Non-PPO providers**, on the other hand, have no agreement to limit
    what they will bill you. When you use a non-PPO provider, you will
    pay your copayment, deductible, and coinsurance, **plus** any
    difference between our allowance and charges on the bill. Here is an
    example: You see a non-PPO physician who charges \$150 and our
    allowance is again \$100. Because you\'ve met your deductible, you
    are responsible for your coinsurance, so you pay 30% of our \$100
    allowance (\$30). Plus, because there is no agreement between the
    non-PPO physician and us, he/she can bill you for the \$50
    difference between our allowance and his/her bill.

The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a PPO physician vs. a non-PPO physician.
The table uses our example of a service for which the physician charges
\$150 and our allowance is \$100**.** The table shows the amount you pay
if you have met your calendar year deductible.

+-----------------+-----------------------+---------------------------+
| **EXAMPLE**     | **PPO physician**     | **Non-PPO physician**     |
+-----------------+-----------------------+---------------------------+
| Physician's     | \$150                 | \$150                     |
| charge          |                       |                           |
+-----------------+-----------------------+---------------------------+
| Our allowance   | We set it at: 100     | We set it at: 100         |
+-----------------+-----------------------+---------------------------+
| We pay          | 85% of our allowance: | 70% of our allowance: 70  |
|                 | 85                    |                           |
+-----------------+-----------------------+---------------------------+
| You owe:        | 15% of our allowance: | 30% of our allowance: 30  |
|                 | 15                    |                           |
| Coinsurance     |                       |                           |
+-----------------+-----------------------+---------------------------+
| +Difference up  | No: 0                 | Yes: 50                   |
| to charge       |                       |                           |
+-----------------+-----------------------+---------------------------+
| **TOTAL YOU     | \$15                  | \$80                      |
| PAY**           |                       |                           |
+-----------------+-----------------------+---------------------------+

For those services with coinsurance (excluding mental health and
substance abuse care), we pay 100% of the Plan allowance for the
remainder of the calendar year after coinsurance expenses total these
amounts:

-   \$4000 per person or family for services of PPO providers/facilities

-   \$6000 per person or family for services of PPO and non-PPO
    providers/facilities, combined

> For mental health and substance abuse benefits, we pay 100% of the
> Plan allowance for the remainder of the calendar year after
> coinsurance expenses total these amounts:

-   \$3000 per person or family for services of network mental health
    and substance abuse providers/facilities

-   \$8000 per person for out-of-network mental health and substance
    abuse inpatient hospital treatment (to a maximum of 50 days)

> Note: Your catastrophic protection out-of-pocket maximum does not
> apply to these benefits:

-   Skilled nursing care

-   Prescription drugs

-   Any out-of-network outpatient mental health and substance abuse
    professional care

> Note: The following cannot be counted toward out-of-pocket expenses:

-   Deductibles

-   Copayments

-   Expenses incurred under Prescription Drug Benefits

-   Expenses in excess of the Plan allowance or maximum benefit
    limitations

-   Any out-of-network expenses for mental health and substance abuse
    professional care, except inpatient hospital stays

-   Amounts you pay for non-compliance with this Plan's cost containment
    requirements

-   Coinsurance for skilled nursing care

> You are responsible for these amounts even after the catastrophic
>
> protection out-of-pocket maximum has been met.
>
> Note: If you are not responsible for the balance after our payment for
> charges incurred at a government facility (such as a facility of the
> Department of Veterans Affairs), the balance cannot be counted toward
> out-of-pocket expenses.

Facilities of the Department of Veterans Affairs, the Department of

Defense, and the Indian Health Service are entitled to seek
reimbursement from us for certain services and supplies they provide to
you or a family member. They may not seek more than their governing laws
allow.

**If we overpay you** We will make diligent efforts to recover benefit
payments we made in error but in good faith. We may reduce subsequent
benefit payments to offset overpayments.

**When you are age 65 or older and you do not have Medicare**

Under the FEHB law, we must limit our payments for **inpatient hospital
care** and **physician care to** those benefits you would be entitled to
if you had Medicare. And, your physician and hospital must follow
Medicare rules and cannot bill you for more than they could bill you if
you had Medicare. You and the FEHB benefit from these payment limits.
Outpatient hospital care is not covered by this law; regular Plan
benefits apply. The following chart has more information about the
limits.

+------+------------------------+-----------------------------+-------+
| **If |                        |                             |       |
| you. |                        |                             |       |
| ..** |                        |                             |       |
|      |                        |                             |       |
| -    |                        |                             |       |
|  are |                        |                             |       |
|      |                        |                             |       |
|  age |                        |                             |       |
|      |                        |                             |       |
|   65 |                        |                             |       |
|      |                        |                             |       |
|   or |                        |                             |       |
|      |                        |                             |       |
|   ol |                        |                             |       |
| der, |                        |                             |       |
|      |                        |                             |       |
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|      |                        |                             |       |
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|      |                        |                             |       |
|   A, |                        |                             |       |
|      |                        |                             |       |
| Part |                        |                             |       |
|      |                        |                             |       |
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|      |                        |                             |       |
|   or |                        |                             |       |
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|      |                        |                             |       |
|  and |                        |                             |       |
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|      |                        |                             |       |
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|      |                        |                             |       |
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|    a |                        |                             |       |
| nnui |                        |                             |       |
| tant |                        |                             |       |
|      |                        |                             |       |
|   or |                        |                             |       |
|      |                        |                             |       |
|   as |                        |                             |       |
|      |                        |                             |       |
|    a |                        |                             |       |
|      |                        |                             |       |
|   fo |                        |                             |       |
| rmer |                        |                             |       |
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| use, |                        |                             |       |
|      |                        |                             |       |
|   ** |                        |                             |       |
| or** |                        |                             |       |
|      |                        |                             |       |
|   as |                        |                             |       |
|      |                        |                             |       |
|    a |                        |                             |       |
|      |                        |                             |       |
|   fa |                        |                             |       |
| mily |                        |                             |       |
|      |                        |                             |       |
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|      |                        |                             |       |
|   of |                        |                             |       |
|      |                        |                             |       |
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| nnui |                        |                             |       |
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|      |                        |                             |       |
|   or |                        |                             |       |
|      |                        |                             |       |
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| rmer |                        |                             |       |
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| use; |                        |                             |       |
|      |                        |                             |       |
|  and |                        |                             |       |
|      |                        |                             |       |
| -    |                        |                             |       |
|  are |                        |                             |       |
|      |                        |                             |       |
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|      |                        |                             |       |
| empl |                        |                             |       |
| oyed |                        |                             |       |
|      |                        |                             |       |
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|      |                        |                             |       |
|    a |                        |                             |       |
|      |                        |                             |       |
| posi |                        |                             |       |
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|      |                        |                             |       |
| that |                        |                             |       |
|      |                        |                             |       |
|    g |                        |                             |       |
| ives |                        |                             |       |
|      |                        |                             |       |
| FEHB |                        |                             |       |
|      |                        |                             |       |
|    c |                        |                             |       |
| over |                        |                             |       |
| age. |                        |                             |       |
|      |                        |                             |       |
|    ( |                        |                             |       |
| Your |                        |                             |       |
|      |                        |                             |       |
|    e |                        |                             |       |
| mplo |                        |                             |       |
| ying |                        |                             |       |
|      |                        |                             |       |
|   of |                        |                             |       |
| fice |                        |                             |       |
|      |                        |                             |       |
|  can |                        |                             |       |
|      |                        |                             |       |
| tell |                        |                             |       |
|      |                        |                             |       |
|  you |                        |                             |       |
|      |                        |                             |       |
|   if |                        |                             |       |
|      |                        |                             |       |
| this |                        |                             |       |
|      |                        |                             |       |
|    a |                        |                             |       |
| ppli |                        |                             |       |
| es.) |                        |                             |       |
+------+------------------------+-----------------------------+-------+
| **T  |                        |                             |       |
| hen, |                        |                             |       |
| for  |                        |                             |       |
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| i    |                        |                             |       |
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| ient |                        |                             |       |
| hosp |                        |                             |       |
| ital |                        |                             |       |
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| e,** |                        |                             |       |
|      |                        |                             |       |
| -    |                        |                             |       |
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|      |                        |                             |       |
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| lent |                        |                             |       |
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|      |                        |                             |       |
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| les* |                        |                             |       |
| *,** |                        |                             |       |
|      |                        |                             |       |
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|      |                        |                             |       |
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|      |                        |                             |       |
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|      |                        |                             |       |
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|      |                        |                             |       |
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|  the |                        |                             |       |
|      |                        |                             |       |
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|      |                        |                             |       |
|    p |                        |                             |       |
| rohi |                        |                             |       |
| bits |                        |                             |       |
|      |                        |                             |       |
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|      |                        |                             |       |
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| ital |                        |                             |       |
|      |                        |                             |       |
| from |                        |                             |       |
|      |                        |                             |       |
|   co |                        |                             |       |
| llec |                        |                             |       |
| ting |                        |                             |       |
|      |                        |                             |       |
| more |                        |                             |       |
|      |                        |                             |       |
| than |                        |                             |       |
|      |                        |                             |       |
|  the |                        |                             |       |
|      |                        |                             |       |
| Medi |                        |                             |       |
| care |                        |                             |       |
|      |                        |                             |       |
|   eq |                        |                             |       |
| uiva |                        |                             |       |
| lent |                        |                             |       |
|      |                        |                             |       |
|  amo |                        |                             |       |
| unt. |                        |                             |       |
+------+------------------------+-----------------------------+-------+
| **   |                        |                             |       |
| And, |                        |                             |       |
| for  |                        |                             |       |
| your |                        |                             |       |
| p    |                        |                             |       |
| hysi |                        |                             |       |
| cian |                        |                             |       |
| car  |                        |                             |       |
| e,** |                        |                             |       |
| the  |                        |                             |       |
| law  |                        |                             |       |
| requ |                        |                             |       |
| ires |                        |                             |       |
| us   |                        |                             |       |
| to   |                        |                             |       |
| base |                        |                             |       |
| our  |                        |                             |       |
| pay  |                        |                             |       |
| ment |                        |                             |       |
| and  |                        |                             |       |
| your |                        |                             |       |
| coi  |                        |                             |       |
| nsur |                        |                             |       |
| ance |                        |                             |       |
| o    |                        |                             |       |
| n... |                        |                             |       |
|      |                        |                             |       |
| -    |                        |                             |       |
|   an |                        |                             |       |
|      |                        |                             |       |
|   am |                        |                             |       |
| ount |                        |                             |       |
|      |                        |                             |       |
|  set |                        |                             |       |
|      |                        |                             |       |
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|      |                        |                             |       |
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| care |                        |                             |       |
|      |                        |                             |       |
|  and |                        |                             |       |
|      |                        |                             |       |
|   ca |                        |                             |       |
| lled |                        |                             |       |
|      |                        |                             |       |
|  the |                        |                             |       |
|      |                        |                             |       |
|    " |                        |                             |       |
| Medi |                        |                             |       |
| care |                        |                             |       |
|      |                        |                             |       |
| appr |                        |                             |       |
| oved |                        |                             |       |
|      |                        |                             |       |
| amou |                        |                             |       |
| nt," |                        |                             |       |
|      |                        |                             |       |
|   or |                        |                             |       |
|      |                        |                             |       |
| -    |                        |                             |       |
|  the |                        |                             |       |
|      |                        |                             |       |
|   ac |                        |                             |       |
| tual |                        |                             |       |
|      |                        |                             |       |
|   ch |                        |                             |       |
| arge |                        |                             |       |
|      |                        |                             |       |
|   if |                        |                             |       |
|      |                        |                             |       |
|   it |                        |                             |       |
|      |                        |                             |       |
|   is |                        |                             |       |
|      |                        |                             |       |
|    l |                        |                             |       |
| ower |                        |                             |       |
|      |                        |                             |       |
| than |                        |                             |       |
|      |                        |                             |       |
|  the |                        |                             |       |
|      |                        |                             |       |
| Medi |                        |                             |       |
| care |                        |                             |       |
|      |                        |                             |       |
| appr |                        |                             |       |
| oved |                        |                             |       |
|      |                        |                             |       |
|  amo |                        |                             |       |
| unt. |                        |                             |       |
+------+------------------------+-----------------------------+-------+
|      | **If your              | **Then you are responsible  |       |
|      | physician...**         | for...**                    |       |
+------+------------------------+-----------------------------+-------+
|      | Participates with      | your deductibles,           |       |
|      | Medicare or accepts    | coinsurance, and            |       |
|      | Medicare assignment    | copayments.                 |       |
|      | for the claim,         |                             |       |
+------+------------------------+-----------------------------+-------+
|      | Does not participate   | your deductibles,           |       |
|      | with Medicare,         | coinsurance, copayments,    |       |
|      |                        | and any balance up to 115%  |       |
|      |                        | of the Medicare approved    |       |
|      |                        | amount.                     |       |
+------+------------------------+-----------------------------+-------+
| It   |                        |                             |       |
| is   |                        |                             |       |
| g    |                        |                             |       |
| ener |                        |                             |       |
| ally |                        |                             |       |
| to   |                        |                             |       |
| your |                        |                             |       |
| f    |                        |                             |       |
| inan |                        |                             |       |
| cial |                        |                             |       |
| a    |                        |                             |       |
| dvan |                        |                             |       |
| tage |                        |                             |       |
| to   |                        |                             |       |
| use  |                        |                             |       |
| a    |                        |                             |       |
| p    |                        |                             |       |
| hysi |                        |                             |       |
| cian |                        |                             |       |
| who  |                        |                             |       |
| part |                        |                             |       |
| icip |                        |                             |       |
| ates |                        |                             |       |
| with |                        |                             |       |
| M    |                        |                             |       |
| edic |                        |                             |       |
| are. |                        |                             |       |
| Such |                        |                             |       |
| ph   |                        |                             |       |
| ysic |                        |                             |       |
| ians |                        |                             |       |
| are  |                        |                             |       |
| p    |                        |                             |       |
| ermi |                        |                             |       |
| tted |                        |                             |       |
| to   |                        |                             |       |
| col  |                        |                             |       |
| lect |                        |                             |       |
| only |                        |                             |       |
| up   |                        |                             |       |
| to   |                        |                             |       |
| the  |                        |                             |       |
| Medi |                        |                             |       |
| care |                        |                             |       |
| appr |                        |                             |       |
| oved |                        |                             |       |
| amo  |                        |                             |       |
| unt. |                        |                             |       |
|      |                        |                             |       |
| Our  |                        |                             |       |
| exp  |                        |                             |       |
| lana |                        |                             |       |
| tion |                        |                             |       |
| of   |                        |                             |       |
| bene |                        |                             |       |
| fits |                        |                             |       |
| (    |                        |                             |       |
| EOB) |                        |                             |       |
| form |                        |                             |       |
| will |                        |                             |       |
| tell |                        |                             |       |
| you  |                        |                             |       |
| how  |                        |                             |       |
| much |                        |                             |       |
| the  |                        |                             |       |
| p    |                        |                             |       |
| hysi |                        |                             |       |
| cian |                        |                             |       |
| or   |                        |                             |       |
| hosp |                        |                             |       |
| ital |                        |                             |       |
| can  |                        |                             |       |
| col  |                        |                             |       |
| lect |                        |                             |       |
| from |                        |                             |       |
| you. |                        |                             |       |
| If   |                        |                             |       |
| your |                        |                             |       |
| p    |                        |                             |       |
| hysi |                        |                             |       |
| cian |                        |                             |       |
| or   |                        |                             |       |
| hosp |                        |                             |       |
| ital |                        |                             |       |
| t    |                        |                             |       |
| ries |                        |                             |       |
| to   |                        |                             |       |
| col  |                        |                             |       |
| lect |                        |                             |       |
| more |                        |                             |       |
| than |                        |                             |       |
| all  |                        |                             |       |
| owed |                        |                             |       |
| by   |                        |                             |       |
| law, |                        |                             |       |
| ask  |                        |                             |       |
| the  |                        |                             |       |
| p    |                        |                             |       |
| hysi |                        |                             |       |
| cian |                        |                             |       |
| or   |                        |                             |       |
| hosp |                        |                             |       |
| ital |                        |                             |       |
| to   |                        |                             |       |
| re   |                        |                             |       |
| duce |                        |                             |       |
| the  |                        |                             |       |
| char |                        |                             |       |
| ges. |                        |                             |       |
| If   |                        |                             |       |
| you  |                        |                             |       |
| have |                        |                             |       |
| paid |                        |                             |       |
| more |                        |                             |       |
| than |                        |                             |       |
| allo |                        |                             |       |
| wed, |                        |                             |       |
| ask  |                        |                             |       |
| for  |                        |                             |       |
| a    |                        |                             |       |
| ref  |                        |                             |       |
| und. |                        |                             |       |
| If   |                        |                             |       |
| you  |                        |                             |       |
| need |                        |                             |       |
| fur  |                        |                             |       |
| ther |                        |                             |       |
| ass  |                        |                             |       |
| ista |                        |                             |       |
| nce, |                        |                             |       |
| call |                        |                             |       |
| us.  |                        |                             |       |
+------+------------------------+-----------------------------+-------+

We limit our payment to an amount that supplements the benefits that

Medicare would pay under Medicare Part A (Hospital insurance) and

Medicare Part B (Medical insurance), regardless of whether Medicare
pays.

Note: We pay our regular benefits for emergency services to an
institutional provider, such as a hospital, that does not participate
with Medicare and is not reimbursed by Medicare.

When you are covered by Medicare Part A and it is primary, you pay no
out-of-pocket expenses for services Medicare Part A covers.

When you are covered by Medicare Part B and it is primary, you pay no
out-of-pocket expenses for services Medicare Part B covers.

-   If your physician **accepts** Medicare assignment, then you pay
    nothing.

-   If your physician **does not accept** Medicare assignment, then you
    pay nothing because we supplement Medicare's payment up to the
    limiting charge.

> It's important to know that a physician who does not accept Medicare
> assignment may not bill you for more than 115% of the amount Medicare
> bases its payment on, called the "limiting charge." The Medicare
> Summary Notice (MSN) that Medicare will send you will have more
> information about the limiting charge. If your physician tries to
> collect more than allowed by law, ask the physician to reduce the
> charges. If the physician does not, report the physician to your
> Medicare carrier who sent you the MSN form. Call us if you need
> further assistance.
>
> Note: When Medicare benefits are exhausted, or services are not
> covered by Medicare, our benefits are subject to the definitions,
> limitations and exclusions in this brochure.

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**. Medicare Part A covers hospital stays,
skilled nursing facility care and other expenses. 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.

> Medicare Part B covers doctors' services and outpatient hospital care.
> 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.
>
> **Please see Section 9. *Coordinating benefits with other coverage*,
> for more information about how we coordinate benefits with Medicare.**

+-----------------------------------------------------------------------+
| **Section 5. Benefits -- OVERVIEW**                                   |
|                                                                       |
| ***(See page 11 for how our benefits changed this year and page 65    |
| for a benefits summary.)***                                           |
+-----------------------------------------------------------------------+

**Note**: This Benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
703/729-4677 or 1-888-636-NALC (6252)*.*

(a) Medical services and supplies provided by physicians and other
    health care professionals 20

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

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

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

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

+----------------------------------+-----------------------------------+
| -   Inpatient hospital           | -   Hospice care                  |
|                                  |                                   |
| -   Outpatient hospital or       | -   Ambulance                     |
|     ambulatory surgical center   |                                   |
|                                  |                                   |
| ```{=html}                       |                                   |
| <!-- -->                         |                                   |
| ```                              |                                   |
| -   Skilled nursing care         |                                   |
|     facility benefits            |                                   |
+----------------------------------+-----------------------------------+

(d) Emergency services/Accidents 37

+----------------------------------+-----------------------------------+
| -   Accidental injury            | -   Ambulance                     |
|                                  |                                   |
| -   Medical emergency            |                                   |
+----------------------------------+-----------------------------------+

(e) Mental health and substance abuse benefits 39

+----------------------------------+-----------------------------------+
| -   In-Network Benefits          | -   Out-of-Network Benefits       |
+----------------------------------+-----------------------------------+

(f) Prescription drug benefits 42

+-----------------------------------------------------------------------+
| -   Covered medications and supplies                                  |
+-----------------------------------------------------------------------+

(g) Special features 44

-   Flexible benefits option

-   24-hour nurse line

-   24-hour help line for mental health and substance abuse

-   Services for deaf and hearing impaired

-   Disease management programs

-   Worldwide coverage

(h) Dental benefits (No benefit) 45

(i) Non-FEHB benefits available to Plan members 46

SUMMARY OF BENEFITS 65

+---+---+----------------------------------+------------------+---+----+
| * |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
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| p |   |                                  |                  |   |    |
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| y |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
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| s |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| \ |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| d |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| l |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
+---+---+----------------------------------+------------------+---+----+
|   | * | **Here are some important things |                  | * |    |
|   | * | you should keep in mind about    |                  | * |    |
|   | I | these benefits:**                |                  | I |    |
|   | * |                                  |                  | * |    |
|   | * | -   Please remember that all     |                  | * |    |
|   |   |     benefits are subject to the  |                  |   |    |
|   | * |     definitions, limitations,    |                  | * |    |
|   | * |     and exclusions in this       |                  | * |    |
|   | M |     brochure and are payable     |                  | M |    |
|   | * |     only when we determine they  |                  | * |    |
|   | * |     are medically necessary.     |                  | * |    |
|   |   |                                  |                  |   |    |
|   | * | -   The PPO calendar year        |                  | * |    |
|   | * |     deductible is \$250 per      |                  | * |    |
|   | P |     person (\$500 per family).   |                  | P |    |
|   | * |     If you use non-PPO           |                  | * |    |
|   | * |     providers**,** your calendar |                  | * |    |
|   |   |     year deductible is \$300 per |                  |   |    |
|   | * |     person (\$600 per family).   |                  | * |    |
|   | * |     Whether you use PPO or       |                  | * |    |
|   | O |     non-PPO providers, your      |                  | O |    |
|   | * |     deductible will not exceed   |                  | * |    |
|   | * |     \$300 per person (\$600 per  |                  | * |    |
|   |   |     family). The calendar year   |                  |   |    |
|   | * |     deductible applies to almost |                  | * |    |
|   | * |     all benefits in this         |                  | * |    |
|   | R |     Section. We say "(No         |                  | R |    |
|   | * |     deductible)" to show when    |                  | * |    |
|   | * |     the calendar year deductible |                  | * |    |
|   |   |     does not apply.              |                  |   |    |
|   | * |                                  |                  | * |    |
|   | * | -   The non-PPO benefits are the |                  | * |    |
|   | T |     standard benefits of this    |                  | T |    |
|   | * |     Plan. PPO benefits apply     |                  | * |    |
|   | * |     only when you use a PPO      |                  | * |    |
|   |   |     provider. When no PPO        |                  |   |    |
|   | * |     provider is available,       |                  | * |    |
|   | * |     non-PPO benefits apply.      |                  | * |    |
|   | A |                                  |                  | A |    |
|   | * | -   Please keep in mind that     |                  | * |    |
|   | * |     when you use a PPO hospital  |                  | * |    |
|   |   |     or a PPO physician, some of  |                  |   |    |
|   | * |     the professionals that       |                  | * |    |
|   | * |     provide related services,    |                  | * |    |
|   | N |     such as emergency room       |                  | N |    |
|   | * |     physicians, radiologists,    |                  | * |    |
|   | * |     anesthetists, and            |                  | * |    |
|   |   |     pathologists, may **not**    |                  |   |    |
|   | * |     all be preferred providers.  |                  | * |    |
|   | * |     If they are not, they will   |                  | * |    |
|   | T |     be paid as non-PPO           |                  | T |    |
|   | * |     providers.                   |                  | * |    |
|   | * |                                  |                  | * |    |
|   |   | ```{=html}                       |                  |   |    |
|   |   | <!-- -->                         |                  |   |    |
|   |   | ```                              |                  |   |    |
|   |   | -   Be sure to read Section 4.   |                  |   |    |
|   |   |     *Your costs for covered      |                  |   |    |
|   |   |     services,* for valuable      |                  |   |    |
|   |   |     information about cost       |                  |   |    |
|   |   |     sharing, with special        |                  |   |    |
|   |   |     sections for members who are |                  |   |    |
|   |   |     age 65 or older. Also read   |                  |   |    |
|   |   |     Section 9. *Coordinating     |                  |   |    |
|   |   |     benefits with other          |                  |   |    |
|   |   |     coverage*.                   |                  |   |    |
+---+---+----------------------------------+------------------+---+----+
| * |   |                                  | **You pay**      |   |    |
| * |   |                                  |                  |   |    |
| B |   |                                  | **After the      |   |    |
| e |   |                                  | calendar year    |   |    |
| n |   |                                  | deductible...**  |   |    |
| e |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
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| n |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
| * |   |                                  |                  |   |    |
+---+---+----------------------------------+------------------+---+----+
| # |   |                                  |                  |   |    |
| # |   |                                  |                  |   |    |
| # |   |                                  |                  |   |    |
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+---+---+----------------------------------+------------------+---+----+
| # |   |                                  | ###              |   |    |
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| t |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
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| r |   |                                  |                  |   |    |
| v |   |                                  |                  |   |    |
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| s |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
+---+---+----------------------------------+------------------+---+----+
| > |   |                                  | > PPO: \$20      |   |    |
|   |   |                                  | > copayment per  |   |    |
| P |   |                                  | > visit (No      |   |    |
| r |   |                                  | > deductible)    |   |    |
| o |   |                                  | >                |   |    |
| f |   |                                  | > Non-PPO: 30%   |   |    |
| e |   |                                  | > of the Plan    |   |    |
| s |   |                                  | > allowance and  |   |    |
| s |   |                                  | > the            |   |    |
| i |   |                                  | > difference, if |   |    |
| o |   |                                  | > any, between   |   |    |
| n |   |                                  | > our allowance  |   |    |
| a |   |                                  | > and the billed |   |    |
| l |   |                                  | > amount         |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| v |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
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| s |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| > |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| h |   |                                  |                  |   |    |
| y |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| - |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| O |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| f |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| c |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| o |   |                                  |                  |   |    |
| u |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| p |   |                                  |                  |   |    |
| a |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| e |   |                                  |                  |   |    |
| n |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
|   |   |                                  |                  |   |    |
| v |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
| t |   |                                  |                  |   |    |
| s |   |                                  |                  |   |    |
+---+---+----------------------------------+------------------+---+----+
| P |   |                                  | > PPO: 15% of    |   |    |
| r |   |                                  | > the Plan       |   |    |
| o |   |                                  | > allowance      |   |    |
| f |   |                                  | >                |   |    |
| e |   |                                  | > Non-PPO: 30%   |   |    |
| s |   |                                  | > of the Plan    |   |    |
| s |   |                                  | > allowance and  |   |    |
| i |   |                                  | > the            |   |    |
| o |   |                                  | > difference, if |   |    |
| n |   |                                  | > any, between   |   |    |
| a |   |                                  | > our allowance  |   |    |
| l |   |                                  | > and the billed |   |    |
| s |   |                                  | > amount         |   |    |
| e |   |                                  |                  |   |    |
| r |   |                                  |                  |   |    |
| v |   |                                  |                  |   |    |
| i |   |                                  |                  |   |    |
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| s |   |                                  |                  |   |    |
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+---+---+----------------------------------+------------------+---+----+

Diagnostic and treatment services -- continued on next page

+-------------------------------------------+-----------------------+---+---+
| ### Diagno                                | ### You pay           |   |   |
| stic and treatment services *(continued)* |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered:*                          | > *All charges*       |   |   |
|                                           |                       |   |   |
| -   *Routine physical checkups and        |                       |   |   |
|     related tests*                        |                       |   |   |
|                                           |                       |   |   |
| -   *Routine eye and hearing              |                       |   |   |
|     examinations*                         |                       |   |   |
|                                           |                       |   |   |
| -   *Services by chiropractors, except in |                       |   |   |
|     those states designated as medically  |                       |   |   |
|     underserved areas*                    |                       |   |   |
|                                           |                       |   |   |
| -   *Nonsurgical treatment for weight     |                       |   |   |
|     reduction or obesity*                 |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ### Lab, X-ray and other diagnostic tests | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Tests and their interpretation, such    | > PPO: 15% of the     |   |   |
| > as:                                     | > Plan allowance      |   |   |
|                                           | >                     |   |   |
| -   Blood tests                           | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
| -   Urinalysis                            | > the difference, if  |   |   |
|                                           | > any, between our    |   |   |
| -   Non-routine pap tests                 | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
| -   Pathology                             | >                     |   |   |
|                                           | > Note: When tests    |   |   |
| -   X-rays                                | > are performed       |   |   |
|                                           | > during an inpatient |   |   |
| -   Non-routine mammograms                | > confinement, no     |   |   |
|                                           | > deductible applies. |   |   |
| -   CAT scans/MRI                         |                       |   |   |
|                                           |                       |   |   |
| -   Ultrasound                            |                       |   |   |
|                                           |                       |   |   |
| -   Electrocardiogram (EKG)               |                       |   |   |
|                                           |                       |   |   |
| -   Electroencephalogram (EEG**)**        |                       |   |   |
|                                           |                       |   |   |
| -   Osteoporosis screening                |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered: Routine tests, except     | > *All charges*       |   |   |
| > listed under* Preventive care, adult    |                       |   |   |
| > *in this section.*                      |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ##### Preventive care, adult              | ### You pay           |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Routine immunizations, limited to:      | > PPO: 15% of the     |   |   |
|                                           | > Plan allowance      |   |   |
| -   Tetanus-diphtheria (Td) boosterone   | >                     |   |   |
|     every 10 years, age 19 and older      | > Non-PPO: 30% of the |   |   |
|     (except as provided for under         | > Plan allowance and  |   |   |
|     *Preventive care, children* in this   | > the difference, if  |   |   |
|     section)                              | > any, between our    |   |   |
|                                           | > allowance and the   |   |   |
| -   Influenza vaccineone annually        | > billed amount       |   |   |
|                                           |                       |   |   |
| -   Pneumococcal vaccine, age 65 and      |                       |   |   |
|     older                                 |                       |   |   |
|                                           |                       |   |   |
| > Routine screenings, limited to:         |                       |   |   |
|                                           |                       |   |   |
| -   Pap test                              |                       |   |   |
|                                           |                       |   |   |
| > Note: We cover the office visit if it   |                       |   |   |
| > is on the same day as the pap test. See |                       |   |   |
| > *Diagnostic and treatment services* in  |                       |   |   |
| > this section.                           |                       |   |   |
|                                           |                       |   |   |
| -   Chlamydial infection test             |                       |   |   |
|                                           |                       |   |   |
| -   Total blood cholesterolone every     |                       |   |   |
|     three years                           |                       |   |   |
|                                           |                       |   |   |
| -   Fasting Lipoprotein Profile (total    |                       |   |   |
|     cholesterol, LDL, HDL, and            |                       |   |   |
|     triglycerides) one every 5 years,    |                       |   |   |
|     age 20 and older                      |                       |   |   |
|                                           |                       |   |   |
| -   Prostate Specific Antigen (PSA) test  |                       |   |   |
|     one annually for men age 40 and      |                       |   |   |
|     older                                 |                       |   |   |
|                                           |                       |   |   |
| -   Osteoporosis screeningfor women with |                       |   |   |
|     increased risk, age 60 and older      |                       |   |   |
|                                           |                       |   |   |
| -   Mammogramfor women age 35 and older, |                       |   |   |
|     as follows:                           |                       |   |   |
|                                           |                       |   |   |
|     -   Ages 35 through 39, one during    |                       |   |   |
|         this five year period             |                       |   |   |
|                                           |                       |   |   |
|     -   Ages 40 through 64, one every     |                       |   |   |
|         calendar year                     |                       |   |   |
|                                           |                       |   |   |
|     -   Ages 65 and older, one every two  |                       |   |   |
|         consecutive calendar years        |                       |   |   |
|                                           |                       |   |   |
| -   Colorectal cancer screening,          |                       |   |   |
|     including:                            |                       |   |   |
|                                           |                       |   |   |
| >  Fecal occult blood testone annually, |                       |   |   |
| > age 40 and older                        |                       |   |   |
| >                                         |                       |   |   |
| >  Double Contrast Barium Enema (DCBE)   |                       |   |   |
| > one every five years, age 50 and older |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| >  Sigmoidoscopy screeningone every     | > PPO: 10% of the     |   |   |
| > five years, age 50 and older            | > Plan allowance      |   |   |
| >                                         | >                     |   |   |
| >  Colonoscopy screeningone every 10    | > Non-PPO: 30% of the |   |   |
| > years, age 50 and older                 | > Plan allowance and  |   |   |
|                                           | > the difference, if  |   |   |
|                                           | > any, between the    |   |   |
|                                           | > Plan allowance and  |   |   |
|                                           | > the billed amount   |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered: Routine office visit      | > *All charges*       |   |   |
| > associated with preventive care, except |                       |   |   |
| > as noted above*                         |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ##### Preventive care, children           | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Childhood immunizations, ages 3 through | > PPO: Nothing (No    |   |   |
| > 21, limited to:                         | > deductible)         |   |   |
|                                           | >                     |   |   |
| -   Immunizations recommended by the      | > Non-PPO: The        |   |   |
|     American Academy of Pediatrics        | > difference, if any, |   |   |
|                                           | > between our         |   |   |
| ```{=html}                                | > allowance and the   |   |   |
| <!-- -->                                  | > billed amount (No   |   |   |
| ```                                       | > deductible)         |   |   |
| -   Meningococcal immunization---lifetime |                       |   |   |
|     limit of two vaccinations             |                       |   |   |
|                                           |                       |   |   |
| ```{=html}                                |                       |   |   |
| <!-- -->                                  |                       |   |   |
| ```                                       |                       |   |   |
| -   Well-child care---routine             |                       |   |   |
|     examinations and immunizations,       |                       |   |   |
|     through age 2                         |                       |   |   |
|                                           |                       |   |   |
| Note: For the coverage of the initial     |                       |   |   |
| newborn exam see *Diagnostic and          |                       |   |   |
| treatment services* in this section.      |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ####                                      | ### You pay           |   |   |
| # Preventive care, children *(continued)* |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Examinations, limited to:             | > PPO: \$20 copayment |   |   |
|                                           | > per visit (No       |   |   |
|     -   Examinations for amblyopia (lazy  | > deductible)         |   |   |
|         eye) and strabismus (crossed      | >                     |   |   |
|         eyes)limited to one screening    | > Non-PPO: 30% of the |   |   |
|         examination, ages 2 through 6     | > Plan allowance and  |   |   |
|                                           | > the difference, if  |   |   |
|     -   Examinations done on the day of   | > any, between our    |   |   |
|         immunizations, ages 3 through 21  | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Maternity care                   | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Complete maternity (obstetrical) care,  | > PPO: 10% of the     |   |   |
| > such as:                                | > Plan allowance      |   |   |
|                                           | >                     |   |   |
| -   Prenatal care                         | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
| -   Delivery                              | > the difference, if  |   |   |
|                                           | > any, between our    |   |   |
| -   Postnatal care                        | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
| -   Amniocentesis                         |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Group B streptococcus infection       | > PPO: 15% of the     |   |   |
|     screening                             | > Plan allowance      |   |   |
|                                           | >                     |   |   |
| -   Sonograms                             | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
| -   Fetal monitoring                      | > the difference, if  |   |   |
|                                           | > any, between our    |   |   |
| -   Other tests medically indicated for   | > allowance and the   |   |   |
|     the unborn child                      | > billed amount       |   |   |
|                                           |                       |   |   |
| > Note: Here are some things to keep in   |                       |   |   |
| > mind:                                   |                       |   |   |
|                                           |                       |   |   |
| -   You do not need to precertify your    |                       |   |   |
|     normal delivery; see Section 3. *How  |                       |   |   |
|     to get approval for...* for other     |                       |   |   |
|     circumstances, such as extended stays |                       |   |   |
|     for you or your baby.                 |                       |   |   |
|                                           |                       |   |   |
| -   You may remain in the hospital up to  |                       |   |   |
|     48 hours after a regular delivery and |                       |   |   |
|     96 hours after a cesarean delivery.   |                       |   |   |
|     We will cover an extended stay if     |                       |   |   |
|     medically necessary, but you, your    |                       |   |   |
|     representative, your physician, or    |                       |   |   |
|     your hospital must precertify.        |                       |   |   |
|                                           |                       |   |   |
| -   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 if we cover the infant      |                       |   |   |
|     under a Self and Family enrollment.   |                       |   |   |
|                                           |                       |   |   |
| -   The circumcision charge for an infant |                       |   |   |
|     covered under a Self and Family       |                       |   |   |
|     enrollment is payable under surgical  |                       |   |   |
|     benefits. See Section 5(b)*. Surgical |                       |   |   |
|     procedures*.                          |                       |   |   |
|                                           |                       |   |   |
| -   We pay hospitalization and surgeon    |                       |   |   |
|     services (delivery) the same as for   |                       |   |   |
|     illness and injury. See Section 5(c). |                       |   |   |
|     *Inpatient hospital* and Section      |                       |   |   |
|     5(b). *Surgical procedures.*          |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered: Routine sonograms to      | > *All charges*       |   |   |
| > determine fetal age, size, or sex*      |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Family planning                  | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Voluntary family planning services,     | > PPO: 10% of the     |   |   |
| > limited to:                             | > Plan allowance      |   |   |
|                                           | >                     |   |   |
| -   Voluntary sterilization (see Section  | > Non-PPO: 30% of the |   |   |
|     5(b). *Surgical procedures*)          | > Plan allowance and  |   |   |
|                                           | > the difference, if  |   |   |
| -   Implanted contraceptives              | > any, between our    |   |   |
|                                           | > allowance and the   |   |   |
| -   Intrauterine devices (IUDs)           | > billed amount       |   |   |
+-------------------------------------------+-----------------------+---+---+
|                                           |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Family planning *(continued)*    | ### You pay           |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Injectable contraceptive drugs (such  | > PPO: 15% of the     |   |   |
|     as Depo provera)                      | > Plan allowance      |   |   |
|                                           | >                     |   |   |
| -   Diaphragms                            | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
| > Note: We cover oral contraceptives only | > the difference, if  |   |   |
| > under the Prescription drug benefit.    | > any, between our    |   |   |
| > See Section 5(f). *Prescription drug    | > allowance and the   |   |   |
| > benefits*.                              | > billed amount       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered: Reversal of voluntary     | ####### All charges   |   |   |
| > surgical sterilization, genetic         |                       |   |   |
| > counseling*                             |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Infertility services             | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Diagnosis and treatment of infertility, | > PPO: 15% of the     |   |   |
| > except as shown in *Not covered*.       | > Plan allowance      |   |   |
| >                                         | >                     |   |   |
| > Note: For surgical services see Section | > Non-PPO: 30% of the |   |   |
| > 5(b). *Surgical procedures*.            | > Plan allowance and  |   |   |
| >                                         | > the difference, if  |   |   |
| > Note: Prescription drugs for            | > any, between our    |   |   |
| > infertility are covered only under the  | > allowance and the   |   |   |
| > Prescription drug benefit. See Section  | > billed amount       |   |   |
| > 5(f). *Prescription drug benefits**.*** |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered:*                          | > *All charges*       |   |   |
|                                           |                       |   |   |
| -   *Infertility services after voluntary |                       |   |   |
|     sterilization*                        |                       |   |   |
|                                           |                       |   |   |
| -   *Assisted reproductive technology     |                       |   |   |
|     (ART) procedures, such as:*           |                       |   |   |
|                                           |                       |   |   |
| ```{=html}                                |                       |   |   |
| <!-- -->                                  |                       |   |   |
| ```                                       |                       |   |   |
| -   *Artificial insemination*             |                       |   |   |
|                                           |                       |   |   |
| -   *In vitro fertilization*              |                       |   |   |
|                                           |                       |   |   |
| -   *Embryo transfer and gamete           |                       |   |   |
|     intrafallopian transfer (GIFT)*       |                       |   |   |
|                                           |                       |   |   |
| ```{=html}                                |                       |   |   |
| <!-- -->                                  |                       |   |   |
| ```                                       |                       |   |   |
| -   *Services and supplies related to ART |                       |   |   |
|     procedures*                           |                       |   |   |
|                                           |                       |   |   |
| -   *Cost of donor sperm*                 |                       |   |   |
|                                           |                       |   |   |
| -   *Cost of donor egg*                   |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > **Allergy care**                        | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Testing                               | > PPO: 15% of the     |   |   |
|                                           | > Plan allowance      |   |   |
| -   Treatment, except for allergy         | >                     |   |   |
|     injections                            | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
| -   Allergy serum                         | > the difference, if  |   |   |
|                                           | > any, between our    |   |   |
|                                           | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Allergy injections                      | > PPO: \$5 copayment  |   |   |
|                                           | > each (No            |   |   |
|                                           | > deductible)         |   |   |
|                                           | >                     |   |   |
|                                           | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
|                                           | > the difference, if  |   |   |
|                                           | > any, between our    |   |   |
|                                           | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered:*                          | > *All charges*       |   |   |
|                                           |                       |   |   |
| -   *Provocative food testing and         |                       |   |   |
|     sublingual allergy desensitization*   |                       |   |   |
|                                           |                       |   |   |
| ```{=html}                                |                       |   |   |
| <!-- -->                                  |                       |   |   |
| ```                                       |                       |   |   |
| -   *Environmental control units, such as |                       |   |   |
|     air conditioners, purifiers,          |                       |   |   |
|     humidifiers, and dehumidifiers*       |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Treatment therapies              | ### You pay           |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Chemotherapy and radiation therapy    | > PPO: 15% of the     |   |   |
|                                           | > Plan allowance      |   |   |
| Note: High dose chemotherapy in           | >                     |   |   |
| association with autologous bone marrow   | > Non-PPO: 30% of the |   |   |
| transplants is limited to those           | > Plan allowance and  |   |   |
| transplants listed in Section 5(b).       | > the difference, if  |   |   |
| *Organ/tissue transplants*.               | > any, between our    |   |   |
|                                           | > allowance and the   |   |   |
| -   Dialysis -- hemodialysis and          | > billed amount       |   |   |
|     peritoneal dialysis                   |                       |   |   |
|                                           |                       |   |   |
| -   Intravenous (IV)/Infusion Therapy --  |                       |   |   |
|     Home IV and antibiotic therapy        |                       |   |   |
|                                           |                       |   |   |
| -   Respiratory and inhalation therapies  |                       |   |   |
|                                           |                       |   |   |
| -   Growth hormone therapy (GHT)          |                       |   |   |
|                                           |                       |   |   |
| Note: We cover GHT only when it is        |                       |   |   |
| preauthorized through our disease         |                       |   |   |
| management program. Call 703/729-4677 or  |                       |   |   |
| 1-888-636-NALC (6252) for                 |                       |   |   |
| preauthorization. If you do not           |                       |   |   |
| preauthorize, we will not cover GHT or    |                       |   |   |
| related services and supplies. See        |                       |   |   |
| Section 3. *Other services*.              |                       |   |   |
|                                           |                       |   |   |
| Note: The growth hormone is covered under |                       |   |   |
| the Prescription drug benefit. See        |                       |   |   |
| Section 5(f). *Prescription drug          |                       |   |   |
| benefits*.                                |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| *Not covered: Chelation therapy, except   | > *All charges*       |   |   |
| as treatment for acute arsenic, gold,     |                       |   |   |
| lead, or mercury poisoning*               |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > **Physical and occupational therapies** | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   A combined total of 50 visits per     | > PPO: 15% of the     |   |   |
|     calendar year for treatment provided  | > Plan allowance      |   |   |
|     by a licensed registered therapist or | >                     |   |   |
|     physician for the following:          | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
| ```{=html}                                | > the difference, if  |   |   |
| <!-- -->                                  | > any, between our    |   |   |
| ```                                       | > allowance and the   |   |   |
| -   Physical therapy                      | > billed amount       |   |   |
|                                           |                       |   |   |
| -   Occupational therapy                  |                       |   |   |
|                                           |                       |   |   |
| Therapy is covered when the attending     |                       |   |   |
| physician:                                |                       |   |   |
|                                           |                       |   |   |
| -   Orders the care;                      |                       |   |   |
|                                           |                       |   |   |
| ```{=html}                                |                       |   |   |
| <!-- -->                                  |                       |   |   |
| ```                                       |                       |   |   |
| -   Identifies the specific professional  |                       |   |   |
|     skills the patient requires and the   |                       |   |   |
|     medical necessity for skilled         |                       |   |   |
|     services; and                         |                       |   |   |
|                                           |                       |   |   |
| -   Indicates the length of time the      |                       |   |   |
|     services are needed.                  |                       |   |   |
|                                           |                       |   |   |
| Note: We cover physical and occupational  |                       |   |   |
| therapy only to restore bodily function   |                       |   |   |
| when there has been a total or partial    |                       |   |   |
| loss of bodily function due to illness or |                       |   |   |
| injury.                                   |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| *Not covered: Maintenance therapy,        | > *All charges*       |   |   |
| including cardiac rehabilitation and      |                       |   |   |
| exercise programs*                        |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > **Speech therapy**                      | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Up to 30 visits per calendar year for | > PPO: 15% of the     |   |   |
|     treatment provided by a licensed      | > Plan allowance      |   |   |
|     registered speech therapist or        |                       |   |   |
|     physician                             | ### N                 |   |   |
|                                           | on-PPO: 30% of the Pl |   |   |
| Therapy is covered when the attending     | an allowance and the  |   |   |
| physician:                                | difference, if any, b |   |   |
|                                           | etween our allowance  |   |   |
| -   Orders the care;                      | and the billed amount |   |   |
|                                           |                       |   |   |
| -   Identifies the specific professional  |                       |   |   |
|     skills the patient requires and the   |                       |   |   |
|     medical necessity for skilled         |                       |   |   |
|     services; and                         |                       |   |   |
|                                           |                       |   |   |
| -   Indicates the length of time the      |                       |   |   |
|     services are needed.                  |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered: Maintenance therapy*      | > *All charges*       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > **Hearing services (testing, treatment, | ### You pay           |   |   |
| > and supplies)**                         |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Hearing testing for covered           | > PPO: 15% of the     |   |   |
|     diagnoses, such as otitis media and   | > Plan allowance      |   |   |
|     mastoiditis                           | >                     |   |   |
|                                           | > Non-PPO: 30% of the |   |   |
| -   First hearing aid and examination,    | > Plan allowance and  |   |   |
|     limited to services necessitated by   | > the difference, if  |   |   |
|     accidental injury                     | > any, between our    |   |   |
|                                           | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered:*                          | > *All charges*       |   |   |
|                                           |                       |   |   |
| -   *Routine hearing testing*             |                       |   |   |
|                                           |                       |   |   |
| -   *Hearing aid and examination, except  |                       |   |   |
|     when necessitated by accidental       |                       |   |   |
|     injury*                               |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > **Vision services (testing, treatment,  | ###                   |   |   |
| > and supplies)**                         |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Eye examinations for covered          | > PPO: \$20 copayment |   |   |
|     diagnoses, such as cataract and       | > per visit (No       |   |   |
|     glaucoma                              | > deductible)         |   |   |
|                                           | >                     |   |   |
|                                           | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
|                                           | > the difference, if  |   |   |
|                                           | > any, between our    |   |   |
|                                           | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   One pair of eyeglasses or contact     | > PPO: 15% of the     |   |   |
|     lenses to correct an impairment       | > Plan allowance      |   |   |
|     directly caused by accidental ocular  | >                     |   |   |
|     injury or intraocular surgery (such   | > Non-PPO: 30% of the |   |   |
|     as for cataracts) when purchased      | > Plan allowance and  |   |   |
|     within one year                       | > the difference, if  |   |   |
|                                           | > any, between our    |   |   |
| > Note: For examinations for amblyopia    | > allowance and the   |   |   |
| > and strabismus, see *Preventive care,   | > billed amount       |   |   |
| > children* in this section.              |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered:*                          | ####### All charges   |   |   |
|                                           |                       |   |   |
| -   *Eyeglasses or contact lenses and     |                       |   |   |
|     examinations for them*                |                       |   |   |
|                                           |                       |   |   |
| -   *Eye exercises and orthoptics*        |                       |   |   |
|                                           |                       |   |   |
| -   *Radial keratotomy and other          |                       |   |   |
|     refractive surgery*                   |                       |   |   |
|                                           |                       |   |   |
| -   *Refractions*                         |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Foot care                        | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Nonsurgical routine foot care when    | > PPO: 15% of the     |   |   |
|     you are under active treatment for a  | > Plan allowance      |   |   |
|     metabolic or peripheral vascular      | >                     |   |   |
|     disease, such as diabetes             | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
|                                           | > the difference, if  |   |   |
|                                           | > any, between our    |   |   |
|                                           | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Surgical procedures for routine foot  | > PPO: 10% of the     |   |   |
|     care when you are under active        | > Plan allowance      |   |   |
|     treatment for a metabolic or          | >                     |   |   |
|     peripheral vascular disease, such as  | > Non-PPO: 30% of the |   |   |
|     diabetes                              | > Plan allowance and  |   |   |
|                                           | > the difference, if  |   |   |
| -   Open cutting, such as the removal of  | > any, between our    |   |   |
|     bunions or bone spurs                 | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
| -   Extracorporeal shock wave treatment   |                       |   |   |
|     (when symptoms have existed for at    |                       |   |   |
|     least 6 months and other standard     |                       |   |   |
|     methods of treatment have been        |                       |   |   |
|     unsuccessful)                         |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Foot care *(continued)*          | ### You pay           |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *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)*             |                       |   |   |
|                                           |                       |   |   |
| -   *Foot orthotics, arch supports, heel  |                       |   |   |
|     pads and cups*                        |                       |   |   |
|                                           |                       |   |   |
| -   *Orthopedic and corrective shoes*     |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > **Orthopedic and prosthetic devices**   | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Artificial limbs and eyes; stump hose | > PPO: 15% of the     |   |   |
|                                           | > Plan allowance      |   |   |
| -   Custom-made durable braces for legs,  | >                     |   |   |
|     arms, neck, and back                  | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
| -   Externally worn breast prostheses and | > the difference, if  |   |   |
|     surgical bras, including necessary    | > any, between our    |   |   |
|     replacements following a mastectomy   | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
| > Note: Internal prosthetic devices, such |                       |   |   |
| > as artificial joints, pacemakers,       |                       |   |   |
| > cochlear implants, and surgically       |                       |   |   |
| > implanted breast implants following     |                       |   |   |
| > mastectomy are paid as hospital         |                       |   |   |
| > benefits. See Section 5(c). *Inpatient  |                       |   |   |
| > hospital.* Insertion of the device is   |                       |   |   |
| > paid as surgery. See Section 5(b).      |                       |   |   |
| > *Surgical procedures.*                  |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered:*                          | > *All charges*       |   |   |
|                                           |                       |   |   |
| -   *Orthopedic and corrective shoes*     |                       |   |   |
|                                           |                       |   |   |
| -   *Arch supports*                       |                       |   |   |
|                                           |                       |   |   |
| -   *Foot orthotics (shoe inserts)*       |                       |   |   |
|                                           |                       |   |   |
| -   *Heel pads and heel cups*             |                       |   |   |
|                                           |                       |   |   |
| -   *Lumbosacral supports*                |                       |   |   |
|                                           |                       |   |   |
| -   *Corsets, trusses, elastic stockings, |                       |   |   |
|     support hose, and other supportive    |                       |   |   |
|     devices*                              |                       |   |   |
|                                           |                       |   |   |
| -   *Bionic prosthetics*                  |                       |   |   |
|                                           |                       |   |   |
| -   *Prosthetic replacement provided less |                       |   |   |
|     than 3 years after the last one we    |                       |   |   |
|     covered*                              |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Durable medical equipment (DME)  | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Durable medical equipment (DME) is      | > PPO: 15% of the     |   |   |
| > equipment and supplies that:            | > Plan allowance      |   |   |
|                                           | >                     |   |   |
| 1.  Are prescribed by your attending      | > Non-PPO: 30% of the |   |   |
|     physician (i.e., the physician who is | > Plan allowance and  |   |   |
|     treating your illness or injury);     | > the difference, if  |   |   |
|                                           | > any, between our    |   |   |
| 2.  Are medically necessary;              | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
| 3.  Are primarily and customarily used    |                       |   |   |
|     only for a medical purpose;           |                       |   |   |
|                                           |                       |   |   |
| 4.  Are generally useful only to a person |                       |   |   |
|     with an illness or injury;            |                       |   |   |
|                                           |                       |   |   |
| 5.  Are designed for prolonged use; and   |                       |   |   |
|                                           |                       |   |   |
| 6.  Serve a specific therapeutic purpose  |                       |   |   |
|     in the treatment of an illness or     |                       |   |   |
|     injury.                               |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Dura                             | ### You pay           |   |   |
| ble medical equipment (DME) *(continued)* |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Note: Call us at 703/729-4677 or        | > PPO: 15% of the     |   |   |
| > 1-888-636-NALC (6252) as soon as your   | > Plan allowance      |   |   |
| > physician prescribes equipment or       | >                     |   |   |
| > supplies. We have arranged with a       | > Non-PPO: 30% of the |   |   |
| > health care provider to rent or sell    | > Plan allowance and  |   |   |
| > durable medical equipment at discounted | > the difference, if  |   |   |
| > rates and will tell you more about this | > any, between our    |   |   |
| > service when you call.                  | > allowance and the   |   |   |
| >                                         | > billed amount       |   |   |
| > We cover rental or purchase (at our     |                       |   |   |
| > option) including repair and adjustment |                       |   |   |
| > of durable medical equipment, such as:  |                       |   |   |
|                                           |                       |   |   |
| -   Oxygen and oxygen apparatus           |                       |   |   |
|                                           |                       |   |   |
| -   Dialysis appliances                   |                       |   |   |
|                                           |                       |   |   |
| -   Hospital beds                         |                       |   |   |
|                                           |                       |   |   |
| -   Wheelchairs                           |                       |   |   |
|                                           |                       |   |   |
| -   Crutches, canes, and walkers          |                       |   |   |
|                                           |                       |   |   |
| > We also cover supplies, such as:        |                       |   |   |
|                                           |                       |   |   |
| -   Insulin and diabetic supplies         |                       |   |   |
|                                           |                       |   |   |
| -   Needles and syringes for covered      |                       |   |   |
|     injectables                           |                       |   |   |
|                                           |                       |   |   |
| ```{=html}                                |                       |   |   |
| <!-- -->                                  |                       |   |   |
| ```                                       |                       |   |   |
| -   Ostomy and catheter supplies          |                       |   |   |
|                                           |                       |   |   |
| -   Home IV and antibiotic therapy        |                       |   |   |
|     supplies                              |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *Not covered:*                          | > *All charges*       |   |   |
|                                           |                       |   |   |
| -   *DME replacements provided less than  |                       |   |   |
|     3 years after the last one we         |                       |   |   |
|     covered*                              |                       |   |   |
|                                           |                       |   |   |
| -   *Sun or heat lamps, whirlpool baths,  |                       |   |   |
|     saunas and similar household          |                       |   |   |
|     equipment*                            |                       |   |   |
|                                           |                       |   |   |
| -   *Safety, convenience, and exercise    |                       |   |   |
|     equipment*                            |                       |   |   |
|                                           |                       |   |   |
| -   *Communication equipment including    |                       |   |   |
|     computer "story boards" or "light     |                       |   |   |
|     talkers"*                             |                       |   |   |
|                                           |                       |   |   |
| -   *Enhanced vision systems, computer    |                       |   |   |
|     switch boards or environmental        |                       |   |   |
|     control units*                        |                       |   |   |
|                                           |                       |   |   |
| -   *Heating pads, air conditioners,      |                       |   |   |
|     purifiers, and humidifiers*           |                       |   |   |
|                                           |                       |   |   |
| -   *Stair climbing equipment, stair      |                       |   |   |
|     glides, ramps, and elevators*         |                       |   |   |
|                                           |                       |   |   |
| -   *Modifications or alterations to      |                       |   |   |
|     vehicles or households*               |                       |   |   |
|                                           |                       |   |   |
| -   *Equipment or devices, such as iBOT   |                       |   |   |
|     Mobility System, that allow increased |                       |   |   |
|     mobility beyond what is provided by   |                       |   |   |
|     standard features of DME*             |                       |   |   |
|                                           |                       |   |   |
| -   *Other items (such as wigs) that do   |                       |   |   |
|     not meet the criteria 1 thru 6 above* |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Home health services             | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Up to 90 days per calendar year (with a | > PPO: 20% of the     |   |   |
| > maximum Plan payment of \$75 per day)   | > Plan allowance (No  |   |   |
| > when:                                   | > deductible) and all |   |   |
|                                           | > charges after we    |   |   |
| -   A registered nurse (R.N.), licensed   | > pay \$75 per day    |   |   |
|     practical nurse (L.P.N.), or licensed | >                     |   |   |
|     vocational nurse (L.V.N.) provides    | > Non-PPO: 20% of the |   |   |
|     the services;                         | > Plan allowance (No  |   |   |
|                                           | > deductible) and all |   |   |
| ```{=html}                                | > charges after we    |   |   |
| <!-- -->                                  | > pay \$75 per day    |   |   |
| ```                                       |                       |   |   |
| -   The attending physician orders the    |                       |   |   |
|     care;                                 |                       |   |   |
|                                           |                       |   |   |
| -   The physician identifies the specific |                       |   |   |
|     professional skills required by the   |                       |   |   |
|     patient and the medical necessity for |                       |   |   |
|     skilled services; and                 |                       |   |   |
|                                           |                       |   |   |
| -   The physician indicates the length of |                       |   |   |
|     time the services are needed.         |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Home health services             | ### You pay           |   |   |
+-------------------------------------------+-----------------------+---+---+
| > *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                            |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Coverage limited to medically           | > PPO: 15% of the     |   |   |
| > underserved areas. See Section 3.       | > Plan allowance      |   |   |
| > *Covered providers.*                    | >                     |   |   |
|                                           | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
|                                           | > the difference, if  |   |   |
|                                           | > any, between our    |   |   |
|                                           | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ######## Alternative treatments           | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Acupuncture, limited to treatment by  | > PPO: 15% of the     |   |   |
|     a doctor of medicine or osteopathy    | > Plan allowance      |   |   |
|     for pain relief                       | >                     |   |   |
|                                           | > Non-PPO: 30% of the |   |   |
|                                           | > Plan allowance and  |   |   |
|                                           | > the difference, if  |   |   |
|                                           | > any, between our    |   |   |
|                                           | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
+-------------------------------------------+-----------------------+---+---+
| ## Not covered: Naturopathic services     | ####### All charges   |   |   |
|                                           |                       |   |   |
| > Note: In medically underserved areas,   |                       |   |   |
| > we may cover services of alternative    |                       |   |   |
| > treatment providers. See Section 3.     |                       |   |   |
| > *Covered providers.*                    |                       |   |   |
+-------------------------------------------+-----------------------+---+---+
| #### **Educational classes and programs** | ###                   |   |   |
+-------------------------------------------+-----------------------+---+---+
| > Coverage is limited to:                 | > PPO: Nothing for    |   |   |
|                                           | > the first \$100 (No |   |   |
| -   Smoking Cessation---One smoking       | > deductible)         |   |   |
|     cessation program per member per      | >                     |   |   |
|     lifetime, up to a maximum Plan        | > Non-PPO: Nothing    |   |   |
|     payment of \$100 including all        | > for the first \$100 |   |   |
|     related expenses such as drugs        | > (No deductible)     |   |   |
+-------------------------------------------+-----------------------+---+---+
| -   Diabetes training for self-management | > PPO: 15% of the     |   |   |
|     when:                                 | > Plan allowance      |   |   |
|                                           | >                     |   |   |
| ```{=html}                                | > Non-PPO: 30% of the |   |   |
| <!-- -->                                  | > Plan allowance and  |   |   |
| ```                                       | > the difference, if  |   |   |
| -   Prescribed by the attending           | > any, between our    |   |   |
|     physician, and                        | > allowance and the   |   |   |
|                                           | > billed amount       |   |   |
| ```{=html}                                |                       |   |   |
| <!-- -->                                  |                       |   |   |
| ```                                       |                       |   |   |
| -   Administered by a covered provider,   |                       |   |   |
|     such as a registered nurse.           |                       |   |   |
+-------------------------------------------+-----------------------+---+---+

+---+---+----------------------------------+------------------+---+---+
| * |   |                                  |                  |   |   |
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| s |   |                                  |                  |   |   |
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| a |   |                                  |                  |   |   |
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| s |   |                                  |                  |   |   |
| \ |   |                                  |                  |   |   |
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| r |   |                                  |                  |   |   |
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| l |   |                                  |                  |   |   |
| t |   |                                  |                  |   |   |
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| o |   |                                  |                  |   |   |
| f |   |                                  |                  |   |   |
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| s |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
| * |   |                                  |                  |   |   |
+---+---+----------------------------------+------------------+---+---+
|   | * | **Here are some important things |                  | * |   |
|   | * | you should keep in mind about    |                  | * |   |
|   | I | these benefits:**                |                  | I |   |
|   | * |                                  |                  | * |   |
|   | * | -   Please remember that all     |                  | * |   |
|   |   |     benefits are subject to the  |                  |   |   |
|   | * |     definitions, limitations,    |                  | * |   |
|   | * |     and exclusions in this       |                  | * |   |
|   | M |     brochure and are payable     |                  | M |   |
|   | * |     only when we determine they  |                  | * |   |
|   | * |     are medically necessary.     |                  | * |   |
|   |   |                                  |                  |   |   |
|   | * | ```{=html}                       |                  | * |   |
|   | * | <!-- -->                         |                  | * |   |
|   | P | ```                              |                  | P |   |
|   | * | -   The PPO calendar year        |                  | * |   |
|   | * |     deductible is \$250 per      |                  | * |   |
|   |   |     person (\$500 per family).   |                  |   |   |
|   | * |     If you use non-PPO           |                  | * |   |
|   | * |     providers**,** your calendar |                  | * |   |
|   | O |     year deductible is \$300 per |                  | O |   |
|   | * |     person (\$600 per family).   |                  | * |   |
|   | * |     Whether you use PPO or       |                  | * |   |
|   |   |     non-PPO providers, your      |                  |   |   |
|   | * |     deductible will not exceed   |                  | * |   |
|   | * |     \$300 per person (\$600 per  |                  | * |   |
|   | R |     family). The calendar year   |                  | R |   |
|   | * |     deductible applies to almost |                  | * |   |
|   | * |     all benefits in this         |                  | * |   |
|   |   |     Section. We say "(No         |                  |   |   |
|   | * |     deductible)" to show when    |                  | * |   |
|   | * |     the calendar year deductible |                  | * |   |
|   | T |     does not apply.              |                  | T |   |
|   | * |                                  |                  | * |   |
|   | * | -   The non-PPO benefits are the |                  | * |   |
|   |   |     standard benefits of this    |                  |   |   |
|   | * |     Plan. PPO benefits apply     |                  | * |   |
|   | * |     only when you use a PPO      |                  | * |   |
|   | A |     provider. When no PPO        |                  | A |   |
|   | * |     provider is available,       |                  | * |   |
|   | * |     non-PPO benefits apply.      |                  | * |   |
|   |   |                                  |                  |   |   |
|   | * | -   Please keep in mind that     |                  | * |   |
|   | * |     when you use a PPO hospital  |                  | * |   |
|   | N |     or a PPO physician, some of  |                  | N |   |
|   | * |     the professionals that       |                  | * |   |
|   | * |     provide related services,    |                  | * |   |
|   |   |     such as emergency room       |                  |   |   |
|   | * |     physicians, radiologists,    |                  | * |   |
|   | * |     anesthetists, and            |                  | * |   |
|   | T |     pathologists, may **not**    |                  | T |   |
|   | * |     all be preferred providers.  |                  | * |   |
|   | * |     If they are not, they will   |                  | * |   |
|   |   |     be paid as non-PPO           |                  |   |   |
|   |   |     providers.                   |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   | -   Be sure to read Section 4.   |                  |   |   |
|   |   |     *Your costs for covered      |                  |   |   |
|   |   |     services,* for valuable      |                  |   |   |
|   |   |     information about cost       |                  |   |   |
|   |   |     sharing, with special        |                  |   |   |
|   |   |     sections for members who are |                  |   |   |
|   |   |     age 65 or older. Also read   |                  |   |   |
|   |   |     Section 9. *Coordinating     |                  |   |   |
|   |   |     benefits with other          |                  |   |   |
|   |   |     coverage*.                   |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   | ```{=html}                       |                  |   |   |
|   |   | <!-- -->                         |                  |   |   |
|   |   | ```                              |                  |   |   |
|   |   | -   The amounts listed below are |                  |   |   |
|   |   |     for the charges billed by a  |                  |   |   |
|   |   |     physician or other health    |                  |   |   |
|   |   |     care professional for your   |                  |   |   |
|   |   |     surgical care. See Section   |                  |   |   |
|   |   |     5(c). *Services provided by  |                  |   |   |
|   |   |     a hospital or other          |                  |   |   |
|   |   |     facility, and ambulance      |                  |   |   |
|   |   |     services,* for charges       |                  |   |   |
|   |   |     associated with the facility |                  |   |   |
|   |   |     (i.e., hospital, surgical    |                  |   |   |
|   |   |     center, etc.).               |                  |   |   |
|   |   |                                  |                  |   |   |
|   |   | -   YOU MUST GET PRIOR           |                  |   |   |
|   |   |     AUTHORIZATION FOR            |                  |   |   |
|   |   |     ORGAN/TISSUE TRANSPLANTS.    |                  |   |   |
|   |   |     See Section 5(b).            |                  |   |   |
|   |   |     *Organ/tissue transplants*.  |                  |   |   |
+---+---+----------------------------------+------------------+---+---+
| * |   |                                  | **You pay**      |   |   |
| * |   |                                  |                  |   |   |
| B |   |                                  | **After the      |   |   |
| e |   |                                  | calendar year    |   |   |
| n |   |                                  | deductible...**  |   |   |
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+---+---+----------------------------------+------------------+---+---+
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+---+---+----------------------------------+------------------+---+---+
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+---+---+----------------------------------+------------------+---+---+
| > |   |                                  | PPO: 10% of the  |   |   |
|   |   |                                  | Plan allowance   |   |   |
| A |   |                                  |                  |   |   |
| > |   |                                  | Non-PPO: 30% of  |   |   |
|   |   |                                  | the Plan         |   |   |
| c |   |                                  | allowance and    |   |   |
| o |   |                                  | the difference,  |   |   |
| m |   |                                  | if any, between  |   |   |
| p |   |                                  | our allowance    |   |   |
| r |   |                                  | and the billed   |   |   |
| e |   |                                  | amount           |   |   |
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+---+---+----------------------------------+------------------+---+---+

Surgical procedures - continued on next page

+------------------------------------------+---------------------------+
| ### Surgical procedures *(continued)*    | ### You pay               |
+------------------------------------------+---------------------------+
| -   Removal of tumors and cysts          | PPO: 10% of the Plan      |
|                                          | allowance                 |
| -   Correction of congenital anomalies   |                           |
|                                          | > Non-PPO: 30% of the     |
| ```{=html}                               | > Plan allowance and the  |
| <!-- -->                                 | > difference, if any,     |
| ```                                      | > between our payment and |
| -   Surgical treatment of morbid         | > the billed amount       |
|     obesity---a condition in which an    |                           |
|     individual weighs 100 pounds or 100% |                           |
|     over his or her normal weight with   |                           |
|     complicating medical conditions**,** |                           |
|     and attempts to reduce weight using  |                           |
|     a doctor-monitored diet and exercise |                           |
|     program were unsuccessful; patients  |                           |
|     must be age 18 or older              |                           |
|                                          |                           |
| -   Insertion of internal prosthetic     |                           |
|     devices. See Section 5(a).           |                           |
|     *Orthopedic and prosthetic devices,* |                           |
|     for device coverage information.     |                           |
|                                          |                           |
| -   Voluntary sterilization (e.g., Tubal |                           |
|     ligation, Vasectomy)                 |                           |
|                                          |                           |
| -   Surgically implanted contraceptives  |                           |
|                                          |                           |
| -   Intrauterine devices (IUDs)          |                           |
|                                          |                           |
| -   Debridement of burns                 |                           |
|                                          |                           |
| > Note: When multiple or bilateral       |                           |
| > surgical procedures add complexity to  |                           |
| > an operative session, the Plan         |                           |
| > allowance for the second or less       |                           |
| > expensive procedure is one-half of     |                           |
| > what the Plan allowance would have     |                           |
| > been if that procedure had been        |                           |
| > performed independently.               |                           |
| >                                        |                           |
| > The Plan allowance for an assistant    |                           |
| > surgeon will not exceed 25% of our     |                           |
| > allowance for the surgeon.             |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | *All charges*             |
|                                          |                           |
| -   *Oral implants and transplants*      |                           |
|                                          |                           |
| -   *Procedures that involve the teeth   |                           |
|     or their supporting structures (such |                           |
|     as the periodontal membrane,         |                           |
|     gingival and alveolar bone)*         |                           |
|                                          |                           |
| -   *Cosmetic surgery, except for:       |                           |
|     repair of accidental injury if       |                           |
|     repair is initiated within six       |                           |
|     months after an accident; correction |                           |
|     of a congenital anomaly; or breast   |                           |
|     reconstruction following a           |                           |
|     mastectomy*                          |                           |
|                                          |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
|                                          |                           |
| -   *Procedures performed through the    |                           |
|     same incision deemed incidental to   |                           |
|     the total surgery, such as           |                           |
|     appendectomy, lysis of adhesion,     |                           |
|     puncture of ovarian cyst*            |                           |
|                                          |                           |
| -   *Reversal of voluntary               |                           |
|     sterilization*                       |                           |
|                                          |                           |
| -   *Services of a standby surgeon,      |                           |
|     except during angioplasty or other   |                           |
|     high risk procedures when we         |                           |
|     determine standby surgeons are       |                           |
|     medically necessary*                 |                           |
|                                          |                           |
| -   *Cutting, trimming, or removal of    |                           |
|     corns, calluses, or the free edge of |                           |
|     toenails; and similar routine        |                           |
|     treatment of conditions of the foot, |                           |
|     except as listed under Section       |                           |
|     5(a)*. Foot care                     |                           |
+------------------------------------------+---------------------------+

+--------------------------------------------+-------------------------+
| ######## Reconstructive surgery            | ### You pay             |
+--------------------------------------------+-------------------------+
| -   Surgery to correct a functional defect | PPO: 10% of the Plan    |
|                                            | allowance               |
| -   Surgery to correct a condition caused  |                         |
|     by injury or illness if:               | Non-PPO: 30% of the     |
|                                            | Plan allowance and the  |
| >  The condition produced a major effect  | difference, if any,     |
| > on the member's appearance; and          | between our allowance   |
| >                                          | and the billed amount   |
| >  The condition can reasonably be        |                         |
| > expected to be corrected by such surgery |                         |
|                                            |                         |
| -   Surgery to correct a congenital        |                         |
|     anomaly (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; and webbed fingers and    |                         |
|     toes.                                  |                         |
|                                            |                         |
| -   All stages of breast reconstruction    |                         |
|     surgery following a mastectomy, such   |                         |
|     as:                                    |                         |
|                                            |                         |
| >  Surgery to produce a symmetrical       |                         |
| > appearance of breasts                    |                         |
| >                                          |                         |
| >  Treatment of any physical              |                         |
| > complications, such as lymphedemas       |                         |
| >                                          |                         |
| > Note: Congenital anomaly does not        |                         |
| > include conditions related to teeth or   |                         |
| > intra-oral structures supporting the     |                         |
| > teeth.                                   |                         |
| >                                          |                         |
| > Note: We cover internal and external     |                         |
| > breast prostheses, surgical bras and     |                         |
| > replacements. See Section 5(a).          |                         |
| > *Orthopedic and prosthetic devices*, and |                         |
| > Section 5(c). *Inpatient hospital*.      |                         |
| >                                          |                         |
| > 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 if repair is      |                         |
|     initiated within six months*           |                         |
|                                            |                         |
| -   *Injections of silicone, collagens,    |                         |
|     and similar substances*                |                         |
|                                            |                         |
| -   *Surgeries related to sex              |                         |
|     transformation or sexual dysfunction*  |                         |
+--------------------------------------------+-------------------------+
| ######## Oral and maxillofacial surgery    | ###                     |
+--------------------------------------------+-------------------------+
| Oral surgical procedures, limited to:      | PPO: 10% of the Plan    |
|                                            | allowance               |
| -   Treatment of fractures of the jaw or   |                         |
|     facial bones                           | Non-PPO: 30% of the     |
|                                            | Plan allowance and the  |
| -   Surgical correction of cleft lip,      | difference, if any,     |
|     cleft palate or severe functional      | between our allowance   |
|     malocclusion                           | and the billed amount   |
|                                            |                         |
| -   Removal of stones from salivary ducts  |                         |
|                                            |                         |
| -   Excision of leukoplakia or             |                         |
|     malignancies                           |                         |
|                                            |                         |
| -   Excision of cysts and incision of      |                         |
|     abscesses when done as independent     |                         |
|     procedures                             |                         |
|                                            |                         |
| -   Other surgical procedures that do not  |                         |
|     involve the teeth or their supporting  |                         |
|     structures                             |                         |
+--------------------------------------------+-------------------------+

*Oral and maxillofacial surgery -- continued on next page*

+------------------------------------------+---------------------------+
| ######## Oral                            | ### You pay               |
|  and maxillofacial surgery *(continued)* |                           |
+------------------------------------------+---------------------------+
| > *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        | ###                       |
+------------------------------------------+---------------------------+
| > Limited to:                            | > Nothing, for services   |
|                                          | > obtained through the    |
| -   Bone                                 | > National Transplant     |
|                                          | > Program. (No            |
| -   Cornea                               | > deductible)             |
|                                          | >                         |
| -   Heart                                | > PPO: 10% of the Plan    |
|                                          | > allowance               |
| -   Heart/lung                           | >                         |
|                                          | > Non-PPO: 30% of the     |
| -   Kidney                               | > Plan allowance and the  |
|                                          | > difference, if any,     |
| -   Kidney/pancreas                      | > between our allowance   |
|                                          | > and the billed amount   |
| -   Liver                                |                           |
|                                          |                           |
| -   Lung: Singleonly for the following  |                           |
|     end-stage pulmonary diseases:        |                           |
|     pulmonary fibrosis, primary          |                           |
|     pulmonary hypertension, or           |                           |
|     emphysema; Doubleonly for patients  |                           |
|     with cystic fibrosis                 |                           |
|                                          |                           |
| -   Pancreas                             |                           |
|                                          |                           |
| -   Allogenic bone marrow transplants,   |                           |
|     limited to patients with acute       |                           |
|     leukemia, advanced Hodgkin's         |                           |
|     lymphoma, advanced non-Hodgkin's     |                           |
|     lymphoma, advanced neuroblastoma,    |                           |
|     aplastic anemia, chronic myelogenous |                           |
|     leukemia, infantile malignant        |                           |
|     osteoporosis, severe combined        |                           |
|     immunodeficiency, thalassemia major, |                           |
|     or Wiskott-Aldrich syndrome          |                           |
|                                          |                           |
| -   Autologous bone marrow transplants   |                           |
|     (autologous stem cell support) and   |                           |
|     autologous peripheral stem cell      |                           |
|     support for acute lymphocytic or     |                           |
|     non-lymphocytic leukemia; advanced   |                           |
|     Hodgkin's lymphoma, advanced         |                           |
|     non-Hodgkin's lymphoma; advanced     |                           |
|     neuroblastoma; breast cancer;        |                           |
|     multiple myeloma; epithelial ovarian |                           |
|     cancer; and testicular, mediastinal  |                           |
|     retroperitoneal, and ovarian germ    |                           |
|     cell tumors                          |                           |
|                                          |                           |
| -   Intestinal transplants (small        |                           |
|     intestine) and the small intestine   |                           |
|     with the liver or small intestine    |                           |
|     with multiple organs such as the     |                           |
|     liver, stomach, and pancreas         |                           |
+------------------------------------------+---------------------------+
| National Transplant ProgramThe Plan     | > Nothing, for services   |
| participates in the First Health        | > obtained through the    |
| National Transplant Program. Before your | > National Transplant     |
| initial evaluation as a potential        | > Program (No deductible) |
| candidate for a transplant procedure,    |                           |
| you or your physician must contact First |                           |
| Health at 1-800-622-6252 and speak to a  |                           |
| Transplant Case Manager. You will be     |                           |
| given information about this program     |                           |
| including a list of participating        |                           |
| providers. Charges for services          |                           |
| performed by a National Transplant       |                           |
| Program provider, whether incurred by    |                           |
| the recipient or donor are paid at 100%. |                           |
| Participants in the program must obtain  |                           |
| prior approval from the Plan to receive  |                           |
| limited travel and lodging benefits.     |                           |
+------------------------------------------+---------------------------+

Organ/tissue transplants -- continued on next page

+------------------------------------------+---------------------------+
| #######                                  | ### You pay               |
| # Organ/tissue transplants *(continued)* |                           |
+------------------------------------------+---------------------------+
| > Limited Benefits---If you do not       | PPO: 10% of the Plan      |
| > obtain prior approval or do not use a  | allowance                 |
| > designated facility, or if we are not  |                           |
| > the primary payer, we pay a maximum of | > Non-PPO: 30% of the     |
| > \$100,000 for each listed transplant   | > Plan allowance and the  |
| > (kidney limit, \$50,000), for these    | > difference, if any,     |
| > combined expenses: pre-transplant      | > between our allowance   |
| > evaluation; organ procurement; and     | > and the billed amount   |
| > inpatient hospital, surgical and       |                           |
| > medical expenses. We pay benefits      |                           |
| > according to the appropriate benefit   |                           |
| > section, such as Section 5(c).         |                           |
| > *Inpatient hospital,* and *Surgical    |                           |
| > procedures*. The limitation applies to |                           |
| > expenses incurred by either the        |                           |
| > recipient or donor.                    |                           |
| >                                        |                           |
| > Treatment for breast cancer, multiple  |                           |
| > myeloma, and epithelial ovarian cancer |                           |
| > may be provided in a National Cancer   |                           |
| > Institute (NCI)- or National Institute |                           |
| > of Health (NIH)-approved clinical      |                           |
| > trial at a designated center for       |                           |
| > excellence when approved by our        |                           |
| > medical director in accordance with    |                           |
| > the Plan's protocols.                  |                           |
| >                                        |                           |
| > Note: Some transplants listed may not  |                           |
| > be covered through the National        |                           |
| > Transplant Program.                    |                           |
| >                                        |                           |
| > Note: We cover related medical and     |                           |
| > hospital expenses of the donor only    |                           |
| > when we cover the recipient.           |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | *All charges*             |
|                                          |                           |
| -   *Donor screening tests and donor     |                           |
|     search expenses, except those        |                           |
|     performed for the actual donor*      |                           |
|                                          |                           |
| -   *Travel and lodging expenses, except |                           |
|     when approved by the Plan*           |                           |
|                                          |                           |
| -   *Implants of artificial organs*      |                           |
|                                          |                           |
| -   *Transplants and related services    |                           |
|     and supplies not listed as covered*  |                           |
+------------------------------------------+---------------------------+
| ######## Anesthesia                      | ###                       |
+------------------------------------------+---------------------------+
| > Professional services provided in:     | PPO: 15% of the Plan      |
|                                          | allowance (No deductible) |
| -   Hospital (inpatient)                 |                           |
|                                          | Non-PPO: 30% of the Plan  |
|                                          | allowance and the         |
|                                          | difference, if any,       |
|                                          | between our allowance and |
|                                          | the billed amount (No     |
|                                          | deductible)               |
|                                          |                           |
|                                          | Note: If your PPO         |
|                                          | provider uses a non-PPO   |
|                                          | anesthesiologist, we will |
|                                          | pay non-PPO benefits for  |
|                                          | the anesthesia charges.   |
+------------------------------------------+---------------------------+
| > Professional services provided in:     | PPO: 15% of the Plan      |
|                                          | allowance                 |
| -   Hospital outpatient department       |                           |
|                                          | Non-PPO: 30% of the Plan  |
| -   Ambulatory surgical center           | allowance and the         |
|                                          | difference, if any,       |
| -   Office                               | between our allowance and |
|                                          | the billed amount         |
| -   Other outpatient facility            |                           |
|                                          | Note: If your PPO         |
|                                          | provider uses a non-PPO   |
|                                          | anesthesiologist, we will |
|                                          | pay non-PPO benefits for  |
|                                          | the anesthesia charges.   |
+------------------------------------------+---------------------------+

+---+---+----------------------------------+--------------------+---+---+
| * |   |                                  |                    |   |   |
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+---+---+----------------------------------+--------------------+---+---+
|   | * | **Here are some important things |                    | * |   |
|   | * | you should keep in mind about    |                    | * |   |
|   | I | these benefits:**                |                    | I |   |
|   | * |                                  |                    | * |   |
|   | * | -   Please remember that all     |                    | * |   |
|   |   |     benefits are subject to the  |                    |   |   |
|   | * |     definitions, limitations,    |                    | * |   |
|   | * |     and exclusions in this       |                    | * |   |
|   | M |     brochure and are payable     |                    | M |   |
|   | * |     only when we determine they  |                    | * |   |
|   | * |     are medically necessary.     |                    | * |   |
|   |   |                                  |                    |   |   |
|   | * | -   In this Section, unlike      |                    | * |   |
|   | * |     Sections 5(a) and (b), the   |                    | * |   |
|   | P |     calendar year deductible     |                    | P |   |
|   | * |     applies to only a few        |                    | * |   |
|   | * |     benefits. In that case, we   |                    | * |   |
|   |   |     say "(calendar year          |                    |   |   |
|   | * |     deductible applies)". The    |                    | * |   |
|   | * |     PPO calendar year deductible |                    | * |   |
|   | O |     is \$250 per person (\$500   |                    | O |   |
|   | * |     per family). If you use      |                    | * |   |
|   | * |     non-PPO providers, your      |                    | * |   |
|   |   |     calendar year deductible is  |                    |   |   |
|   | * |     \$300 per person (\$600 per  |                    | * |   |
|   | * |     family). Whether you use PPO |                    | * |   |
|   | R |     or non-PPO providers, your   |                    | R |   |
|   | * |     deductible will not exceed   |                    | * |   |
|   | * |     \$300 per person (\$600 per  |                    | * |   |
|   |   |     family).                     |                    |   |   |
|   | * |                                  |                    | * |   |
|   | * | ```{=html}                       |                    | * |   |
|   | T | <!-- -->                         |                    | T |   |
|   | * | ```                              |                    | * |   |
|   | * | -   The non-PPO benefits are the |                    | * |   |
|   |   |     standard benefits of this    |                    |   |   |
|   | * |     Plan. PPO benefits apply     |                    | * |   |
|   | * |     only when you use a PPO      |                    | * |   |
|   | A |     provider. When no PPO        |                    | A |   |
|   | * |     provider is available,       |                    | * |   |
|   | * |     non-PPO benefits apply.      |                    | * |   |
|   |   |                                  |                    |   |   |
|   | * | -   Please keep in mind that     |                    | * |   |
|   | * |     when you use a PPO hospital  |                    | * |   |
|   | N |     or a PPO physician, some of  |                    | N |   |
|   | * |     the professionals that       |                    | * |   |
|   | * |     provide related services,    |                    | * |   |
|   |   |     such as emergency room       |                    |   |   |
|   | * |     physicians, radiologists,    |                    | * |   |
|   | * |     anesthetists, and            |                    | * |   |
|   | T |     pathologists, may **not**    |                    | T |   |
|   | * |     all be preferred providers.  |                    | * |   |
|   | * |     If they are not, they will   |                    | * |   |
|   |   |     be paid as non-PPO           |                    |   |   |
|   |   |     providers.                   |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   | -   Be sure to read Section      |                    |   |   |
|   |   |     4.*Your costs for covered    |                    |   |   |
|   |   |     services,* for valuable      |                    |   |   |
|   |   |     information about cost       |                    |   |   |
|   |   |     sharing, with special        |                    |   |   |
|   |   |     sections for members who are |                    |   |   |
|   |   |     age 65 or older. Also read   |                    |   |   |
|   |   |     Section 9. *Coordinating     |                    |   |   |
|   |   |     benefits with other          |                    |   |   |
|   |   |     coverage*.                   |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   | ```{=html}                       |                    |   |   |
|   |   | <!-- -->                         |                    |   |   |
|   |   | ```                              |                    |   |   |
|   |   | -   The amounts listed below are |                    |   |   |
|   |   |     for charges billed by the    |                    |   |   |
|   |   |     facility (i.e., hospital or  |                    |   |   |
|   |   |     surgical center) or          |                    |   |   |
|   |   |     ambulance service for your   |                    |   |   |
|   |   |     surgery or care. See         |                    |   |   |
|   |   |     Sections 5(a) or (b) for     |                    |   |   |
|   |   |     costs associated with the    |                    |   |   |
|   |   |     professional charge (i.e.,   |                    |   |   |
|   |   |     physicians, etc.).           |                    |   |   |
|   |   |                                  |                    |   |   |
|   |   | ```{=html}                       |                    |   |   |
|   |   | <!-- -->                         |                    |   |   |
|   |   | ```                              |                    |   |   |
|   |   | -   **YOU MUST GET               |                    |   |   |
|   |   |     PRECERTIFICATION FOR         |                    |   |   |
|   |   |     HOSPITAL STAYS; FAILURE TO   |                    |   |   |
|   |   |     DO SO WILL RESULT IN A \$500 |                    |   |   |
|   |   |     PENALTY.** Please refer to   |                    |   |   |
|   |   |     the precertification         |                    |   |   |
|   |   |     information shown in Section |                    |   |   |
|   |   |     3 to be sure which services  |                    |   |   |
|   |   |     require precertification.    |                    |   |   |
+---+---+----------------------------------+--------------------+---+---+
| * |   |                                  | **You pay**        |   |   |
| * |   |                                  |                    |   |   |
| B |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| n |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| f |   |                                  |                    |   |   |
| i |   |                                  |                    |   |   |
| t |   |                                  |                    |   |   |
| D |   |                                  |                    |   |   |
| e |   |                                  |                    |   |   |
| s |   |                                  |                    |   |   |
| c |   |                                  |                    |   |   |
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| n |   |                                  |                    |   |   |
| * |   |                                  |                    |   |   |
| * |   |                                  |                    |   |   |
+---+---+----------------------------------+--------------------+---+---+
| # |   |                                  |                    |   |   |
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| # |   |                                  |                    |   |   |
|   |   |                                  |                    |   |   |
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+---+---+----------------------------------+--------------------+---+---+
| # |   |                                  | ###                |   |   |
| # |   |                                  |                    |   |   |
| # |   |                                  |                    |   |   |
| # |   |                                  |                    |   |   |
| # |   |                                  |                    |   |   |
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| # |   |                                  |                    |   |   |
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+---+---+----------------------------------+--------------------+---+---+
| > |   |                                  | > PPO: 10% of the  |   |   |
|   |   |                                  | > Plan allowance   |   |   |
| R |   |                                  | >                  |   |   |
| o |   |                                  | > Non-PPO: \$100   |   |   |
| o |   |                                  | > copayment per    |   |   |
| m |   |                                  | > admission and    |   |   |
| > |   |                                  | > 30% of the Plan  |   |   |
|   |   |                                  | > allowance        |   |   |
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+---+---+----------------------------------+--------------------+---+---+

Inpatient hospital - continued on next page

+--------------------------------------------+-------------------------+
| ######## Inpatient hospital *(continued)*  | ### You pay             |
+--------------------------------------------+-------------------------+
| #### Othe                                  | > PPO: 10% of the Plan  |
| r hospital services and supplies, such as: | > allowance             |
|                                            | >                       |
| -   Operating, recovery, maternity, and    | > Non-PPO: \$100        |
|     other treatment rooms                  | > copayment per         |
|                                            | > admission and 30% of  |
| -   Prescribed drugs and medicines         | > the Plan allowance    |
|                                            |                         |
| -   Diagnostic laboratory tests and X-rays |                         |
|                                            |                         |
| -   Preadmission testing (within 7 days of |                         |
|     admission), limited to:                |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Chest X-rays                           |                         |
|                                            |                         |
| -   Electrocardiograms                     |                         |
|                                            |                         |
| -   Urinalysis                             |                         |
|                                            |                         |
| -   Blood work                             |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Blood or blood plasma, if not donated  |                         |
|     or replaced                            |                         |
|                                            |                         |
| -   Dressings, splints, casts, and sterile |                         |
|     tray services                          |                         |
|                                            |                         |
| -   Medical supplies and equipment,        |                         |
|     including oxygen                       |                         |
|                                            |                         |
| -   Anesthetics, including nurse           |                         |
|     anesthetist services                   |                         |
|                                            |                         |
| -   Internal prostheses                    |                         |
|                                            |                         |
| -   Professional ambulance service to the  |                         |
|     nearest hospital equipped to handle    |                         |
|     your condition                         |                         |
|                                            |                         |
| -   Occupational, physical, and speech     |                         |
|     therapy                                |                         |
|                                            |                         |
| > Note: We base payment on who bills for   |                         |
| > the services or supplies. For example,   |                         |
| > when the hospital bills for its nurse    |                         |
| > anesthetist's services, we pay hospital  |                         |
| > benefits (*Inpatient hospital)* and when |                         |
| > the anesthesiologist bills, we pay       |                         |
| > anesthesia benefits**.** See Section     |                         |
| > 5(b). *Surgical procedures*.             |                         |
| >                                          |                         |
| > Note: We cover your admission for dental |                         |
| > procedures only when you have a          |                         |
| > nondental physical impairment that makes |                         |
| > admission necessary to safeguard your    |                         |
| > health. We do not cover the dental       |                         |
| > procedures.                              |                         |
| >                                          |                         |
| > Note: We cover your admission for        |                         |
| > inpatient foot treatment even if no      |                         |
| > other benefits are payable.              |                         |
| >                                          |                         |
| > Note: Diagnostic tests, such as magnetic |                         |
| > resonance imaging, throat cultures, or   |                         |
| > similar studies are not considered as    |                         |
| > preadmission testing.                    |                         |
+--------------------------------------------+-------------------------+
| > Take-home items                          | > PPO: 15% of the Plan  |
|                                            | > allowance (calendar   |
| -   Medical supplies, appliances, and      | > year deductible       |
|     equipment; and any covered items       | > applies)              |
|     billed by a hospital for use at home   | >                       |
|                                            | > Non-PPO: 30% of the   |
| ####                                       | > Plan allowance        |
|                                            | > (calendar year        |
|                                            | > deductible applies)   |
+--------------------------------------------+-------------------------+

*Inpatient hospital -- continued on next page*

+--------------------------------------------+-------------------------+
| ######## Inpatient hospital *(continued)*  | ### You pay             |
+--------------------------------------------+-------------------------+
| > *Not covered:*                           | > *All charges*         |
|                                            |                         |
| -   *Any part of a hospital admission that |                         |
|     is not medically necessary (See        |                         |
|     Section 10.* Definitions . . . Medical |                         |
|     Necessity*), such as subacute care,    |                         |
|     long term care, long term acute care,  |                         |
|     intermediate care, or when you do not  |                         |
|     need acute hospital inpatient care,    |                         |
|     but could receive care in some other   |                         |
|     setting without adversely affecting    |                         |
|     your condition or the quality of your  |                         |
|     medical care. In this event, we pay    |                         |
|     benefits for services and supplies     |                         |
|     other than room and board and          |                         |
|     in-hospital physician care at the      |                         |
|     level they would have been covered if  |                         |
|     provided in an alternative setting.*   |                         |
|                                            |                         |
| -   *Custodial care; see Section 10.*      |                         |
|     Definitions *.* . . Custodial care     |                         |
|                                            |                         |
| -   *Non-covered facilities, such as       |                         |
|     nursing homes, extended care           |                         |
|     facilities and schools*                |                         |
|                                            |                         |
| -   *Personal comfort items, such as       |                         |
|     telephone, television, barber          |                         |
|     services, guest meals and beds*        |                         |
|                                            |                         |
| -   *Private nursing care*                 |                         |
+--------------------------------------------+-------------------------+
| #### **Outpatien                           | ###                     |
| t hospital or ambulatory surgical center** |                         |
+--------------------------------------------+-------------------------+
| > Services and supplies, such as:          | > PPO: 15% of the Plan  |
|                                            | > allowance (calendar   |
| -   Operating, recovery, and other         | > year deductible       |
|     treatment rooms                        | > applies)              |
|                                            | >                       |
| #### Prescribed drugs and medicines        | > Non-PPO: 30% of the   |
|                                            | > Plan allowance and    |
| -   Diagnostic laboratory tests, X-rays,   | > the difference, if    |
|     and pathology services                 | > any, between our      |
|                                            | > allowance and the     |
| -   Administration of blood, blood plasma, | > billed amount         |
|     and other biologicals                  | > (calendar year        |
|                                            | > deductible applies)   |
| -   Blood and blood plasma, if not donated |                         |
|     or replaced                            |                         |
|                                            |                         |
| -   Dressings, splints, casts, and sterile |                         |
|     tray services                          |                         |
|                                            |                         |
| -   Medical supplies, including oxygen     |                         |
|                                            |                         |
| -   Anesthetics and anesthesia service     |                         |
|                                            |                         |
| > Note: We cover hospital services and     |                         |
| > supplies related to dental procedures    |                         |
| > when necessitated by a nondental         |                         |
| > physical impairment. We do not cover the |                         |
| > dental procedures.                       |                         |
+--------------------------------------------+-------------------------+
| > Plan pays for pre-operative testing      | > PPO: 10% of the Plan  |
| > within 7 days of surgery. Screening      | > allowance             |
| > tests, limited to:                       | >                       |
|                                            | > Non-PPO: 30% of the   |
| -   Chest X-rays                           | > Plan allowance, and   |
|                                            | > the difference, if    |
| -   Electrocardiograms                     | > any, between our      |
|                                            | > allowance and the     |
| -   Urinalysis                             | > billed amount         |
|                                            |                         |
| -   Blood work                             |                         |
|                                            |                         |
| Note: Diagnostic tests, such as magnetic   |                         |
| resonance imaging, throat cultures, or     |                         |
| similar studies are not considered as      |                         |
| preadmission testing.                      |                         |
+--------------------------------------------+-------------------------+
| # *Not covered: Personal comfort items*    | > *All charges*         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| ### Skilled nursing care facility benefits | ### You pay             |
+--------------------------------------------+-------------------------+
| > Limited to care in a skilled nursing     | > PPO: Nothing          |
| > facility (SNF) when your Medicare Part A | >                       |
| > is primary, and:                         | > Non-PPO: Nothing      |
|                                            |                         |
| -   Medicare has made payment, we cover    |                         |
|     the applicable copayments; or          |                         |
|                                            |                         |
| -   Medicare's benefits are exhausted, we  |                         |
|     cover semiprivate room, board,         |                         |
|     services, and supplies in a SNF during |                         |
|     the initial 30 days per confinement    |                         |
|     provided:                              |                         |
|                                            |                         |
| 1.  You are admitted directly from a       |                         |
|     hospital stay of at least 3            |                         |
|     consecutive days;                      |                         |
|                                            |                         |
| 2.  You are admitted for the same          |                         |
|     condition as the hospital stay; and    |                         |
|                                            |                         |
| 3.  Your skilled nursing care is           |                         |
|     supervised by a physician and provided |                         |
|     by an R.N., L.P.N., or L.V.N.          |                         |
+--------------------------------------------+-------------------------+
| > *Not covered: Custodial care*            | > *All charges*         |
+--------------------------------------------+-------------------------+
| #### **Hospice care**                      | ###                     |
+--------------------------------------------+-------------------------+
| > Hospice is a coordinated program of      | > PPO: 15% of the Plan  |
| > maintenance and supportive care for the  | > allowance, and all    |
| > terminally ill provided by a medically   | > charges after we pay  |
| > supervised team under the direction of a | > \$3000 (calendar year |
| > Plan-approved independent hospice        | > deductible applies)   |
| > administration.                          | >                       |
| >                                          | > Non-PPO: 30% of the   |
| > Limited benefits: We pay up to \$3000    | > Plan allowance, and   |
| > per lifetime for a combination of        | > all charges after we  |
| > inpatient and outpatient services.       | > pay \$3000 (calendar  |
|                                            | > year deductible       |
|                                            | > applies)              |
+--------------------------------------------+-------------------------+
| > *Not covered:*                           | ####### All charges     |
|                                            |                         |
| -   *Private nursing care*                 |                         |
|                                            |                         |
| -   *Homemaker services*                   |                         |
|                                            |                         |
| -   *Bereavement services*                 |                         |
+--------------------------------------------+-------------------------+
| ######## Ambulance                         | ###                     |
+--------------------------------------------+-------------------------+
| > Local professional ambulance service     | > PPO: 15% of the Plan  |
| > when medically necessary                 | > allowance (calendar   |
|                                            | > year deductible       |
|                                            | > applies)              |
|                                            | >                       |
|                                            | > Non-PPO: 30% of the   |
|                                            | > Plan allowance and    |
|                                            | > the difference, if    |
|                                            | > any, between our      |
|                                            | > allowance and the     |
|                                            | > billed amount         |
|                                            | > (calendar year        |
|                                            | > deductible applies)   |
+--------------------------------------------+-------------------------+
| > *Not covered: Transportation (other than | > *All charges*         |
| > professional ambulance services), such   |                         |
| > as by ambulette or medicab*              |                         |
+--------------------------------------------+-------------------------+

#####  {#section-25 .unnumbered}

#####  {#section-26 .unnumbered}

+----+---+---------------------------------+-------------------+---+---+
| ## |   |                                 |                   |   |   |
| ## |   |                                 |                   |   |   |
| #  |   |                                 |                   |   |   |
| Se |   |                                 |                   |   |   |
| ct |   |                                 |                   |   |   |
| io |   |                                 |                   |   |   |
| n  |   |                                 |                   |   |   |
| 5( |   |                                 |                   |   |   |
| d) |   |                                 |                   |   |   |
| .  |   |                                 |                   |   |   |
| Em |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| ge |   |                                 |                   |   |   |
| nc |   |                                 |                   |   |   |
| y  |   |                                 |                   |   |   |
| se |   |                                 |                   |   |   |
| rv |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
| /a |   |                                 |                   |   |   |
| cc |   |                                 |                   |   |   |
| id |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| ts |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| ## | * | **Here are some important       |                   | * |   |
| ## | * | things to keep in mind about    |                   | * |   |
| #  | I | these benefits:**               |                   | I |   |
|    | * |                                 |                   | * |   |
|    | * | -   Please remember that all    |                   | * |   |
|    |   |     benefits are subject to the |                   |   |   |
|    | * |     definitions, limitations,   |                   | * |   |
|    | * |     and exclusions in this      |                   | * |   |
|    | M |     brochure and are payable    |                   | M |   |
|    | * |     only when we determine they |                   | * |   |
|    | * |     are medically necessary.    |                   | * |   |
|    |   |                                 |                   |   |   |
|    | * | ```{=html}                      |                   | * |   |
|    | * | <!-- -->                        |                   | * |   |
|    | P | ```                             |                   | P |   |
|    | * | -   The PPO calendar year       |                   | * |   |
|    | * |     deductible is \$250 per     |                   | * |   |
|    |   |     person (\$500 per family).  |                   |   |   |
|    | * |     If you use non-PPO          |                   | * |   |
|    | * |     providers**,** your         |                   | * |   |
|    | O |     calendar year deductible is |                   | O |   |
|    | * |     \$300 per person (\$600 per |                   | * |   |
|    | * |     family). Whether you use    |                   | * |   |
|    |   |     PPO or non-PPO providers,   |                   |   |   |
|    | * |     your deductible will not    |                   | * |   |
|    | * |     exceed \$300 per person     |                   | * |   |
|    | R |     (\$600 per family). The     |                   | R |   |
|    | * |     calendar year deductible    |                   | * |   |
|    | * |     applies to almost all       |                   | * |   |
|    |   |     benefits in this Section.   |                   |   |   |
|    | * |     We say "(No deductible)" to |                   | * |   |
|    | * |     show when the calendar year |                   | * |   |
|    | T |     deductible does not apply.  |                   | T |   |
|    | * |                                 |                   | * |   |
|    | * | -   The non-PPO benefits are    |                   | * |   |
|    |   |     the standard benefits of    |                   |   |   |
|    | * |     this Plan. PPO benefits     |                   | * |   |
|    | * |     apply only when you use a   |                   | * |   |
|    | A |     PPO provider. When no PPO   |                   | A |   |
|    | * |     provider is available,      |                   | * |   |
|    | * |     non-PPO benefits apply.     |                   | * |   |
|    |   |                                 |                   |   |   |
|    | * | -   Please keep in mind that    |                   | * |   |
|    | * |     when you use a PPO hospital |                   | * |   |
|    | N |     or a PPO physician, some of |                   | N |   |
|    | * |     the professionals that      |                   | * |   |
|    | * |     provide related services,   |                   | * |   |
|    |   |     such as emergency room      |                   |   |   |
|    | * |     physicians, radiologists,   |                   | * |   |
|    | * |     anesthetists, and           |                   | * |   |
|    | T |     pathologists, may **not**   |                   | T |   |
|    | * |     all be preferred providers. |                   | * |   |
|    | * |     If they are not, they will  |                   | * |   |
|    |   |     be paid as non-PPO          |                   |   |   |
|    |   |     providers.                  |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   | -   Be sure to read Section 4.  |                   |   |   |
|    |   |     *Your costs for covered     |                   |   |   |
|    |   |     services,* for valuable     |                   |   |   |
|    |   |     information about cost      |                   |   |   |
|    |   |     sharing, with special       |                   |   |   |
|    |   |     sections for members who    |                   |   |   |
|    |   |     are age 65 or older. Also   |                   |   |   |
|    |   |     read Section 9.             |                   |   |   |
|    |   |     *Coordinating benefits with |                   |   |   |
|    |   |     other coverage*.            |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   | #####                           |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| ** |   |                                 |                   |   |   |
| Wh |   |                                 |                   |   |   |
| at |   |                                 |                   |   |   |
| is |   |                                 |                   |   |   |
| an |   |                                 |                   |   |   |
| ac |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| i  |   |                                 |                   |   |   |
| nj |   |                                 |                   |   |   |
| ur |   |                                 |                   |   |   |
| y? |   |                                 |                   |   |   |
| ** |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
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| ac |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ju |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
| is |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| bo |   |                                 |                   |   |   |
| di |   |                                 |                   |   |   |
| ly |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ju |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
| s  |   |                                 |                   |   |   |
| us |   |                                 |                   |   |   |
| ta |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| so |   |                                 |                   |   |   |
| le |   |                                 |                   |   |   |
| ly |   |                                 |                   |   |   |
| t  |   |                                 |                   |   |   |
| hr |   |                                 |                   |   |   |
| ou |   |                                 |                   |   |   |
| gh |   |                                 |                   |   |   |
| vi |   |                                 |                   |   |   |
| ol |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| t, |   |                                 |                   |   |   |
| e  |   |                                 |                   |   |   |
| xt |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| na |   |                                 |                   |   |   |
| l, |   |                                 |                   |   |   |
| a  |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
| ac |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| me |   |                                 |                   |   |   |
| an |   |                                 |                   |   |   |
| s. |   |                                 |                   |   |   |
| We |   |                                 |                   |   |   |
| do |   |                                 |                   |   |   |
| n  |   |                                 |                   |   |   |
| ot |   |                                 |                   |   |   |
| c  |   |                                 |                   |   |   |
| ov |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| ca |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| f  |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
| ac |   |                                 |                   |   |   |
| ci |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| i  |   |                                 |                   |   |   |
| nj |   |                                 |                   |   |   |
| ur |   |                                 |                   |   |   |
| y* |   |                                 |                   |   |   |
| .* |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| *  |   |                                 | **You pay**       |   |   |
| *B |   |                                 |                   |   |   |
| en |   |                                 | **After the       |   |   |
| ef |   |                                 | calendar year     |   |   |
| it |   |                                 | deductible...**   |   |   |
| D  |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
| cr |   |                                 |                   |   |   |
| ip |   |                                 |                   |   |   |
| ti |   |                                 |                   |   |   |
| on |   |                                 |                   |   |   |
| ** |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| #  |   |                                 |                   |   |   |
| ## |   |                                 |                   |   |   |
|  N |   |                                 |                   |   |   |
| ot |   |                                 |                   |   |   |
| e: |   |                                 |                   |   |   |
|  T |   |                                 |                   |   |   |
| he |   |                                 |                   |   |   |
|  c |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| da |   |                                 |                   |   |   |
| r  |   |                                 |                   |   |   |
| ye |   |                                 |                   |   |   |
| ar |   |                                 |                   |   |   |
|  d |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| uc |   |                                 |                   |   |   |
| ti |   |                                 |                   |   |   |
| bl |   |                                 |                   |   |   |
| e  |   |                                 |                   |   |   |
| ap |   |                                 |                   |   |   |
| pl |   |                                 |                   |   |   |
| ie |   |                                 |                   |   |   |
| s  |   |                                 |                   |   |   |
| to |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| lm |   |                                 |                   |   |   |
| os |   |                                 |                   |   |   |
| t  |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| l  |   |                                 |                   |   |   |
| be |   |                                 |                   |   |   |
| ne |   |                                 |                   |   |   |
| fi |   |                                 |                   |   |   |
| ts |   |                                 |                   |   |   |
|  i |   |                                 |                   |   |   |
| n  |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| is |   |                                 |                   |   |   |
|  S |   |                                 |                   |   |   |
| ec |   |                                 |                   |   |   |
| ti |   |                                 |                   |   |   |
| on |   |                                 |                   |   |   |
| .  |   |                                 |                   |   |   |
| We |   |                                 |                   |   |   |
|  s |   |                                 |                   |   |   |
| ay |   |                                 |                   |   |   |
|  " |   |                                 |                   |   |   |
| (N |   |                                 |                   |   |   |
| o  |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| du |   |                                 |                   |   |   |
| ct |   |                                 |                   |   |   |
| ib |   |                                 |                   |   |   |
| le |   |                                 |                   |   |   |
| )" |   |                                 |                   |   |   |
|  w |   |                                 |                   |   |   |
| he |   |                                 |                   |   |   |
| n  |   |                                 |                   |   |   |
| it |   |                                 |                   |   |   |
|  d |   |                                 |                   |   |   |
| oe |   |                                 |                   |   |   |
| s  |   |                                 |                   |   |   |
| no |   |                                 |                   |   |   |
| t  |   |                                 |                   |   |   |
| ap |   |                                 |                   |   |   |
| pl |   |                                 |                   |   |   |
| y. |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| ## |   |                                 | ###               |   |   |
| ## |   |                                 |                   |   |   |
| ## |   |                                 |                   |   |   |
| ## |   |                                 |                   |   |   |
|  A |   |                                 |                   |   |   |
| cc |   |                                 |                   |   |   |
| id |   |                                 |                   |   |   |
| en |   |                                 |                   |   |   |
| ta |   |                                 |                   |   |   |
| l  |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| ju |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+
| >  |   |                                 | > PPO: Nothing    |   |   |
| If |   |                                 | > (No deductible) |   |   |
| >  |   |                                 | >                 |   |   |
|  y |   |                                 | > Non-PPO: The    |   |   |
| ou |   |                                 | > difference, if  |   |   |
| >  |   |                                 | > any, between    |   |   |
|  r |   |                                 | > the Plan        |   |   |
| ec |   |                                 | > allowance and   |   |   |
| ei |   |                                 | > the billed      |   |   |
| ve |   |                                 | > amount (No      |   |   |
| >  |   |                                 | > deductible)     |   |   |
|  t |   |                                 |                   |   |   |
| he |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| ca |   |                                 |                   |   |   |
| re |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| wi |   |                                 |                   |   |   |
| th |   |                                 |                   |   |   |
| in |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| 72 |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
|  h |   |                                 |                   |   |   |
| ou |   |                                 |                   |   |   |
| rs |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| ft |   |                                 |                   |   |   |
| er |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| yo |   |                                 |                   |   |   |
| ur |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| ac |   |                                 |                   |   |   |
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| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
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| ur |   |                                 |                   |   |   |
| y, |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| we |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
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| ve |   |                                 |                   |   |   |
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|    |   |                                 |                   |   |   |
| -  |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|  R |   |                                 |                   |   |   |
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| at |   |                                 |                   |   |   |
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|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| or |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
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| tp |   |                                 |                   |   |   |
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| nt |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| se |   |                                 |                   |   |   |
| rv |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| nd |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| su |   |                                 |                   |   |   |
| pp |   |                                 |                   |   |   |
| li |   |                                 |                   |   |   |
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|    |   |                                 |                   |   |   |
| -  |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|  L |   |                                 |                   |   |   |
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|    |   |                                 |                   |   |   |
| pr |   |                                 |                   |   |   |
| of |   |                                 |                   |   |   |
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|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|  a |   |                                 |                   |   |   |
| mb |   |                                 |                   |   |   |
| ul |   |                                 |                   |   |   |
| an |   |                                 |                   |   |   |
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|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
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|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
| wh |   |                                 |                   |   |   |
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|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|  m |   |                                 |                   |   |   |
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|    |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
|  n |   |                                 |                   |   |   |
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| es |   |                                 |                   |   |   |
| sa |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
|    |   |                                 |                   |   |   |
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| >  |   |                                 |                   |   |   |
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| >  |   |                                 |                   |   |   |
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| ur |   |                                 |                   |   |   |
| ge |   |                                 |                   |   |   |
| ry |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
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| to |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| yo |   |                                 |                   |   |   |
| ur |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
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| ci |   |                                 |                   |   |   |
| de |   |                                 |                   |   |   |
| nt |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
|  i |   |                                 |                   |   |   |
| nj |   |                                 |                   |   |   |
| ur |   |                                 |                   |   |   |
| y, |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
|  s |   |                                 |                   |   |   |
| ee |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
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| ec |   |                                 |                   |   |   |
| ti |   |                                 |                   |   |   |
| on |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
|  5 |   |                                 |                   |   |   |
| (b |   |                                 |                   |   |   |
| ). |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
|  * |   |                                 |                   |   |   |
| Su |   |                                 |                   |   |   |
| rg |   |                                 |                   |   |   |
| ic |   |                                 |                   |   |   |
| al |   |                                 |                   |   |   |
| >  |   |                                 |                   |   |   |
| pr |   |                                 |                   |   |   |
| oc |   |                                 |                   |   |   |
| ed |   |                                 |                   |   |   |
| ur |   |                                 |                   |   |   |
| es |   |                                 |                   |   |   |
| .* |   |                                 |                   |   |   |
+----+---+---------------------------------+-------------------+---+---+

*Accidental injury - continued on next page*

+------------------------------------------+---------------------------+
| ######## Accidental injury *(continued)* | ### You pay               |
+------------------------------------------+---------------------------+
| > If you receive care for your           | > PPO: 15% of the Plan    |
| > accidental injury after 72 hours, we   | > allowance               |
| > cover outpatient hospital and          | >                         |
| > physician services and supplies not    | > Non-PPO: 30% of the     |
| > related to surgical procedures.        | > Plan allowance and the  |
|                                          | > difference, if any,     |
|                                          | > between the Plan        |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > **Medical emergency**                  | ###                       |
+------------------------------------------+---------------------------+
| > Outpatient medical services and        | > PPO: 15% of the Plan    |
| > supplies. See Section 5(a). *Medical   | > allowance               |
| > services and supplies . . .*           | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and the  |
|                                          | > difference, if any,     |
|                                          | > between our allowance   |
|                                          | > and the billed amount   |
+------------------------------------------+---------------------------+
| > Surgical services. See Section 5(b).   | > PPO: 10% of the Plan    |
| > *Surgical procedures.*                 | > allowance               |
|                                          | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and the  |
|                                          | > difference, if any,     |
|                                          | > between our allowance   |
|                                          | > and the billed amount   |
+------------------------------------------+---------------------------+
| > **Ambulance**                          | ###                       |
+------------------------------------------+---------------------------+
| > Local professional ambulance service   | > PPO: 15% of the Plan    |
| > when medically necessary, not related  | > allowance               |
| > to an accidental injury                | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and the  |
|                                          | > difference, if any,     |
|                                          | > between our allowance   |
|                                          | > and the billed amount   |
+------------------------------------------+---------------------------+
| > *Not covered: Transportation (other    | > *All charges*           |
| > than professional ambulance services), |                           |
| > such as by ambulette or medicab*       |                           |
+------------------------------------------+---------------------------+

+---+---+---------------------------------+------------------------+---+---+---+
| # |   |                                 |                        |   |   |   |
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| 5 |   |                                 |                        |   |   |   |
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| ) |   |                                 |                        |   |   |   |
| . |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| M |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
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|   |   |                                 |                        |   |   |   |
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| n |   |                                 |                        |   |   |   |
| d |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| s |   |                                 |                        |   |   |   |
| u |   |                                 |                        |   |   |   |
| b |   |                                 |                        |   |   |   |
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| t |   |                                 |                        |   |   |   |
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| n |   |                                 |                        |   |   |   |
| c |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| a |   |                                 |                        |   |   |   |
| b |   |                                 |                        |   |   |   |
| u |   |                                 |                        |   |   |   |
| s |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| b |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
| n |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
| f |   |                                 |                        |   |   |   |
| i |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
| s |   |                                 |                        |   |   |   |
+---+---+---------------------------------+------------------------+---+---+---+
| # |   |                                 |                        |   |   |   |
| # |   |                                 |                        |   |   |   |
| # |   |                                 |                        |   |   |   |
| # |   |                                 |                        |   |   |   |
| # |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| I |   |                                 |                        |   |   |   |
| n |   |                                 |                        |   |   |   |
| - |   |                                 |                        |   |   |   |
| N |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
| w |   |                                 |                        |   |   |   |
| o |   |                                 |                        |   |   |   |
| r |   |                                 |                        |   |   |   |
| k |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| B |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
| n |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
| f |   |                                 |                        |   |   |   |
| i |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
| s |   |                                 |                        |   |   |   |
+---+---+---------------------------------+------------------------+---+---+---+
|   | * | You may choose to get care      |                        | * |   |   |
|   | * | In-Network or Out-of-Network.   |                        | * |   |   |
|   | I | When you receive In-Network     |                        | I |   |   |
|   | * | care, you must get our approval |                        | * |   |   |
|   | * | for services and follow a       |                        | * |   |   |
|   |   | treatment plan we approve. If   |                        |   |   |   |
|   | * | you do, cost-sharing and        |                        | * |   |   |
|   | * | limitations for In-Network      |                        | * |   |   |
|   | M | mental health and substance     |                        | M |   |   |
|   | * | abuse benefits will be no       |                        | * |   |   |
|   | * | greater than for similar        |                        | * |   |   |
|   |   | benefits for other illnesses    |                        |   |   |   |
|   | * | and conditions.                 |                        | * |   |   |
|   | * |                                 |                        | * |   |   |
|   | P | **Here are some important       |                        | P |   |   |
|   | * | things to keep in mind about    |                        | * |   |   |
|   | * | these benefits:**               |                        | * |   |   |
|   |   |                                 |                        |   |   |   |
|   | * | -   Please remember that all    |                        | * |   |   |
|   | * |     benefits are subject to the |                        | * |   |   |
|   | O |     definitions, limitations,   |                        | O |   |   |
|   | * |     and exclusions in this      |                        | * |   |   |
|   | * |     brochure and are payable    |                        | * |   |   |
|   |   |     only when we determine they |                        |   |   |   |
|   | * |     are medically necessary.    |                        | * |   |   |
|   | * |                                 |                        | * |   |   |
|   | R | -   There is a separate         |                        | R |   |   |
|   | * |     calendar year deductible    |                        | * |   |   |
|   | * |     for In-Network mental       |                        | * |   |   |
|   |   |     health and substance abuse  |                        |   |   |   |
|   | * |     of \$250 per person (\$500  |                        | * |   |   |
|   | * |     per family). This calendar  |                        | * |   |   |
|   | T |     year deductible applies to  |                        | T |   |   |
|   | * |     almost all benefits in this |                        | * |   |   |
|   | * |     Section. We say "(No        |                        | * |   |   |
|   |   |     deductible)" to show when   |                        |   |   |   |
|   | * |     the calendar year           |                        | * |   |   |
|   | * |     deductible does not apply.  |                        | * |   |   |
|   | A |                                 |                        | A |   |   |
|   | * | -   When no In-Network provider |                        | * |   |   |
|   | * |     is available or covered     |                        | * |   |   |
|   |   |     services are not            |                        |   |   |   |
|   | * |     preauthorized,              |                        | * |   |   |
|   | * |     Out-of-Network benefits     |                        | * |   |   |
|   | N |     will be paid.               |                        | N |   |   |
|   | * |                                 |                        | * |   |   |
|   | * | -   Be sure to read Section 4.  |                        | * |   |   |
|   |   |     *Your costs for covered     |                        |   |   |   |
|   | * |     services,* for valuable     |                        | * |   |   |
|   | * |     information about cost      |                        | * |   |   |
|   | T |     sharing, with special       |                        | T |   |   |
|   | * |     sections for members who    |                        | * |   |   |
|   | * |     are age 65 or older. Also   |                        | * |   |   |
|   |   |     read Section 9**.**         |                        |   |   |   |
|   |   |     *Coordinating benefits with |                        |   |   |   |
|   |   |     other coverage.*            |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   | -   **YOU MUST GET              |                        |   |   |   |
|   |   |     PREAUTHORIZATION OF THESE   |                        |   |   |   |
|   |   |     SERVICES.** See the         |                        |   |   |   |
|   |   |     instructions after the      |                        |   |   |   |
|   |   |     benefits descriptions       |                        |   |   |   |
|   |   |     below.                      |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   | -   In-Network mental health    |                        |   |   |   |
|   |   |     and substance abuse         |                        |   |   |   |
|   |   |     benefits are below; then    |                        |   |   |   |
|   |   |     Out-of-Network benefits     |                        |   |   |   |
|   |   |     begin on page 41.           |                        |   |   |   |
+---+---+---------------------------------+------------------------+---+---+---+
| > |   |                                 | **You pay**            |   |   |   |
|   |   |                                 |                        |   |   |   |
| * |   |                                 | **After the calendar   |   |   |   |
| * |   |                                 | year deductible...**   |   |   |   |
| B |   |                                 |                        |   |   |   |
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|   |   |                                 |                        |   |   |   |
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| n |   |                                 |                        |   |   |   |
| * |   |                                 |                        |   |   |   |
| * |   |                                 |                        |   |   |   |
+---+---+---------------------------------+------------------------+---+---+---+
| # |   |                                 |                        |   |   |   |
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| # |   |                                 |                        |   |   |   |
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| . |   |                                 |                        |   |   |   |
+---+---+---------------------------------+------------------------+---+---+---+
| # |   |                                 | ###                    |   |   |   |
| # |   |                                 |                        |   |   |   |
| # |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| I |   |                                 |                        |   |   |   |
| n |   |                                 |                        |   |   |   |
| - |   |                                 |                        |   |   |   |
| N |   |                                 |                        |   |   |   |
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| t |   |                                 |                        |   |   |   |
| w |   |                                 |                        |   |   |   |
| o |   |                                 |                        |   |   |   |
| r |   |                                 |                        |   |   |   |
| k |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| b |   |                                 |                        |   |   |   |
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| n |   |                                 |                        |   |   |   |
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| f |   |                                 |                        |   |   |   |
| i |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
| s |   |                                 |                        |   |   |   |
+---+---+---------------------------------+------------------------+---+---+---+
| > |   |                                 | > Your cost-sharing    |   |   |   |
|   |   |                                 | > responsibilities are |   |   |   |
| A |   |                                 | > no greater than for  |   |   |   |
| l |   |                                 | > other illnesses or   |   |   |   |
| l |   |                                 | > conditions, such as  |   |   |   |
| > |   |                                 | > \$20 copayment per   |   |   |   |
|   |   |                                 | > office visit, or 15% |   |   |   |
| d |   |                                 | > of the Plan          |   |   |   |
| i |   |                                 | > allowance for other  |   |   |   |
| a |   |                                 | > outpatient services  |   |   |   |
| g |   |                                 | > after the calendar   |   |   |   |
| n |   |                                 | > year deductible is   |   |   |   |
| o |   |                                 | > met.                 |   |   |   |
| s |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
| i |   |                                 |                        |   |   |   |
| c |   |                                 |                        |   |   |   |
| > |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
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| d |   |                                 |                        |   |   |   |
| > |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
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| m |   |                                 |                        |   |   |   |
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| . |   |                                 |                        |   |   |   |
+---+---+---------------------------------+------------------------+---+---+---+
| - |   |                                 | > \$20 copayment per   |   |   |   |
|   |   |                                 | > visit (No            |   |   |   |
|   |   |                                 | > deductible)          |   |   |   |
|   |   |                                 |                        |   |   |   |
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|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| m |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
| d |   |                                 |                        |   |   |   |
| i |   |                                 |                        |   |   |   |
| c |   |                                 |                        |   |   |   |
| a |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
| i |   |                                 |                        |   |   |   |
| o |   |                                 |                        |   |   |   |
| n |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| m |   |                                 |                        |   |   |   |
| a |   |                                 |                        |   |   |   |
| n |   |                                 |                        |   |   |   |
| a |   |                                 |                        |   |   |   |
| g |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
| m |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
| n |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
+---+---+---------------------------------+------------------------+---+---+---+
| - |   |                                 | > 15% of the Plan      |   |   |   |
|   |   |                                 | > allowance            |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| O |   |                                 |                        |   |   |   |
| u |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
| p |   |                                 |                        |   |   |   |
| a |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
| i |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
| n |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| d |   |                                 |                        |   |   |   |
| i |   |                                 |                        |   |   |   |
| a |   |                                 |                        |   |   |   |
| g |   |                                 |                        |   |   |   |
| n |   |                                 |                        |   |   |   |
| o |   |                                 |                        |   |   |   |
| s |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
| i |   |                                 |                        |   |   |   |
| c |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
|   |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
| e |   |                                 |                        |   |   |   |
| s |   |                                 |                        |   |   |   |
| t |   |                                 |                        |   |   |   |
| s |   |                                 |                        |   |   |   |
+---+---+---------------------------------+------------------------+---+---+---+

*In-Network benefits - continued on next page*

+----------------------------------------+-----------------------------+
| ### In-Network benefits *(continued)*  | ### You pay                 |
+----------------------------------------+-----------------------------+
| -   Inpatient professional services,   | > 15% of the Plan allowance |
|     including individual or group      |                             |
|     therapy by providers such as       |                             |
|     psychiatrists, psychologists, or   |                             |
|     clinical social workers            |                             |
+----------------------------------------+-----------------------------+
| -   Inpatient services provided by a   | > Nothing (No deductible)   |
|     hospital or other facility         |                             |
|                                        |                             |
| -   Services in approved alternative   |                             |
|     care settings such as partial      |                             |
|     hospitalization, half-way house,   |                             |
|     residential treatment, full-day    |                             |
|     hospitalization, facility based    |                             |
|     intensive outpatient treatment     |                             |
+----------------------------------------+-----------------------------+
| ## Not covered:                        | > *All charges*             |
|                                        |                             |
| -   *Services we have not approved*    |                             |
|                                        |                             |
| -   *Treatment for learning            |                             |
|     disabilities and mental            |                             |
|     retardation*                       |                             |
|                                        |                             |
| -   *Treatment for marital discord*    |                             |
|                                        |                             |
| > Note: Exclusions that apply to other |                             |
| > benefits apply to these mental       |                             |
| > health and substance abuse benefits, |                             |
| > unless the services are included in  |                             |
| > a treatment plan that we approve.    |                             |
| >                                      |                             |
| > Note: OPM will base its review of    |                             |
| > disputes about treatment plans on    |                             |
| > the treatment plan\'s clinical       |                             |
| > appropriateness. OPM will generally  |                             |
| > not order us to pay or provide one   |                             |
| > clinically appropriate treatment     |                             |
| > plan in favor of another.            |                             |
+----------------------------------------+-----------------------------+
| > **Preauthorization** To be eligible  |                             |
| > to receive these enhanced mental     |                             |
| > health and substance abuse benefits  |                             |
| > you must obtain a treatment plan and |                             |
| > follow all of the following network  |                             |
| > authorization processes:             |                             |
| >                                      |                             |
| > United Behavioral Health provides    |                             |
| > our mental health and substance      |                             |
| > abuse benefits. Call 1-877-468-1016  |                             |
| > to locate network clinicians who can |                             |
| > best meet your needs, and to receive |                             |
| > authorization to see a provider. You |                             |
| > and your provider will receive       |                             |
| > written confirmation of the          |                             |
| > authorization from United Behavioral |                             |
| > Health for the initial and any       |                             |
| > ongoing authorizations.              |                             |
|                                        |                             |
| ###### Exceptions When M               |                             |
| edicare is the primary payer, call the |                             |
|  Plan at 703/729-4677 or 1-888-636-NAL |                             |
| C (6252) to preauthorize treatment if: |                             |
|                                        |                             |
| -   Medicare does not cover your       |                             |
|     services; or                       |                             |
|                                        |                             |
| -   Medicare hospital benefits are     |                             |
|     exhausted and you do not want to   |                             |
|     use your Medicare lifetime reserve |                             |
|     days.                              |                             |
|                                        |                             |
| > Note: You do not need to             |                             |
| > preauthorize treatment when Medicare |                             |
| > covers your services.                |                             |
+----------------------------------------+-----------------------------+
| > **Where to file claims** If you are  |                             |
| > using In-Network benefits for mental |                             |
| > health and substance                 |                             |
| >                                      |                             |
| > abuse treatment, you will not have   |                             |
| > to submit a claim. United            |                             |
| >                                      |                             |
| > Behavioral Health's network          |                             |
| > providers are responsible for        |                             |
| > filing. Claims should be submitted   |                             |
| > to:                                  |                             |
| >                                      |                             |
| > United Behavioral Health             |                             |
| >                                      |                             |
| > P.O. Box 30755                       |                             |
| >                                      |                             |
| > Salt Lake City, UT 84130-0755        |                             |
| >                                      |                             |
| > Questions? 1-877-468-1016            |                             |
+----------------------------------------+-----------------------------+

+---+---+---------------------------------+------------------------+---+---+
| # |   |                                 |                        |   |   |
| # |   |                                 |                        |   |   |
| # |   |                                 |                        |   |   |
| # |   |                                 |                        |   |   |
| # |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
| O |   |                                 |                        |   |   |
| u |   |                                 |                        |   |   |
| t |   |                                 |                        |   |   |
| - |   |                                 |                        |   |   |
| o |   |                                 |                        |   |   |
| f |   |                                 |                        |   |   |
| - |   |                                 |                        |   |   |
| N |   |                                 |                        |   |   |
| e |   |                                 |                        |   |   |
| t |   |                                 |                        |   |   |
| w |   |                                 |                        |   |   |
| o |   |                                 |                        |   |   |
| r |   |                                 |                        |   |   |
| k |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
| B |   |                                 |                        |   |   |
| e |   |                                 |                        |   |   |
| n |   |                                 |                        |   |   |
| e |   |                                 |                        |   |   |
| f |   |                                 |                        |   |   |
| i |   |                                 |                        |   |   |
| t |   |                                 |                        |   |   |
| s |   |                                 |                        |   |   |
+---+---+---------------------------------+------------------------+---+---+
|   | * | > **You may choose to get care  |                        | * |   |
|   | * | > In-Network or                 |                        | * |   |
|   | I | > Out-of-Network.**             |                        | I |   |
|   | * | >                               |                        | * |   |
|   | * | > **Here are some important     |                        | * |   |
|   |   | > things to keep in mind about  |                        |   |   |
|   | * | > these benefits:**             |                        | * |   |
|   | * |                                 |                        | * |   |
|   | M | -   Please remember that all    |                        | M |   |
|   | * |     benefits are subject to the |                        | * |   |
|   | * |     definitions, limitations,   |                        | * |   |
|   |   |     and exclusions in this      |                        |   |   |
|   | * |     brochure and are payable    |                        | * |   |
|   | * |     only when we determine they |                        | * |   |
|   | P |     are medically necessary.    |                        | P |   |
|   | * |                                 |                        | * |   |
|   | * | -   The calendar year           |                        | * |   |
|   |   |     deductible for inpatient    |                        |   |   |
|   | * |     and outpatient professional |                        | * |   |
|   | * |     services is \$300 per       |                        | * |   |
|   | O |     person (\$600 per family).  |                        | O |   |
|   | * |     The calendar year           |                        | * |   |
|   | * |     deductible applies to       |                        | * |   |
|   |   |     almost all benefits in this |                        |   |   |
|   | * |     Section. We say "(No        |                        | * |   |
|   | * |     deductible)" to show when   |                        | * |   |
|   | R |     the calendar year           |                        | R |   |
|   | * |     deductible does not apply.  |                        | * |   |
|   | * |                                 |                        | * |   |
|   |   | -   The calendar year           |                        |   |   |
|   | * |     deductible in a treatment   |                        | * |   |
|   | * |     facility is \$300 per       |                        | * |   |
|   | T |     person.                     |                        | T |   |
|   | * |                                 |                        | * |   |
|   | * | -   Be sure to read Section 4.  |                        | * |   |
|   |   |     *Your costs for covered     |                        |   |   |
|   | * |     services,* for valuable     |                        | * |   |
|   | * |     information about cost      |                        | * |   |
|   | A |     sharing, with special       |                        | A |   |
|   | * |     sections for members who    |                        | * |   |
|   | * |     are age 65 or older. Also   |                        | * |   |
|   |   |     read Section 9.             |                        |   |   |
|   | * |     *Coordinating benefits with |                        | * |   |
|   | * |     other coverage*.            |                        | * |   |
|   | N |                                 |                        | N |   |
|   | * | -   **YOU MUST GET              |                        | * |   |
|   | * |     PRECERTIFICATION FOR        |                        | * |   |
|   |   |     HOSPITAL STAYS; FAILURE TO  |                        |   |   |
|   | * |     DO SO WILL RESULT IN A      |                        | * |   |
|   | * |     \$500 PENALTY.** Please     |                        | * |   |
|   | T |     refer to the                |                        | T |   |
|   | * |     precertification            |                        | * |   |
|   | * |     information shown in        |                        | * |   |
|   |   |     Section 3 to be sure which  |                        |   |   |
|   |   |     services require            |                        |   |   |
|   |   |     precertification.           |                        |   |   |
+---+---+---------------------------------+------------------------+---+---+
| > |   |                                 | **You pay**            |   |   |
|   |   |                                 |                        |   |   |
| * |   |                                 | **After the calendar   |   |   |
| * |   |                                 | year deductible...**   |   |   |
| B |   |                                 |                        |   |   |
| e |   |                                 |                        |   |   |
| n |   |                                 |                        |   |   |
| e |   |                                 |                        |   |   |
| f |   |                                 |                        |   |   |
| i |   |                                 |                        |   |   |
| t |   |                                 |                        |   |   |
| > |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
| D |   |                                 |                        |   |   |
| e |   |                                 |                        |   |   |
| s |   |                                 |                        |   |   |
| c |   |                                 |                        |   |   |
| r |   |                                 |                        |   |   |
| i |   |                                 |                        |   |   |
| p |   |                                 |                        |   |   |
| t |   |                                 |                        |   |   |
| i |   |                                 |                        |   |   |
| o |   |                                 |                        |   |   |
| n |   |                                 |                        |   |   |
| * |   |                                 |                        |   |   |
| * |   |                                 |                        |   |   |
+---+---+---------------------------------+------------------------+---+---+
| # |   |                                 |                        |   |   |
| # |   |                                 |                        |   |   |
| # |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
| N |   |                                 |                        |   |   |
| o |   |                                 |                        |   |   |
| t |   |                                 |                        |   |   |
| e |   |                                 |                        |   |   |
| : |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
| T |   |                                 |                        |   |   |
| h |   |                                 |                        |   |   |
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+---+---+---------------------------------+------------------------+---+---+
| # |   |                                 | ###                    |   |   |
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+---+---+---------------------------------+------------------------+---+---+
| > |   |                                 | > \$300 mental         |   |   |
|   |   |                                 | > conditions/substance |   |   |
| I |   |                                 | > abuse calendar year  |   |   |
| n |   |                                 | > deductible, then 50% |   |   |
| p |   |                                 | > of the Plan          |   |   |
| a |   |                                 | > allowance and the    |   |   |
| t |   |                                 | > difference, if any,  |   |   |
| i |   |                                 | > between our          |   |   |
| e |   |                                 | > allowance and the    |   |   |
| n |   |                                 | > billed amount; all   |   |   |
| t |   |                                 | > charges after 30     |   |   |
| > |   |                                 | > visits               |   |   |
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+---+---+---------------------------------+------------------------+---+---+
| # |   |                                 | > \$500 copayment per  |   |   |
| # |   |                                 | > admission plus 50%   |   |   |
|   |   |                                 | > of the Plan          |   |   |
| U |   |                                 | > allowance (No        |   |   |
| p |   |                                 | > deductible); all     |   |   |
|   |   |                                 | > charges after 50     |   |   |
| t |   |                                 | > days                 |   |   |
| o |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
| 5 |   |                                 |                        |   |   |
| 0 |   |                                 |                        |   |   |
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|   |   |                                 |                        |   |   |
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|   |   |                                 |                        |   |   |
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|   |   |                                 |                        |   |   |
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|   |   |                                 |                        |   |   |
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|   |   |                                 |                        |   |   |
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| s |   |                                 |                        |   |   |
+---+---+---------------------------------+------------------------+---+---+
| # |   |                                 | > \$300 treatment      |   |   |
| # |   |                                 | > facility calendar    |   |   |
|   |   |                                 | > year deductible,     |   |   |
| U |   |                                 | > then 50% of the Plan |   |   |
| p |   |                                 | > allowance; all       |   |   |
|   |   |                                 | > charges after 30     |   |   |
| t |   |                                 | > days                 |   |   |
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| n |   |                                 |                        |   |   |
| s |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
| - |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
| O |   |                                 |                        |   |   |
| t |   |                                 |                        |   |   |
| h |   |                                 |                        |   |   |
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| r |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
|   |   |                                 |                        |   |   |
| c |   |                                 |                        |   |   |
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| s |   |                                 |                        |   |   |
+---+---+---------------------------------+------------------------+---+---+

*Out-of-Network benefits - continued on next page*

+----------------------------------------+-----------------------------+
| ###                                    | ### You pay                 |
|  Out-of-Network benefits *(continued)* |                             |
+----------------------------------------+-----------------------------+
| ## Not covered:                        | > *All charges*             |
|                                        |                             |
| -   *Services by pastoral, marital,    |                             |
|     drug/alcohol, and other            |                             |
|     counselors*                        |                             |
|                                        |                             |
| -   *Treatment for learning            |                             |
|     disabilities and mental            |                             |
|     retardation*                       |                             |
|                                        |                             |
| -   *Treatment for marital discord*    |                             |
|                                        |                             |
| -   *Services rendered or billed by    |                             |
|     schools, residential treatment     |                             |
|     centers, or half-way houses, and   |                             |
|     members of their staffs*           |                             |
|                                        |                             |
| > Note: In medically underserved       |                             |
| > areas, we may cover services of      |                             |
| > pastoral counselors. See Section 3.  |                             |
| > *Covered providers.*                 |                             |
+----------------------------------------+-----------------------------+
| **Lifetime maximum** Out-of-Network    |                             |
| inpatient care for the treatment of    |                             |
| substance abuse in a treatment         |                             |
| facility is limited to a 30-day        |                             |
| lifetime benefit.                      |                             |
+----------------------------------------+-----------------------------+
| **Precertification** The medical       |                             |
| necessity of your admission to a       |                             |
| hospital or other covered facility     |                             |
| must be precertified for you to        |                             |
| receive these Out-of-Network benefits. |                             |
| Emergency admissions must be reported  |                             |
| within two business days following the |                             |
| day of admission even if you have been |                             |
| discharged. Otherwise, the benefits    |                             |
| payable will be reduced by \$500. See  |                             |
| Section 3 for details.                 |                             |
+----------------------------------------+-----------------------------+
| **Where to file claims** United        |                             |
| Behavioral Health                      |                             |
|                                        |                             |
| > P.O. Box 30755                       |                             |
| >                                      |                             |
| > Salt Lake City, UT 84130-0755        |                             |
| >                                      |                             |
| > Questions? 1-877-468-1016            |                             |
+----------------------------------------+-----------------------------+

+---+----+-----------------------------------------------------+---+---+
| * |    |                                                     |   |   |
| * |    |                                                     |   |   |
| S |    |                                                     |   |   |
| e |    |                                                     |   |   |
| c |    |                                                     |   |   |
| t |    |                                                     |   |   |
| i |    |                                                     |   |   |
| o |    |                                                     |   |   |
| n |    |                                                     |   |   |
| 5 |    |                                                     |   |   |
| ( |    |                                                     |   |   |
| f |    |                                                     |   |   |
| ) |    |                                                     |   |   |
| . |    |                                                     |   |   |
| P |    |                                                     |   |   |
| r |    |                                                     |   |   |
| e |    |                                                     |   |   |
| s |    |                                                     |   |   |
| c |    |                                                     |   |   |
| r |    |                                                     |   |   |
| i |    |                                                     |   |   |
| p |    |                                                     |   |   |
| t |    |                                                     |   |   |
| i |    |                                                     |   |   |
| o |    |                                                     |   |   |
| n |    |                                                     |   |   |
| d |    |                                                     |   |   |
| r |    |                                                     |   |   |
| u |    |                                                     |   |   |
| g |    |                                                     |   |   |
| b |    |                                                     |   |   |
| e |    |                                                     |   |   |
| n |    |                                                     |   |   |
| e |    |                                                     |   |   |
| f |    |                                                     |   |   |
| i |    |                                                     |   |   |
| t |    |                                                     |   |   |
| s |    |                                                     |   |   |
| * |    |                                                     |   |   |
| * |    |                                                     |   |   |
+---+----+-----------------------------------------------------+---+---+
|   | *  | **Here are some important things to keep in mind    | * |   |
|   | *I | about these benefits:**                             | * |   |
|   | ** |                                                     | I |   |
|   |    | -   We cover prescribed medications and supplies as | * |   |
|   | *  |     described in the chart beginning on page 43.    | * |   |
|   | *M |                                                     |   |   |
|   | ** | -   All benefits are subject to the definitions,    | * |   |
|   |    |     limitations, and exclusions in this brochure    | * |   |
|   | *  |     and are payable only when we determine they are | M |   |
|   | *P |     medically necessary.                            | * |   |
|   | ** |                                                     | * |   |
|   |    | -   The calendar year drug deductible of \$25 per   |   |   |
|   | *  |     person or \$50 per family applies only to       | * |   |
|   | *O |     non-network benefits. The calendar year         | * |   |
|   | ** |     deductible applies ONLY when we say "(calendar  | P |   |
|   |    |     year deductible applies)".                      | * |   |
|   | *  |                                                     | * |   |
|   | *R | -   Some drugs require prior authorization. Call    |   |   |
|   | ** |     the Plan at 703/729-4677 or                     | * |   |
|   |    |     1-888-636-NALC (6252) for information.          | * |   |
|   | *  |                                                     | O |   |
|   | *T | -   Maximum dosage dispensed may be limited by      | * |   |
|   | ** |     protocols established by the Plan.              | * |   |
|   |    |                                                     |   |   |
|   | *  | -   When we say "Medicare" in this Section we mean  | * |   |
|   | *A |     you have Medicare Part B and it is primary.     | * |   |
|   | ** |                                                     | R |   |
|   |    | -   Be sure to read Section 4.*Your costs for       | * |   |
|   | *  |     covered services,* for valuable information     | * |   |
|   | *N |     about cost sharing, with special sections for   |   |   |
|   | ** |     members who are age 65 or older. Also read      | * |   |
|   |    |     Section 9. *Coordinating benefits with other    | * |   |
|   | *  |     coverage*.                                      | T |   |
|   | *T |                                                     | * |   |
|   | ** |                                                     | * |   |
|   |    |                                                     |   |   |
|   |    |                                                     | * |   |
|   |    |                                                     | * |   |
|   |    |                                                     | A |   |
|   |    |                                                     | * |   |
|   |    |                                                     | * |   |
|   |    |                                                     |   |   |
|   |    |                                                     | * |   |
|   |    |                                                     | * |   |
|   |    |                                                     | N |   |
|   |    |                                                     | * |   |
|   |    |                                                     | * |   |
|   |    |                                                     |   |   |
|   |    |                                                     | * |   |
|   |    |                                                     | * |   |
|   |    |                                                     | T |   |
|   |    |                                                     | * |   |
|   |    |                                                     | * |   |
+---+----+-----------------------------------------------------+---+---+

> **There are important features you should be aware of. These
> include:**

-   **Who can write your prescription.** Any provider licensed to
    prescribe drugs may write your prescription.

-   **Where you can obtain them.** You may fill the prescription at a
    network pharmacy, a non-network pharmacy, or by mail. We pay a
    higher level of benefits when you purchase your generic drug at a
    network pharmacy or through our mail order program.

-   **Network pharmacy**Present your Plan identification card at an
    NALC CareSelect Network pharmacy to purchase prescription drugs.
    Call 1-800-933-NALC (6252) to locate the nearest network pharmacy.

-   **Non*-*network pharmacy**You may purchase prescriptions at
    pharmacies that are not part of our network. You pay full cost and
    must file a claim for reimbursement. See *When you have to file a
    claim* in this Section.

-   **Mail order**Complete the patient profile/order form. Send it
    along with your prescription(s) and payment, in the preaddressed
    envelope to:

> NALC Prescription Drug Program
>
> P.O. Box 94465
>
> Palatine, IL 60094-4465

-   **We use a formulary.** Our formulary is open and voluntary. If your
    physician believes a brand name drug is necessary, or if there is no
    generic available, ask your physician to prescribe a brand name drug
    from our formulary list. These preferred brand name drugs are
    selected to meet patient needs at a lower cost. To order the
    formulary pamphlet, call 1-800-933-NALC (6252).

-   **These are the dispensing limitations.**

```{=html}
<!-- -->
```
-   Network retail pharmacyYou may obtain up to a 30-day supply plus
    one refill for each prescription. No deductible applies. You may
    continue to purchase refills at a Network pharmacy, however benefits
    will be payable at the non-network retail pharmacy benefit
    level**.**

-   Non-network retail pharmacyYou may obtain up to a 30-day supply and
    unlimited refills for each prescription. You will need to file a
    claim for reimbursement.

-   Mail order---You may order up to a 60-day or 90-day (21-day minimum)
    supply of medication for each prescription or refill. No deductible
    applies. You cannot obtain a refill until 75% of the drug has been
    used. Medications dispensed through the mail order program are
    subject to the following standards: the professional judgment of the
    pharmacist, limitations imposed on controlled substances,
    manufacturer's recommendations, and applicable state law.

> Note: In the event of a disaster or emergency where additional or
> early fills of medications are needed, call the Plan for
> authorization.

-   A generic equivalent will be dispensed if it is available, unless
    your physician specifically requires a brand name. If you receive a
    brand name drug when a Federally-approved generic drug is available,
    and your physician has not specified Dispense as Written for the
    brand name drug, you have to pay the difference in cost between the
    brand name drug and the generic.

-   **Why use generic drugs?** Generic drugs offer a safe and economic
    way to meet your prescription drug needs. The generic name of a drug
    is its chemical name; the brand name is the name under which the
    manufacturer advertises and sells a drug. Under federal law, generic
    and brand name drugs must meet the same standards for safety,
    purity, strength, and effectiveness. A generic drug costs you---and
    us---less than a brand name drug.

> **When you have to file a claim.** If you purchase prescriptions at a
> non-network pharmacy, or elect to purchase additional refills at an
> NALC CareSelect Network pharmacy, complete the short-term prescription
> claim form. Mail it with your prescription receipts to the NALC
> Prescription Drug Program. Receipts must include the prescription
> number, name of drug, prescribing doctor's name, date, charge, and
> name of pharmacy.
>
> When you have other prescription drug coverage, and the other carrier
> is primary, use that carrier's drug benefit first. After the primary
> carrier has processed the claim, complete the short-term prescription
> claim form, attach the drug receipts and other carrier's payment
> explanation and mail to the NALC Prescription Drug Program.
>
> NALC Prescription Drug Program
>
> P.O. Box 686005
>
> San Antonio, TX 78268-6005

Note: If you have questions about the Program, wish to locate an NALC
CareSelect Network retail pharmacy, or need additional claim forms, call
1-800-933-NALC (6252) (24 hours a day, seven days a week).

*Benefit Description begins on next page*

+------------------------------------------+---------------------------+
| **Benefit Description**                  | **You pay**               |
+------------------------------------------+---------------------------+
| ### Note: The calendar yea               |                           |
| r drug deductible applies ONLY when we s |                           |
| ay "(calendar year deductible applies)". |                           |
+------------------------------------------+---------------------------+
| #                                        | ###                       |
| ####### Covered medications and supplies |                           |
+------------------------------------------+---------------------------+
| > You may purchase the following         | > Retail:                 |
| > medications and supplies from a        |                           |
| > pharmacy or by mail:                   | -   Network retail: 25%   |
|                                          |     of cost               |
| -   Drugs and medicines (including those |                           |
|     administered during a non-covered    | -   Network retail        |
|     admission or in a non-covered        |     Medicare: 15% of cost |
|     facility) that by Federal law of the |                           |
|     United States require a physician's  | -   Non-network retail:   |
|     prescription for their purchase,     |     50% of the Plan       |
|     except as shown in *Not covered*     |     allowance, and the    |
|                                          |     difference, if any,   |
| -   Insulin                              |     between our allowance |
|                                          |     and the billed amount |
| -   Needles and syringes for the         |     (calendar year        |
|     administration of covered            |     deductible applies)   |
|     medications                          |                           |
|                                          | -   Non-network retail    |
| ```{=html}                               |     Medicare: 50% of the  |
| <!-- -->                                 |     Plan allowance, and   |
| ```                                      |     the difference, if    |
| -   Contraceptive drugs and devices      |     any, between our      |
|                                          |     allowance and the     |
| -   Drugs for sexual dysfunction (only   |     billed amount         |
|     when the dysfunction is caused by    |                           |
|     medically documented organic disease | > Mail order:             |
|     and prior authorization has been     |                           |
|     given)                               | -   60-day supply:        |
|                                          |                           |
|                                          | > \$8 generic             |
|                                          | >                         |
|                                          | > \$24 brand name         |
|                                          |                           |
|                                          | -   90-day supply:        |
|                                          |                           |
|                                          | > \$12 generic            |
|                                          | >                         |
|                                          | > \$35 brand name         |
|                                          | >                         |
|                                          | > Mail order Medicare:    |
|                                          |                           |
|                                          | -   60-day supply:        |
|                                          |                           |
|                                          | > \$7 generic             |
|                                          | >                         |
|                                          | > \$20 brand name         |
|                                          |                           |
|                                          | -   90-day supply:        |
|                                          |                           |
|                                          | > \$10 generic            |
|                                          | >                         |
|                                          | > \$30 brand name         |
|                                          | >                         |
|                                          | > Note: If there is no    |
|                                          | > generic equivalent      |
|                                          | > available, you will     |
|                                          | > have to pay the brand   |
|                                          | > name copay.             |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Drugs and supplies when prescribed  |                           |
|     for cosmetic purposes*               |                           |
|                                          |                           |
| -   *Vitamins, nutrients and food        |                           |
|     supplements, even when a physician   |                           |
|     prescribes or administers them*      |                           |
|                                          |                           |
| -   *Over-the-counter medicines and      |                           |
|     supplies*                            |                           |
|                                          |                           |
| -   *Drugs for smoking cessation, except |                           |
|     as described in Section 5(a).*       |                           |
|     Educational Classes and Programs*.*  |                           |
+------------------------------------------+---------------------------+

+------------------------+---------------------------------------------+
| > Section 5(g).        |                                             |
| > Special features     |                                             |
+========================+=============================================+
| > **Special features** | > **Description**                           |
+------------------------+---------------------------------------------+
| > **Flexible benefits  | > Under the flexible benefits option, we    |
| > option**             | > determine the most effective way to       |
|                        | > provide services.                         |
|                        |                                             |
|                        | -   We may identify medically appropriate   |
|                        |     alternatives to traditional care and    |
|                        |     coordinate other benefits as a less     |
|                        |     costly alternative benefit.             |
|                        |                                             |
|                        | -   Alternative benefits are subject to our |
|                        |     ongoing review.                         |
|                        |                                             |
|                        | -   By approving an alternative benefit, we |
|                        |     cannot guarantee you will get it in the |
|                        |     future.                                 |
|                        |                                             |
|                        | -   The decision to offer an alternative    |
|                        |     benefit is solely ours, and we may      |
|                        |     withdraw it at any time and resume      |
|                        |     regular contract benefits.              |
|                        |                                             |
|                        | -   Our decision to offer or withdraw       |
|                        |     alternative benefits is not subject to  |
|                        |     OPM review under the disputed claims    |
|                        |     process.                                |
+------------------------+---------------------------------------------+
| > **24-hour nurse      | > You may call a registered nurse at        |
| > line**               | > 1**-**800-622-NALC (6252) 24 hours a day, |
|                        | > 7 days a week, to discuss your health     |
|                        | > concerns and treatment options.           |
+------------------------+---------------------------------------------+
| > **24-hour help line  | > You may call 1-877-468-1016, 24 hours a   |
| > for mental health    | > day, 7 days a week, to access in-person   |
| > and substance        | > support for a wide range of concerns,     |
| > abuse**              | > including depression, eating disorders,   |
|                        | > coping with grief and loss, alcohol or    |
|                        | > drug dependency, physical abuse and       |
|                        | > managing stress.                          |
+------------------------+---------------------------------------------+
| > **Services for deaf  | > TTY lines are available for the           |
| > and hearing          | > following:                                |
| > impaired**           | >                                           |
|                        | > CAREMARK: 1-800-238-1217                  |
|                        | >                                           |
|                        | > (prescription benefit information)        |
|                        | >                                           |
|                        | > First Health: 1-800-259-8179              |
|                        | >                                           |
|                        | > (PPO locator, 24-hour nurse line, medical |
|                        | > inpatient hospital precertification,      |
|                        | > National Transplant Program)              |
|                        | >                                           |
|                        | > United Behavioral Health: 1-800-842-2479  |
|                        | >                                           |
|                        | > (mental health and substance abuse        |
|                        | > information)                              |
+------------------------+---------------------------------------------+
| > **Disease management | > These programs offer a considerable       |
| > programs**           | > amount of personalized attention from     |
|                        | > clinicians and program educators. Nurse   |
|                        | > educators are available to discuss        |
|                        | > lifestyle changes, therapeutic outcomes,  |
|                        | > and other health related matters to       |
|                        | > assist patients in dealing with their     |
|                        | > experiences. Support is available for     |
|                        | > patients with multiple sclerosis, growth  |
|                        | > hormone deficiency, hemophilia,           |
|                        | > hepatitis, diabetes, and other diseases.  |
|                        | > You may be contacted about one of these   |
|                        | > programs.                                 |
+------------------------+---------------------------------------------+
| > **Worldwide          | We cover the medical care you receive       |
| > coverage**           | outside the United States, subject to the   |
|                        | terms and conditions of this brochure. See  |
|                        | Section 7. *Overseas claims*.               |
+------------------------+---------------------------------------------+

+-----------------------------------------------------------------------+
| > Section 5(h). Dental benefits                                       |
+=======================================================================+
| > We have no dental benefit.                                          |
+-----------------------------------------------------------------------+

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

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

**The benefits described on this page are not part of the FEHB contract
or premium, and you cannot file a**

**FEHB disputed claim about them.** Fees you pay for these services do
not count toward FEHB plan deductibles or

out-of-pocket maximums.

**The following non‑FEHB Program benefit is available only to letter
carriers who are members in good standing with the National Association
of Letter Carriers, their spouses, children, and retired NALC members.**

**Hospital Plus (hospital indemnity)**

> Hospital Plus is a hospital indemnity policy available for purchase
> from the United States Letter Carriers
>
> Mutual Benefit Association. This policy may be purchased throughout
> the year and is not subject to the health benefit plan open season.
>
> Hospital Plus means money in your pocket when you are hospitalized,
> from the first day of your stay up to one full
>
> year. These benefits are not subject to federal income tax.
>
> Hospital Plus allows you to choose the amount of coverage you need.
> You may elect to receive a \$75 a day, \$50 a day, or \$30 a day plan.
> Members can insure their spouses and eligible children also. The
> spousal coverage is the same as the member's. Children's coverages are
> limited to either \$45 a day, \$30 a day, or \$18 a day plans.
> Benefits will be based on the number of days in the hospital, up to
> 365 days or as much as \$27,375 (if a \$75 a day benefit is chosen).
>
> Use your benefits to pay for travel to and from the hospital,
> childcare, medical costs not covered by health insurance, legal fees,
> or other costs.
>
> This plan is available to all qualified members regardless of their
> age. Hospital Plus is renewable for life and you may keep your policy
> for as long as you like, regardless of benefits you have received or
> future health conditions.
>
> For more information and current benefits, please call the United
> States Letter Carriers Mutual Benefit Association at 202/638‑4318
> Monday through Friday, 8:00 a.m. -- 3:30 p.m. or 1-800-424-5184
> Tuesdays and Thursdays, 8:00 a.m. ‑ 3:30 p.m., Eastern time.

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

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

The exclusions in this section apply to all benefits. **Although we may
list a specific service as a benefit, we will not cover it unless we
determine it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury, or condition.**

We do not cover the following:

-   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 in the United
    States;

-   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, sexual
    inadequacy, or sexual dysfunction (except with prior authorization);

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

```{=html}
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```
-   Charges that would not be made if a covered individual had no health
    insurance;

```{=html}
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```
-   Services, drugs, or supplies you receive without charge while in
    active military service;

-   Services furnished by a household member or immediate relative such
    as spouse, parent, child, brother or sister by blood, marriage, or
    adoption;

```{=html}
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```
-   Charges billed by a noncovered facility or provider, except
    medically necessary prescription drugs;

```{=html}
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```
-   Charges for which you or the Plan have no legal obligation to pay,
    such as state premium taxes or surcharges;

```{=html}
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```
-   Charges for interest, completion of claim forms, missed or canceled
    appointments, and/or administrative fees;

```{=html}
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```
-   Nonmedical social services or recreational therapy;

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```
-   Testing for mental aptitude or scholastic ability;

```{=html}
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```
-   Therapy, other than speech therapy, for developmental delays and
    learning disabilities;

```{=html}
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```
-   Transportation (other than professional ambulance services or travel
    under the National Transplant Program);

```{=html}
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```
-   Dental services and supplies (except those oral surgical procedures
    listed in Section 5 (b). *Oral and maxillofacial surgery*);

-   Services for and/or related to procedures not listed as covered;

-   Charges in excess of the Plan allowance; or

-   Treatment for cosmetic purposes and/or related expenses.

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

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

**How to claim benefits** To obtain claim forms, claims filing advice,
or answers about our benefits, contact us at 703/729-4677 or
1-888-636-NALC (6252) or at our Web site at
[www.nalc.org/depart/hbp](http://www.nalc.org/depart/hbp).

In most cases, providers and facilities file claims for you. Your
physician must file on the form HCFA-1500, Health Insurance Claim Form.
Your facility will file on the UB-92 form. For claims questions and
assistance, call us at 703/729-4677 or 1-888-636-NALC (6252).

When you must file a claimsuch as for services you receive overseas or
when another group health plan is primary, or you are seeing an
Out-of-Network providersubmit it on the HCFA-1500 or a claim form that
includes the information shown below. Bills and receipts must be
itemized and show:

-   Patient's name and relationship to enrollee;

-   Member \# as shown on your identification card;

-   Name, address, and tax identification number of person or facility
    providing the service or supply;

-   Signature of physician or supplier including degrees or credentials
    of individual providing the service;

-   Dates that services or supplies were furnished;

-   Diagnosis (ICD-9 Code);

-   Type of each service or supply (CPT/HCPCS Code); and

-   Charge for each service or supply.

> Note: Canceled checks, cash register receipts, or balance due
> statements are not acceptable substitutes for itemized bills.

In addition:

-   You must send a copy of the explanation of benefits from any primary
    payer (such as the Medicare Summary Notice (MSN)) with your claim.

```{=html}
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```
-   Bills for home health services must show that the nurse is a
    registered nurse (R.N.), licensed practical nurse (L.P.N.), or
    licensed vocational nurse (L.V.N.).

-   Claims for rental or purchase of durable medical equipment; private
    nursing care; and physical, occupational, and speech therapy require
    a written statement from the physician specifying the medical
    necessity for the service or supply and the length of time needed.

-   Claims for prescription drugs and supplies purchased without your
    card or those that are not purchased through a CareSelect Network
    pharmacy or the Mail Service Prescription Drug Program must include
    receipts that show the prescription number, name of drug or supply,
    prescribing physician's name, date, charge, and name of drugstore.

**Records** Keep a separate record of the medical expenses of each
covered family member as deductibles and maximum allowances apply
separately to each person. Save copies of all medical bills, including
those you accumulate to satisfy a deductible. In most instances they
will serve as evidence of your claim. We will not provide duplicate or
year-end statements**,** except as required by the HIPAA Privacy Rule.
See Section 1. *Facts about this fee-for-service plan***.**

**Deadline for filing your claim** Send us all of the documents for your
claim as soon as possible. You must submit the claim within two years
from the date the expense was incurred, unless timely filing was
prevented by administrative operations of Government or legal
incapacity, provided the claim was submitted as soon as reasonably
possible. Once we pay benefits, there is a three-year limitation on the
reissuance of uncashed checks.

**Overseas claims** Claims for overseas (foreign) services must include
an English translation. Charges must be converted to U.S. dollars using
the exchange rate applicable at the time the expense was incurred.

**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.

The Plan, its medical staff and/or an independent medical review
determines whether services, supplies and charges meet the coverage
requirements of the Plan (subject to the disputed claims procedure
described in Section 8. *The disputed claims process*). We are entitled
to obtain medical or other information---including an independent
medical examination---that we feel is necessary to determine whether a
service or supply is covered.

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

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

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

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | -   Write to us within 6 months from the date of our decision;   |
| * |                                                                  |
| * | -   Send your request to us at: NALC Health Benefit Plan, 20547  |
|   |     Waverly Court, Ashburn, VA 20149;                            |
|   |                                                                  |
|   | -   Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | -   Include copies of documents that support your claim, such as |
|   |     physicians' letters, operative reports, bills, medical       |
|   |     records, and explanation of benefits forms.                  |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | -   Pay the claim (or, if applicable, arrange for the health     |
| * |     care provider to give you the care);                         |
| * |                                                                  |
|   | -   Write to you and maintain our denial---go to step 4; or      |
|   |                                                                  |
|   | -   Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request---go   |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us---if we did not answer  |
|   |     that request in some way within 30 days; or                  |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: United States Office of Personnel Management,   |
|   | Insurance Services Programs, Health Insurance Group 2, 1900 E    |
|   | Street, NW, Washington, DC 20415-3620.                           |
+---+------------------------------------------------------------------+
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians' letters, operative reports, bills, medical       |
|   |     records, and explanation of benefits forms;                  |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must include a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
|   | If you do not agree with OPM's decision, your only recourse is   |
|   | to sue. If you decide to sue, you must file the suit against OPM |
|   | in Federal court by December 31 of the third year after the year |
|   | in which you received the disputed services, drugs, or supplies  |
|   | or from the year in which you were denied precertification or    |
|   | prior approval. This is the only deadline that may not be        |
|   | extended.                                                        |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support 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 to your initial request for care or
    preauthorization/prior approval, then call us at 703/729-4677 or
    1-888-636-NALC (6252) and we will expedite our review; or

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

-   If we expedite our review and maintain our denial, we will inform
    OPM so that they too can expedite your request, or

-   **You may call OPM's Health Insurance Group 2 at 202/606-3818
    between 8:00 a.m. and 5:00 p.m. Eastern time.**

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

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

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

When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as
the secondary payer. Like other insurers, we 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 usually pay what is left after the
primary plan pays, up to our regular benefit for each claim. We will not
pay more than our allowance.

The Plan limits some benefits, such as physical therapy and home health
visits. If the primary plan pays, we may pay over these limits as long
as our payment on the claim does not exceed our Plan allowance.

**What is Medicare?** Medicare is a health insurance program for:

-   People 65 years of age and older.

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

-   People with end-stage renal disease (permanent kidney failure
    requiring dialysis or a transplant).

Medicare has two parts:

-   Part A (Hospital Insurance). Most people do not have to pay for
    Part A. If you or your spouse worked for at least 10 years in
    Medicare-covered employment, you should be able to qualify for
    premium-free Part A insurance. Otherwise, if you are age 65 or
    older, you may be able to buy it. Contact 1-800-MEDICARE
    (1-800-633-4227) for more information.

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

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+Choice plan you have.

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.

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

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

-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In most cases, your claim will be coordinated
    automatically and we will then provide secondary benefits. You will
    not need to do anything. If you have questions, call us at
    703/729-4677 or 1-888-636-NALC (6252).

> **We waive some costs if the Original Medicare Plan is your primary
> payer ** We will waive some out-of-pocket costs as follows:

-   If you have Medicare Part A as primary payer, we waive:

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```
-   The copayment for a hospital admission.

-   The coinsurance for a hospital admission.

-   The deductible for inpatient care in a treatment facility.

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```
-   If you have Medicare Part B as primary payer, we waive:

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```
-   The PPO copayments for office or outpatient visits.

-   The PPO copayments for allergy injections.

-   The coinsurance for services billed by physicians, other health care
    professionals, and facilities.

-   All calendar year deductibles.

> Note: If you have Medicare Part B as primary payer, we will not waive
> the copayments for mail order drugs, or the coinsurance for retail
> prescription drugs.

+----------------------------------------------------+-----+---+----------+
| > **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     | **  |   | ****    |
|     your employment status                         | ** |   | for      |
|                                                    | 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 sol                           |     | * |          |
| ely 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...          |     | * |          |
|                                                    |     |  |          |
| -   This Plan was the primary payer before         |     | * |          |
|     eligibility due to ESRD                        |     | * |          |
|                                                    |     | f |          |
|                                                    |     | o |          |
|                                                    |     | r |          |
|                                                    |     | 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                                  |     | m |          |
|                                                    |     | a |          |
|                                                    |     | r |          |
|                                                    |     | k |          |
|                                                    |     | } |          |
+----------------------------------------------------+-----+---+----------+
| -   You have FEHB coverage through your spouse who |     | * |          |
|     is an active employee                          |     | * |          |
|                                                    |     |  |          |
|                                                    |     | * |          |
|                                                    |     | * |          |
+----------------------------------------------------+-----+---+----------+
| > **D. When covered under the FEHB Spouse Equity   | **  |   |          |
| > provision**                                      | ** |   |          |
+----------------------------------------------------+-----+---+----------+

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

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

> **• Medicare + Choice** If you are eligible for Medicare, you may
> choose to enroll in and get your

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

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

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

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

> A physician may ask you to sign a private contract agreeing that you
> can be billed directly for services ordinarily covered by Original
> Medicare. Should
>
> you sign an agreement, Medicare will not pay any portion of the
> charges, and we will not increase our payment. We will still limit our
> payment to the amount we would have paid after Original Medicare's
> payment.

**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 illness or injury that the
    Office of Workers' Compensation Programs (OWCP) or a similar Federal
    or State agency determines they must provide; or

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-   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.

> If OWCP or a similar agency disallows benefits for your treatment, we
> will pay the benefits described in this brochure.

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.

**Workers' Compensation**

We do not cover services and supplies when a local, State, or Federal
Government agency directly or indirectly pays for them.

**Subrogation/Reimbursement guidelines:** If your illness or injury is
caused by the act or omission of a third party, the Plan has the right
to reimbursement of benefits paid on your behalf from any recovery made
to you by a third party or third party's insurer. "Third party" means
another person or organization. Our right to reimbursement is limited to
the benefits we have paid or will pay to you or on your behalf related
to the illness or injury.

You must notify us promptly if you are seeking a recovery from a third
party because of the act or omission of another person. Further, you
must keep the Plan advised of developments in your claim and promptly
notify us of any recovery you receive, whether in or out of court. You
must reimburse us to the extent the Plan paid benefits. You have the
right to retain any recovery that exceeds the amount of the Plan's
subrogation claim.

We will pay benefits for your illness or injury provided you do not
interfere with or take any action to prejudice our attempts to recover
the amounts we have paid in benefits, and that you cooperate with us in
obtaining reimbursement. If you do not seek damages from the third
party, you must agree to let us seek damages on your behalf. We may
require you to assign the proceeds of your claim or the right to take
action against the third party in your name, and we may withhold payment
of benefits until the assignment is provided. You must sign a
subrogation agreement and provide us with any other relevant information
about the claim if we ask you to do so. However, a subrogation agreement
is not necessary to enforce the Plan's rights.

All payments from the third party must be used to reimburse the Plan for
benefits paid**,** regardless of whether the recovery is by court order
or by settlement, and regardless of how the recovery is characterized
(i.e., pain and suffering). The Plan has the right of first
reimbursement for the full amount of our claim from any recovery you
receive, even if your total recovery does not fully compensate you for
the full amount of damages claimed. In other words, unless we agree in
writing to a reduction, you are required to reimburse the Plan in full
for its claim even if you are not "made whole" for your loss. In
addition, the Plan's claim is not subject to reduction for attorney's
fees or costs under the "common fund" doctrine or otherwise. Any
reduction of the Plan's claim for attorney's fees or costs related to
the claim is subject to prior written approval by the Plan.

We may reduce subsequent benefit payments if we are not reimbursed for
the benefits we paid pursuant to these subrogation/reimbursement
guidelines.

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

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

**Admission** The period from entry (admission) into a hospital or other
covered facility until discharge. In counting days of inpatient care,
the date of entry and the date of discharge are counted as a single day.

**Assignment** Your authorization for us to issue payment of benefits
directly to the provider. We reserve the right to pay you directly for
all covered services.

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

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care. See Section 4. *Your costs for covered
services.*

**Congenital anomaly** A condition that existed at or from birth and is
a significant deviation from the common form or norm. For purposes of
this Plan, congenital anomalies include protruding ear deformities,
cleft lips, cleft palates, birthmarks, webbed fingers or toes, and other
conditions that the Plan may determine to be congenital anomalies. In no
event will the term congenital anomaly include conditions relating to
teeth or intra-oral structure supporting the teeth.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See Section 4. *Your costs for covered
services.*

**Cosmetic surgery** Any operative procedure or any portion of a
procedure performed primarily to improve physical appearance and/or
treat a mental condition through change in bodily form.

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

**Custodial care** Treatment or services that help the patient with
daily living activities, or can safely and reasonably be provided by a
person that is not medically skilled, regardless of who recommends them
or where they are provided. Custodial care, sometimes called "long term
care," includes such services as:

-   Caring for personal needs, such as helping the patient bathe, dress,
    or eat;

-   Homemaking, such as preparing meals or planning special diets;

-   Moving the patient, or helping the patient walk, get in and out of
    bed, or exercise;

-   Acting as a companion or sitter;

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-   Supervising self-administered medication; or

-   Performing services that require minimal instruction, such as
    recording temperature, pulse, and respirations; or administration
    and monitoring of feeding systems.

The Plan determines whether services are custodial care.

**Deductible** A deductible is a fixed amount of covered expenses you
must incur for certain covered services and supplies before we start
paying benefits for those services. See Section 4. *Your costs for
covered services.*

**Effective date** The effective date of benefits described in this
brochure is:

-   January 1 for continuing enrollments and for all annuitant
    enrollments;

-   The first day of the first full pay period of the new year for
    enrollees who change plans or options or elect FEHB coverage during
    the Open Season; or

-   Determined by the employing office or retirement system for
    enrollments and changes that are not Open Season actions.

**Experimental or** A drug, device, or biological product that cannot
lawfully be marketed

**investigational services** without approval of the U.S. Food and Drug
Administration (FDA) and that approval has not been given at the time
the drug, device, or biological product is furnished. "Approval" means
all forms of acceptance by the FDA.

> A medical treatment or procedure, or a drug, device, or biological
> product is considered experimental or investigational if reliable
> evidence shows that:

-   It is the subject of ongoing phase I, II, or III clinical trials or
    > under study to determine its maximum tolerated dose, its toxicity,
    > safety, effectiveness, or effectiveness as compared with the
    > standard means of treatment or diagnosis; or

-   The consensus of opinion among experts is that further studies or
    > clinical trials are necessary to determine its toxicity, safety,
    > effectiveness, or effectiveness as compared with the standard
    > means of treatment or diagnosis.

> Our Medical Director reviews current medical resources to determine
> whether a service or supply is experimental or investigational. We
> will seek an independent expert opinion if necessary.

**Group health coverage** Coverage through employment (including
benefits through COBRA) or membership in an organization that provides
payment for hospital, medical, or other health care services or
supplies, or that pays more than \$200 per day for each day of
hospitalization.

**Medical necessity** Services, drugs, supplies, or equipment provided
by a hospital or covered provider of the health care services that we
determine:

-   Are appropriate to diagnose or treat your condition, illness, or
    injury;

-   Are consistent with standards of good medical practice in the United
    States;

-   Are not primarily for the personal comfort or convenience of you,
    your family, or your provider;

-   Are not related to your scholastic education or vocational training;
    and

-   In the case of inpatient care, cannot be provided safely on an
    outpatient basis.

The fact that a covered provider has prescribed, recommended, or
approved a service, supply, drug, or equipment does not, in itself, make
it medically necessary.

Conditions and diseases listed in the most recent edition of the

International Classification of Diseases (ICD) as psychoses, neurotic
disorders, or personality disorders; other nonpsychotic mental disorders
listed in the ICD, to be determined by the Plan; or disorders listed in
the ICD requiring treatment for abuse of or dependence upon substances
such as alcohol, narcotics, or hallucinogens.

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

**PPO benefits:**

For services rendered by a covered provider that participates in the
Plan's PPO network, our allowance is based on a negotiated rate agreed
to under the providers' network agreement. These providers accept the
Plan allowance as their charge.

> **In-Network mental health and substance abuse benefits:**
>
> For services rendered by a covered provider that participates in the
> Plan's mental health and substance abuse network, our allowance is
> based on a negotiated rate agreed to under the providers' network
> agreement. These providers accept the Plan allowance as their charge.
>
> **Non-PPO benefits:**
>
> When you do not use a PPO provider, we may use one of the following
> methods:

-   If you receive care in an area that has a fully developed PPO
    network, (one in which you have adequate access to a PPO provider,
    regardless of the availability of a specialist), we use the average
    PPO rate for your area. This non-PPO allowance represents an average
    of the PPO fee schedules for a particular service in a geographic
    area. We call this our "average fee schedule";

-   If you do not have adequate access to a PPO provider, our allowance
    is based on the 80^th^ percentile of data gathered from health care
    sources that compare charges of other providers for similar services
    in the same geographic area; or

-   For medication charges, our allowance is based on the average
    wholesale price.

> **Out-of-Network mental health and substance abuse benefits:**
>
> Our allowance is based on the 80^th^ percentile of data gathered from
> health care sources that compare charges of other providers for
> similar services in the same geographic area when you:

-   Do not preauthorize your treatment;

-   Do not follow the authorized treatment plan; or

-   Do not use an In-Network provider.

> **Note:** For other categories of benefits and for certain specific
> services within each of the above categories, exceptions to the usual
> method of determining the Plan allowance may exist. At times, we may
> seek an independent expert opinion to determine our Plan allowance.

For more information, see Section 4. *Differences between our allowance
and the bill*.

**Preadmission testing** Routine tests ordered by a physician and
usually required prior to surgery or hospital inpatient admission that
are not diagnostic in nature.

**Us/We** Us and we refer to the NALC Health Benefit Plan.

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

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

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

**Coverage information**

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

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

-   **Where you can get** See
    [www.opm.gov/insure/health](http://www.opm.gov/insure/health) for
    enrollment as well as:

> **information about enrolling** • Information on the FEHB Program and
> plans available to you
>
> **in the FEHB Program** • A health plan comparison tool

• A list of agencies who participate in Employee Express

• A link to Employee Express

• Information on and links to other electronic enrollment systems

> Also, your employing or retirement office can answer your questions
> and give you a *Guide to Federal Employees Health Benefits Plans,*
> brochures for other plans, and other materials you need to make an
> informed decision about your FEHB coverage. These materials tell you:

-   When you may change your enrollment;

-   How you can cover your family members;

-   What happens when you transfer to another Federal agency, go on
    leave without pay, enter military service, or retire;

-   When your enrollment ends; and

-   When the next Open Season for enrollment begins.

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

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

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

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

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

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.

> 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 FEHB, 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

> **premiums start** joined this Plan during Open Season, your coverage
> begins on the first day of your first pay period that starts on or
> after January 1. If you changed plans or plan options during Open
> Season and you receive care between January 1 and the effective date
> of coverage under your new plan or option, your claims will be paid
> according to the 2004 benefits of your old plan or option. However, if
> your old plan left the FEHB 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 receive an additional 31 days of
coverage, for no additional premium, when:

-   Your enrollment ends, unless you cancel your enrollment; or

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

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

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

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

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

**of Coverage (TCC)** longer qualify as a family member, you may be
eligible for Temporary Continuation of Coverage (TCC). For example, you
can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your Federal job, if you are a covered
dependent child and you turn 22 or marry, etc.

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

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

If you leave Federal service your employing office will notify you of
your right to enroll under TCC. You must enroll within 60 days of
leaving, or receiving this notice, whichever is later.

> Children: You must notify your employing or retirement office within
> 60 days after your child is no longer an eligible family member. That
> office will send you information about enrolling in TCC. You must
> enroll your child within 60 days after he or she becomes eligible for
> TCC, or receives this notice, whichever is later.
>
> Former spouses: You or your former spouse must notify your employing
> or retirement office within 60 days of one of these qualifying events:

-   Divorce; or

-   Loss of spouse equity coverage within 36 months after the divorce.

> Your employing or retirement office will then send your former spouse
> information about enrolling in TCC. Your former spouse must enroll
> within 60 days after the event that qualifies them for coverage, or
> receiving the information, whichever is later.
>
> Note: Your child or former spouse loses TCC eligibility unless you or
> your former spouse notifies your employing or retirement office within
> the 60-day deadline.

**• Converting to** You may convert to a non-FEHB individual policy if:

> **individual coverage**

-   Your coverage under Temporary Continuation of Coverage (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.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
is a Federal law that offers limited Federal protection 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.

Get OPM pamphlet RI 79-27, *Temporary Continuation of Coverage (TCC)
under the FEHB Program*. See also the FEHB Web site
([www.opm.gov/insure/health](http://www.opm.gov/insure/health)): refer
to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA
rules, such as the requirement that Federal employees must exhaust any
TCC eligibility as one condition for guaranteed access to individual
health coverage under HIPAA, and have information about Federal and
State agencies you can contact for more information.

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

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

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

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

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

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

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

```{=html}
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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.

```{=html}
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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.

-   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!

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

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

> **What is SHPS?** SHPS is a third-party administrator hired by OPM to
> manage the FSAFEDS Program. SHPS is the largest FSA administrator in
> the nation and will be responsible for enrollment, claims processing,
> customer service, and day-to-day operations of
>
> FSAFEDS.
>
> []{.mark}
>
> **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.
>
> Plan carefully when deciding how much to contribute to an FSA. Because
> of the tax benefits of an FSA, the IRS places strict guidelines on
> them. You need to estimate how much you want to allocate to an FSA
> because current IRS regulations require you forfeit any funds
> remaining in your account(s) at the end of the FSA plan year. This is
> referred to as the "use-it-or-lose-it" rule. You will have until April
> 29, 2004 to submit claims for your eligible expenses incurred during
> 2003 if you enrolled in FSAFEDS when it was initially offered. You
> will have until April 30, 2005 to submit claims for your eligible
> expenses incurred from January 1 through December 31, 2004 if you
> elect FSAFEDS during this Open Season.
>
> The **FSAFEDS Calculator** at
> [www.fsafeds.com](http://www.fsafeds.com/) will help you plan your FSA
> allocations and provide an estimate of your tax savings based on your
> individual situation.
>
> Every FEHB health plan includes cost sharing features, such as
> deductibles you must meet before the Plan provides benefits,
> coinsurance or copayments that you pay when you and the Plan share
> costs, and medical services and supplies that are not covered by the
> Plan and for which you must pay. These out-of-pocket costs are
> summarized on page 16 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:

-   Medical services provided by covered physicians

-   Prescription drugs

-   Surgical and anesthesia services

> Under this Plan, typical expenses not covered include:

-   Routine dental care

-   Cosmetic surgery

-   Routine vision care

> 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.
>
> An FSA lets you allot money for eligible expenses [before]{.underline}
> 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 an 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 on the retirement system in which 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.
>
> You *cannot* claim expenses on your Federal income tax return if you
> receive reimbursement for them from your HCFSA or DCFSA. Below are
> some guidelines that may help you decide whether to participate in
> FSAFEDS.
>
> **Health care expenses** The HCFSA is tax-free from the first dollar.
> In addition, you may be reimbursed from the HCFSA at any time during
> 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.
>
> Probably not. While there is an administrative fee of \$4.00 per month
> for 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 don't spend your entire account balance
> by the end of the plan year and wind up forfeiting your end of year
> account balance, per the IRS "use-it-or-lose-it" rule.

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

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

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

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

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

**The Federal Long Term Care Insurance Program**

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

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

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

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

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

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

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

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

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

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

**A**bortion 47

Accidental injury 37

Acupuncture 27

Allergy care 23

Allogenic (donor) bone marrow transplant 32

Alternative treatments 27

Ambulance 36, 38

Ambulatory surgical center 12, 35

Anesthesia 33

Auto insurance 51, 54

**B**iopsies 29

Blood and blood plasma 35, 36

**C**arryover 15

Catastrophic protection 16, 19

Certificate of Coverage 59

Changes for 2004 11

Chemotherapy 24

Children's Equity Act 57

Chiropractic 27

Chlamydial testing 21

Cholesterol tests 21

Claim filing 48

Coinsurance 15, 55

Colorectal cancer screening 21

Congenital anomalies 31, 55

Contraceptive devices and drugs 23, 43

Coordinating benefits with other coverage 51-54

Copayment 15, 55

Covered facilities 12, 13

Covered providers 12

Custodial care 55

**D**eductible 15, 55

Definitions 55-56

Dental care 45

Diabetic supplies 26

Diagnostic testing 21, 39

Dialysis 24

Disease management 44

Disputed claims process 49-50

Donor expenses (transplants) 33

Durable medical equipment 26-27

**E**ducational classes and programs 28

Effective date of enrollment 55, 58

Emergency 38

Experimental or investigational 47, 55

Family planning 23

Fecal occult blood test 21

Flexible benefits option 44\
Flexible spending account 60-62

Foot care 25

Fraud 5

Freestanding ambulatory facilities 12

**G**eneral exclusions 47

Genetic counseling 23

Government facilities 16

Group health coverage 51, 56

Growth hormone 14, 24

**H**earing services 25

Home health services 27

Hospice care 36

Hospital 12, 34-36

**I**dentification cards 12

Immunizations 21-22

Infertility 23

Influenza vaccine 21

Inhospital physician care 20, 40, 41

Inpatient hospital 34-36, 40, 41

Insulin 26, 43

**L**ab and pathology services 21, 35

Long term care 62

**M**ail order prescription drugs 42-43

Mammograms 21

Mastectomy 31

Maternity benefits 22

Medicaid 54

Medical necessity 56

Medically underserved areas (MUA) 12

Medicare 18, 51-53

Medicare, 65 or older without Medicare 17

Mental health/substance abuse benefits 39-41

MRIs (Magnetic Resonance Imagings) 21

**N**ewborn care 22

Non-FEHB benefits 46

Nurse

-   Licensed practical nurse 27

-   Licensed vocational nurse 27

-   Nurse anesthetist 12, 35

-   Nurse midwife 12

-   Nurse practitioner 12

-   Registered nurse 27

    Nursery charges 22

    **O**besity 20, 34

    Occupational therapy 24

    Ocular injury 25

    Office visits 21, 39

    Oral and maxillofacial surgery 31, 47

Orthopedic devices 26

Ostomy and catheter supplies 26

Out-of-pocket expenses 15-18

Outpatient facility care 35-36

Overpayments 16

Overseas claims 48

Oxygen 26

**P**ap test 21

Physical therapy 24

Plan allowance 15-16, 56

Pneumococcal vaccine 21

Preadmission testing 34, 56

Preauthorization 14, 24, 39-40

Precertification 13-14, 34, 39

Preferred Provider Organization (PPO) 7, 15, 56

Prescription drugs 42-43

Preventing medical mistakes 6

Preventive care, adult 21

Preventive care, children 22

Prostate cancer screening 21

Prosthetic devices 26

Psychiatrist 39, 40, 41

Psychologist 12, 39, 40, 41

**R**adiation therapy 24

Renal dialysis 24

**S**econd surgical opinion 20

Skilled nursing facility care 13, 36

Smoking cessation 28

Social worker 12, 39, 40, 41

Speech therapy 24

Spouse equity 58

Sterilization procedures 23, 30

Subrogation 54

Substance abuse 39-40, 41

Surgery 29-33

-   Assistant surgeon 30

-   Cosmetic 30, 47, 55

```{=html}
<!-- -->
```
-   Multiple procedures 30

-   Oral 30, 31

-   Reconstructive 31

    Syringes 26, 43

    **T**emporary Continuation of Coverage (TCC) 59

    Transitional care 13

    Transplants 14, 32-33

    TRICARE 53

Treatment therapies 24

**V**ision services 25, 30

**W**heelchairs 26

Workers' compensation 53

**X**-rays 21, 34, 35, 36

  -----------------------------------------------------------------------
  **Notes**

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

  -----------------------------------------------------------------------
  **Summary of benefits for the NALC Health Benefit Plan -- 2004**

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

-   **Do not rely on this chart alone.** All benefits 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.

-   Below, an asterisk (\*) means the item is subject to the \$250 PPO
    or \$300 Non-PPO calendar year deductible. And, after we pay, you
    generally pay any difference between our allowance and the billed
    amount if you use a Non-PPO physician or other health care
    professional.

+---------------------+---+------+----------------------------------+---+
| **Benefits**        |   | *    |                                  | * |
|                     |   | *You |                                  | * |
|                     |   | P    |                                  | P |
|                     |   | ay** |                                  | a |
|                     |   |      |                                  | g |
|                     |   |      |                                  | e |
|                     |   |      |                                  | * |
|                     |   |      |                                  | * |
+---------------------+---+------+----------------------------------+---+
| Medical services    |   | PPO: |                                  | > |
| provided by         |   | \$20 |                                  |   |
| physicians:         |   | c    |                                  | 2 |
|                     |   | opay |                                  | 0 |
| -   Diagnostic and  |   | ment |                                  |   |
|     treatment       |   | per  |                                  |   |
|     services        |   | of   |                                  |   |
|     provided in the |   | fice |                                  |   |
|     office          |   | vi   |                                  |   |
|                     |   | sit; |                                  |   |
|                     |   | \$5  |                                  |   |
|                     |   | c    |                                  |   |
|                     |   | opay |                                  |   |
|                     |   | ment |                                  |   |
|                     |   | per  |                                  |   |
|                     |   | all  |                                  |   |
|                     |   | ergy |                                  |   |
|                     |   | in   |                                  |   |
|                     |   | ject |                                  |   |
|                     |   | ion; |                                  |   |
|                     |   | rou  |                                  |   |
|                     |   | tine |                                  |   |
|                     |   | s    |                                  |   |
|                     |   | cree |                                  |   |
|                     |   | ning |                                  |   |
|                     |   | serv |                                  |   |
|                     |   | ices |                                  |   |
|                     |   | and  |                                  |   |
|                     |   | o    |                                  |   |
|                     |   | ther |                                  |   |
|                     |   | non  |                                  |   |
|                     |   | surg |                                  |   |
|                     |   | ical |                                  |   |
|                     |   | s    |                                  |   |
|                     |   | ervi |                                  |   |
|                     |   | ces, |                                  |   |
|                     |   | 1    |                                  |   |
|                     |   | 5%\* |                                  |   |
|                     |   | of   |                                  |   |
|                     |   | our  |                                  |   |
|                     |   | a    |                                  |   |
|                     |   | llow |                                  |   |
|                     |   | ance |                                  |   |
|                     |   |      |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | Non- |                                  |   |
|                     |   | PPO: |                                  |   |
|                     |   | > 3  |                                  |   |
|                     |   | 0%\* |                                  |   |
|                     |   | > of |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  our |                                  |   |
|                     |   | > a  |                                  |   |
|                     |   | llow |                                  |   |
|                     |   | ance |                                  |   |
+---------------------+---+------+----------------------------------+---+
| Services provided   |   | >    |                                  | > |
| by a hospital:      |   | PPO: |                                  |   |
|                     |   | >    |                                  | 3 |
| -   Inpatient       |   |  10% |                                  | 4 |
|                     |   | > of |                                  | > |
| -   Outpatient      |   | >    |                                  | > |
|                     |   |  our |                                  |   |
|                     |   | > a  |                                  | 3 |
|                     |   | llow |                                  | 5 |
|                     |   | ance |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | Non- |                                  |   |
|                     |   | PPO: |                                  |   |
|                     |   | > \  |                                  |   |
|                     |   | $100 |                                  |   |
|                     |   | > c  |                                  |   |
|                     |   | opay |                                  |   |
|                     |   | ment |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  per |                                  |   |
|                     |   | > ad |                                  |   |
|                     |   | miss |                                  |   |
|                     |   | ion, |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  30% |                                  |   |
|                     |   | > of |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  our |                                  |   |
|                     |   | > a  |                                  |   |
|                     |   | llow |                                  |   |
|                     |   | ance |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | PPO: |                                  |   |
|                     |   | > 1  |                                  |   |
|                     |   | 5%\* |                                  |   |
|                     |   | > of |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  our |                                  |   |
|                     |   | > a  |                                  |   |
|                     |   | llow |                                  |   |
|                     |   | ance |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | Non- |                                  |   |
|                     |   | PPO: |                                  |   |
|                     |   | > 3  |                                  |   |
|                     |   | 0%\* |                                  |   |
|                     |   | > of |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  our |                                  |   |
|                     |   | > a  |                                  |   |
|                     |   | llow |                                  |   |
|                     |   | ance |                                  |   |
+---------------------+---+------+----------------------------------+---+
| Emergency benefits: |   | > Wi |                                  | > |
|                     |   | thin |                                  |   |
| -   Accidental      |   | > 72 |                                  | 3 |
|     injury          |   | > ho |                                  | 7 |
|                     |   | urs: |                                  | > |
| -   Medical         |   | >    |                                  | > |
|     emergency       |   |  Not |                                  |   |
|                     |   | hing |                                  | 3 |
|                     |   | >    |                                  | 8 |
|                     |   |  for |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  non |                                  |   |
|                     |   | surg |                                  |   |
|                     |   | ical |                                  |   |
|                     |   | > ou |                                  |   |
|                     |   | tpat |                                  |   |
|                     |   | ient |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | care |                                  |   |
|                     |   | > A  |                                  |   |
|                     |   | fter |                                  |   |
|                     |   | > 72 |                                  |   |
|                     |   | > ho |                                  |   |
|                     |   | urs: |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | PPO: |                                  |   |
|                     |   | > 1  |                                  |   |
|                     |   | 5%\* |                                  |   |
|                     |   | > of |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  our |                                  |   |
|                     |   | > a  |                                  |   |
|                     |   | llow |                                  |   |
|                     |   | ance |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | Non- |                                  |   |
|                     |   | PPO: |                                  |   |
|                     |   | > 3  |                                  |   |
|                     |   | 0%\* |                                  |   |
|                     |   | > of |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  our |                                  |   |
|                     |   | > a  |                                  |   |
|                     |   | llow |                                  |   |
|                     |   | ance |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  Reg |                                  |   |
|                     |   | ular |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | cost |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  sha |                                  |   |
|                     |   | ring |                                  |   |
+---------------------+---+------+----------------------------------+---+
| Mental health and   |   | >    |                                  | > |
| substance abuse     |   |  In- |                                  |   |
| treatment           |   | Netw |                                  | 3 |
|                     |   | ork: |                                  | 9 |
|                     |   | >    |                                  | \ |
|                     |   |  Reg |                                  | > |
|                     |   | ular |                                  |   |
|                     |   | >    |                                  | 4 |
|                     |   | cost |                                  | 1 |
|                     |   | >    |                                  |   |
|                     |   |  sha |                                  |   |
|                     |   | ring |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  Out |                                  |   |
|                     |   | -of- |                                  |   |
|                     |   | Netw |                                  |   |
|                     |   | ork: |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | Bene |                                  |   |
|                     |   | fits |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  are |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  lim |                                  |   |
|                     |   | ited |                                  |   |
+---------------------+---+------+----------------------------------+---+
| Prescription drugs  |   | >    |                                  | > |
|                     |   |  Net |                                  |   |
|                     |   | work |                                  | 4 |
|                     |   | >    |                                  | 2 |
|                     |   |  ret |                                  |   |
|                     |   | ail: |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  25% |                                  |   |
|                     |   | > of |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | cost |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  Net |                                  |   |
|                     |   | work |                                  |   |
|                     |   | > re |                                  |   |
|                     |   | tail |                                  |   |
|                     |   | > M  |                                  |   |
|                     |   | edic |                                  |   |
|                     |   | are: |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  15% |                                  |   |
|                     |   | > of |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | cost |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  Non |                                  |   |
|                     |   | -net |                                  |   |
|                     |   | work |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  ret |                                  |   |
|                     |   | ail: |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | \$25 |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  ded |                                  |   |
|                     |   | ucti |                                  |   |
|                     |   | ble, |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  50* |                                  |   |
|                     |   | *%** |                                  |   |
|                     |   | > of |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  our |                                  |   |
|                     |   | > a  |                                  |   |
|                     |   | llow |                                  |   |
|                     |   | ance |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  Non |                                  |   |
|                     |   | -net |                                  |   |
|                     |   | work |                                  |   |
|                     |   | > re |                                  |   |
|                     |   | tail |                                  |   |
|                     |   | > M  |                                  |   |
|                     |   | edic |                                  |   |
|                     |   | are: |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  50* |                                  |   |
|                     |   | *%** |                                  |   |
|                     |   | > of |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  our |                                  |   |
|                     |   | > a  |                                  |   |
|                     |   | llow |                                  |   |
|                     |   | ance |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | Mail |                                  |   |
|                     |   | > or |                                  |   |
|                     |   | der: |                                  |   |
|                     |   | > 60 |                                  |   |
|                     |   | -day |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  sup |                                  |   |
|                     |   | ply, |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  \$8 |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | gene |                                  |   |
|                     |   | ric/ |                                  |   |
|                     |   | \$24 |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | name |                                  |   |
|                     |   | > b  |                                  |   |
|                     |   | rand |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | Mail |                                  |   |
|                     |   | > or |                                  |   |
|                     |   | der: |                                  |   |
|                     |   | > 90 |                                  |   |
|                     |   | -day |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  sup |                                  |   |
|                     |   | ply, |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | \$12 |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | gene |                                  |   |
|                     |   | ric/ |                                  |   |
|                     |   | \$35 |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | name |                                  |   |
|                     |   | > b  |                                  |   |
|                     |   | rand |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | Mail |                                  |   |
|                     |   | > o  |                                  |   |
|                     |   | rder |                                  |   |
|                     |   | > M  |                                  |   |
|                     |   | edic |                                  |   |
|                     |   | are: |                                  |   |
|                     |   | > 60 |                                  |   |
|                     |   | -day |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  sup |                                  |   |
|                     |   | ply, |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  \$7 |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | gene |                                  |   |
|                     |   | ric/ |                                  |   |
|                     |   | \$20 |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | name |                                  |   |
|                     |   | > b  |                                  |   |
|                     |   | rand |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | Mail |                                  |   |
|                     |   | > o  |                                  |   |
|                     |   | rder |                                  |   |
|                     |   | > M  |                                  |   |
|                     |   | edic |                                  |   |
|                     |   | are: |                                  |   |
|                     |   | > 90 |                                  |   |
|                     |   | -day |                                  |   |
|                     |   | >    |                                  |   |
|                     |   |  sup |                                  |   |
|                     |   | ply, |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | \$10 |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | gene |                                  |   |
|                     |   | ric/ |                                  |   |
|                     |   | \$30 |                                  |   |
|                     |   | >    |                                  |   |
|                     |   | name |                                  |   |
|                     |   | > b  |                                  |   |
|                     |   | rand |                                  |   |
+---------------------+---+------+----------------------------------+---+
| Dental Care         |   | >    |                                  | > |
|                     |   |  All |                                  |   |
|                     |   | >    |                                  | 4 |
|                     |   |  cha |                                  | 5 |
|                     |   | rges |                                  |   |
+---------------------+---+------+----------------------------------+---+
| Special features:   |   |      | -   Services for deaf and        | > |
|                     |   |      |     hearing impaired             |   |
| -   Flexible        |   |      |                                  | 4 |
|     benefits option |   |      | -   Disease management programs  | 4 |
|                     |   |      |                                  |   |
| -   24-hour nurse   |   |      | -   Worldwide coverage           |   |
|     line            |   |      |                                  |   |
|                     |   |      |                                  |   |
| -   24-hour help    |   |      |                                  |   |
|     line for mental |   |      |                                  |   |
|     health and      |   |      |                                  |   |
|     substance abuse |   |      |                                  |   |
+---------------------+---+------+----------------------------------+---+
| Protection against  | > |      |                                  | > |
| catastrophic costs  |   |      |                                  |   |
|                     | S |      |                                  | 1 |
| (your out-of-pocket | e |      |                                  | 6 |
| maximum)            | r |      |                                  |   |
|                     | v |      |                                  |   |
|                     | i |      |                                  |   |
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|                     | i |      |                                  |   |
|                     | o |      |                                  |   |
|                     | n |      |                                  |   |
|                     | . |      |                                  |   |
+---------------------+---+------+----------------------------------+---+

**2004 Rate Information for**

#### **NALC Health Benefit 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 published for Postal Service Inspectors and Office of
Inspector General (OIG) employees (see RI 70-2IN).

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

+------------+----+------+-------+--------+-------+--------+-------+
|            |    | **No |       |        |       | **     |       |
|            |    | n-Po |       |        |       | Postal |       |
|            |    | stal |       |        |       | Pre    |       |
|            |    | P    |       |        |       | mium** |       |
|            |    | remi |       |        |       |        |       |
|            |    | um** |       |        |       |        |       |
+------------+----+------+-------+--------+-------+--------+-------+
|            |    | **Bi |       | **Mon  |       | **Biwe |       |
|            |    | week |       | thly** |       | ekly** |       |
|            |    | ly** |       |        |       |        |       |
+------------+----+------+-------+--------+-------+--------+-------+
| **Type of  | ** | *    | **Y   | **G    | **Y   | **     | **Y   |
| En         | Co | *Gov | our** | ov't** | our** | USPS** | our** |
| rollment** | de | 't** |       |        |       |        |       |
|            | ** |      | **Sh  | **S    | **Sh  | **S    | **Sh  |
|            |    | *    | are** | hare** | are** | hare** | are** |
|            |    | *Sha |       |        |       |        |       |
|            |    | re** |       |        |       |        |       |
+------------+----+------+-------+--------+-------+--------+-------+

+------------+----+------+-------+--------+-------+--------+-------+
| **High     | *  | **\$ | *     | **\$26 | **    | **\$14 | *     |
| Option**   | *3 | 121. | *\$51 | 3.03** | \$111 | 3.32** | *\$29 |
|            | 21 | 40** | .68** |        | .98** |        | .76** |
| **Self     | ** |      |       |        |       |        |       |
| Only**     |    |      |       |        |       |        |       |
+------------+----+------+-------+--------+-------+--------+-------+
| **High     | *  | **\$ | *     | **\$60 | **    | **\$32 | *     |
| Option**   | *3 | 277. | *\$92 | 0.36** | \$201 | 7.12** | *\$42 |
|            | 22 | 09** | .78** |        | .03** |        | .75** |
| **Self and | ** |      |       |        |       |        |       |
| Family**   |    |      |       |        |       |        |       |
+------------+----+------+-------+--------+-------+--------+-------+