**Kaiser Foundation**

**Health Plan of Georgia, Inc.**

[http://members.kaiserpermanente.org](http://members.kaiserpermanente.org/)

![](media/image1.wmf){width="1.4979166666666666in"
height="0.5263888888888889in"} **2004**

**A Health Maintenance Organization**

![](media/image2.png){width="1.5in" height="1.5118055555555556in"}

**Serving:** *Atlanta, Georgia metropolitan area*

#########  

Enrollment in this Plan is limited. You must live or work in our

Geographic service area to enroll. See page 9 for requirements.

![](media/image3.jpeg){width="0.7208333333333333in"
height="0.7208333333333333in"}

Enrollment codes for this Plan:

**F81 Self Only**

**F82 Self and Family**

![](media/image4.bmp)

![](media/image5.png)

**RI 73-321**

![](media/image6.png){width="4.84375in" height="1.1354166666666667in"}

Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

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

![](media/image8.png){width="1.195138888888889in"
height="1.0354166666666667in"}
![](media/image9.png){width="1.1715277777777777in"
height="0.9208333333333333in"}

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

# **Privacy Practices**

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

By law, the 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.

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

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

[Introduction](#introduction) 5

[Plain Language](#plainlanguage) 5

[Stop Health Care Fraud!](#stophealthcarefraud) 5

Preventing medical mistakes 6

Section 1. [Facts about this HMO plan](#factsaboutthishmoplan) 8

[How we pay providers](#howwepayproviders) 8

[Your Rights](#yourrights) 8

[Service Area](#servicearea) 9

Section 2. [How we change for 2004](#howwechangefor2003) 10

[Program-wide changes](#programwidechanges) 10

[Changes to this Plan](#changestothisplan) 10

Section 3. [How you get care](#howyougetcare) 11

[Identification cards](#identificationcards) 11

[Where you get covered care](#whereyougetcoveredcare) 11

[Plan providers](#planproviders) 11

[Plan facilities](#planfacilities) 11

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

[Primary care](#primarycare) 12

[Specialty care](#specialtycare) 12

[Hospital care](#hospitalcare) 13

[Circumstances beyond our control](#circumstancesbeyondourcontrol) 14

[Services requiring our prior approval](#servicerequiringour) 14

Section 4. [Your costs for covered
services](#yourcostsforcoveredservices) 15

[Copayments](#copayments) 15

[Deductible](#deductable) 15

[Coinsurance](#coinsurance) 15

[Fees when you fail to make your copayment or
coinsurance](#feeswhenyoufailto) 15

[Your catastrophic protection out-of-pocket maximum for copayments and
coinsurance](#yourcatastrophicprotection) 15

Section 5. [Benefits](#benefits) 16

[Overview](#overview) 16

(a) [Medical services and supplies provided by physicians and other
    health care professionals](#medicalservicesandsuppliesprovided) 17

(b) [Surgical and anesthesia services provided by physicians and other
    health care professionals](#surgicalandanesthesiaservices) 31

(c) [Services provided by a hospital or other facility, and ambulance
    services](#servicesprovidedbyahospital) 36

(d) [Emergency
    services/accidents](#section-5-d.-emergency-servicesaccidents) 40

(e) [Mental health and substance abuse
    benefits](#mentalhealthandsubstanceabuse) 43

(f) [Prescription drug benefits](#prescriptiondrugbenefits) 46

(g) [Special features](#specialfeatures) 50

[Flexible benefits option](#flexiblebenefits) 50

[24 hour nurse line](#hournurseline) 50

[Services for deaf and hearing impaired](#servicesfordeaf) 50

[High risk pregnancies](#highriskpregnancies) 50

[Centers of excellence](#centersofexcellence) 51

[Travel benefit](#travelbenefit) 51

[Smoking cessation](#smokingcessation) 52

[Services from other Kaiser Permanente plans](#servicesfromother) 52

(h) [Dental benefits](#dentalbenefits) 53

> \(i\) [Non-FEHB benefits available to Plan members](#nonfehbbenefits)
> 55

Section 6. [General exclusions \-- things we don\'t
cover](#generalexclusions) 56

Section 7. [Filing a claim for covered
services](#filingaclaimforcoveredservices) 57

Section 8. [The disputed claims process](#thedisputedclaimsprocess) 58

Section 9. [Coordinating benefits with other
coverage](#coordinatingbenefitswithothercoverage) 60

[When you have other health coverage](#whenyouhaveotherhealthcoverage)
60

-   [What is Medicare?](#whatismedicare) 60

-   Should I enroll in Medicare? 60

-   If you do enroll in Medicare Part B 61

-   [The Original Medicare Plan (Part A or Part
    B)](#theoriginalmedicareplan) 61

-   [Medicare+Choice](#medicaremanagedcareplan) 63

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-   [TRICARE and CHAMPVA](#tricareandchampva) 64

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-   [Workers' Compensation](#workerscompensation) 64

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-   [Medicaid](#medicaid) 64

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-   [When other Government agencies are responsible for your
    care](#whenothergovernmentagencies) 65

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-   [When others are responsible for
    injuries](#whenothersareresponsible) 65

Section 10. [Definitions of terms we use in this
brochure](#definitionsoftermsweuseinthisbrochure) 66

Section 11. [FEHB facts](#fehbfacts) 68

Coverage information 68

-   [No pre-existing condition limitation](#nopreexistingcondition) 68

-   [Where you can get information about enrolling in the FEHB
    Program](#whereyoucangetinformation) 68

-   [Types of coverage available for you and your
    family](#typesofcoverageavailable) 68

-   [Children\'s Equity Act](#childrensequityact) 69

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-   [When benefits and premiums start](#whenbenefitsand) 69

-   [When you retire](#whenyouretire) 69

[When you lose benefits](#whenyoulosebenefits) 70

[When FEHB coverage ends](#whenfehbcoverageends) 70

[Spouse equity coverage](#spouseequitycoverage) 70

[Temporary continuation of coverage
(TCC)](#temporarycontinuatuonofcoverage) 70

[Converting to individual coverage](#convertingto) 70

[Getting a Certificate of Group Health Plan
Coverage](#gettingacertificateof) 71

Two new Federal Programs complement FEHB benefits 72

The Federal Flexible Spending Account Program -- *FSAFEDS* 72

The Federal Long Term Care Insurance Program 75

[Index](#index) 77

[Summary of benefits](#summaryofbenefits) 78

[Rates](#rateinformation) Back cover

  -----------------------------------------------------------------------
  []{#introduction .anchor}Introduction

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

This brochure describes the benefits of Kaiser Foundation Health Plan of
Georgia, Inc. under our contract (CS 2163) with the United States Office
of Personnel Management, as authorized by the Federal Employees Health
Benefits law. The address for Kaiser Foundation Health Plan of Georgia,
Inc.\'s administrative office is:

Kaiser Foundation Health Plan of Georgia, Inc.

Nine Piedmont Center

3495 Piedmont Road, NE

Atlanta, Georgia 30305-1736

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 10. Rates are shown on the back cover of this brochure.

  -----------------------------------------------------------------------
  []{#plainlanguage .anchor}Plain Language

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

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

-   Except for necessary technical terms, we use common words. For
    instance, \"you\" means the enrollee or family member; \"we\" or
    \"Plan\" means Kaiser Foundation Health Plan of Georgia, Inc.

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-   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.

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

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

  -----------------------------------------------------------------------
  []{#stophealthcarefraud .anchor}Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at 404/261-2590
    and explain the situation.

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-   If we do not resolve the issue:

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

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

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

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

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

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

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

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

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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

    Want more information on patient safety?

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

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

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

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

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

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

  -----------------------------------------------------------------------
  Section 1. []{#factsaboutthishmoplan .anchor}Facts about this HMO plan

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

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

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

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

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

[]{#howwepayproviders .anchor}How we pay providers

We contract with The Southeast Permanente Medical Group, Inc. and
hospitals to provide the benefits in this brochure. Your medical group
physicians are paid in a number of ways, including salary, capitation,
per diem rates, case rates, fee-for-service, and incentive payments.
Other Plan providers accept a negotiated payment from us. You will only
be responsible for your copayments or coinsurance. If you would like
further information about the way Kaiser Permanente physicians are paid
to provide or arrange medical and hospital care for you, please call us
at 404/261-2590.

[]{#yourrights .anchor}Your Rights

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

-   Kaiser Foundation Health Plan of Georgia, Inc., a Georgia non-profit
    corporation, is a wholly owned subsidiary of Kaiser Foundation
    Health Plan, Inc. We are a federally qualified health maintenance
    organization. This Plan is part of the Kaiser Permanente Medical
    Care Program, a group of non-profit organizations and contracting
    medical groups that serve over 8 million members nationwide.

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-   In October 1985, Kaiser Permanente began operations in the State of
    Georgia. Kaiser Permanente is the state's largest non-profit health
    plan, providing health care to more than 270,000 members in the
    metro-Atlanta area.

-   In 2000, we received a three-year, full accreditation now known as
    \"Excellent Accreditation\" from the National Committee for Quality
    Assurance (NCQA).

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-   All Kaiser Permanente affiliated hospitals are accredited by the
    Joint Commission on Accreditation of Healthcare Organizations
    (JCAHO), the commission that sets nationally recognized health care
    standards for hospitals and other health care organizations.

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-   Kaiser Permanente reviews the credentials -- including licensing,
    education, training, experience, health status, judgement, and
    office conditions -- of physicians before they are selected to
    participate in our medical care program, and we review them on an
    ongoing basis.

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-   We credential Plan providers in accord with national standards.

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-   Plan physicians are members of American Specialty Boards or are
    Board eligible.

If you want more information about us, call 404/261-2590, or write to:
Kaiser Permanente, Member Services Department, Nine Piedmont Center,
3495 Piedmont Road, NE, Atlanta, GA 30305-1736.

You may also contact us by visiting our website at
[http://members.kaiserpermanente.org](http://members.kaiserpermanente.org/)**.**

[]{#servicearea .anchor}Service Area

To enroll in this Plan, you must live or work in our service area. This
is where our providers practice. Our service area includes these
counties:

Bartow, Barrow, Butts, Cherokee, Clayton, Cobb, Coweta, DeKalb, Douglas,
Fayette, Forsyth, Fulton, Gwinnett, Hall, Henry, Newton, Paulding,
Rockdale, Spalding, and Walton.

NOTE: Here are some things to keep in mind.

If you are currently enrolled in, or plan to enroll in, our Senior
Advantage plan, the service area requirements may be different from the
service area shown above for other federal members.

To enroll in the Senior Advantage plan you must live in the following
counties: Cherokee, Clayton, Cobb, Coweta, DeKalb, Douglas, Fayette,
Forsyth, Fulton, Gwinnett, Henry, and these zip codes in Paulding county
-- 20134, 30127, and 30141.

If you lose eligibility for the Kaiser Permanente Senior Advantage plan
because you move outside the Senior Advantage service area, you will no
longer be entitled to the enhanced benefits under Section 9 of this
brochure.

Ordinarily, you must get your care from providers who contract with us.
However, we are part of the Kaiser Permanente Medical Care Program, and
if you are visiting another Kaiser Permanente service area, you can
receive virtually all of the benefits of this Plan at any other Kaiser
Permanente facility, including our mail order prescription program. You
must pay the charges or copayments imposed by the Kaiser Permanente Plan
you are visiting, with the exception of mail order prescriptions which
are administered by your home Plan. See Section 5(g), Special Features,
for more details. We also pay for certain follow-up services or
continuing care services while you are traveling outside the service
area, as described on page 51; and for emergency care obtained from any
non-Plan provider, as described on page 40. We will not pay for any
other health care services.

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

  -----------------------------------------------------------------------
  Section 2. []{#howwechangefor2003 .anchor}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.

[]{#programwidechanges .anchor}Program-wide changes

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Programs -- FSAFEDS and the Federal Long Term Care Insurance
    Program. See page 72.

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

-   We added information regarding enrolling in Medicare. See page 60.

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-   We revised the Medicare Primary Payer Chart. See page 62.

[]{#changestothisplan .anchor}Changes to this Plan

-   Your share of the non-Postal premium will increase by 11.6% for Self
    Only or 11.6% for Self and Family.

```{=html}
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```
-   We increased your out-of-pocket maximum for copayments from \$2,000
    per person or \$5,000 per family to \$2,000 per person or \$6,000
    per family.

```{=html}
<!-- -->
```
-   We increased your office visit copayment for outpatient care from
    \$10 to \$15 per visit.

```{=html}
<!-- -->
```
-   We increased your Plan after-hours care center copayment from \$20
    to \$30 per visit.

```{=html}
<!-- -->
```
-   We decreased the charge for our smoking cessation program from \$20
    to no charge.

```{=html}
<!-- -->
```
-   We increased your copayment for outpatient surgery and surgical
    procedures from no charge to \$50.

```{=html}
<!-- -->
```
-   We increased your inpatient hospital services copayment from no
    charge to \$250 per admission.

```{=html}
<!-- -->
```
-   We increased your copayment for emergency services in our service
    area from \$50 to \$75 per visit.

```{=html}
<!-- -->
```
-   We increased your copayment for emergency services outside our
    service area from \$50 to \$75 per visit.

```{=html}
<!-- -->
```
-   We increased your copayment for ambulance service from \$50 to \$75
    per trip.

```{=html}
<!-- -->
```
-   We increased your copayment for mental health and substance abuse
    group therapy visits from \$5 to \$7 per visit.

```{=html}
<!-- -->
```
-   We increased your copayment for extraction of teeth for radiation
    treatment from \$10 to \$50 per visit.

```{=html}
<!-- -->
```
-   We changed your copayment for implanted time-release contraceptive
    drugs from \$180 to \$10 times the number of months the drug is
    expected to be effective, not to exceed \$200.

```{=html}
<!-- -->
```
-   We increased the copayments of Senior Advantage-FEHBP members on
    certain enhanced benefits.

  -----------------------------------------------------------------------
  Section 3. []{#howyougetcare .anchor}How you get care
  -----------------------------------------------------------------------

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

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

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call our
Member Services Department at 404/261-2590 (locally), 800/611-1811 (long
distance), or 800/255-0056 (TTY number), or write to us at: Kaiser
Foundation Health Plan of Georgia, Inc., Member Services Department,
Nine Piedmont Center, 3495 Piedmont Rd., NE, Atlanta, GA 30305-1736. You
may also request replacement cards through our website at
[http://members.kaiserpermanente.org](http://members.kaiserpermanente.org/).

[]{#whereyougetcoveredcare .anchor}**Where you get covered care** You
get care from \"Plan providers\" and \"Plan facilities.\" You will only
pay copayments or coinsurance, and you will not have to file claims.

[]{#planproviders .anchor}**Plan providers** Plan providers are
physicians and other health care professionals in our service area that
we contract with to provide covered services to our members. We contract
with The Southeast Permanente Medical Group, Inc. (Plan physicians), an
independent multi-specialty group of physicians, to provide or arrange
all necessary physician care. Plan physicians, nurse practitioners,
physician assistants, and other skilled medical personnel working as
medical teams provide your health care services. Specialists consult
with these medical teams in determining your treatment. Plan physicians
refer patients to community specialists when necessary.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website at
[http://members.kaiserpermanente.org](http://members.kaiserpermanente.org/).

[]{#planfacilities .anchor}**Plan facilities** Plan facilities are
hospitals and other facilities in our service area that we contract with
to provide covered services to our members. Other services, such as
physical therapy, laboratory, and X-ray, are available at Plan
facilities and other designated locations. Hospital care is provided at
local community hospitals. We list these in the provider directory,
which we update periodically. The list is also on our website.

> You must receive your health services at Plan facilities, except if
> you have an emergency. If you are visiting another Kaiser Permanente
> service area, you may receive health care services at those Kaiser
> Permanente facilities. Under the circumstances specified in this
> brochure, you may receive follow-up or continuing care while you
> travel anywhere.

[]{#whatyoumustdotoget .anchor}**What you must do to get** It depends on
the type of care you need. First, you and each family **covered care**
member should choose a primary care physician. This decision is

important since your primary care physician provides or arranges for
most of your health care. Our website has information about our
providers.

> []{#primarycare .anchor}**Primary care** We require you to choose a
> primary care physician when you enroll. Every member of your family
> should have his or her own primary care physician. If you do not
> select a primary care physician upon enrollment, we will assist you by
> identifying a physician in a medical center near your home and
> including you in that physician's panel of patients. That physician
> will be listed in our records as your primary care physician until you
> make a selection and inform us of your decision.

When choosing your primary care physician, keep in mind that your choice
will determine where you will receive specialty care. Your primary care
physician has an established relationship with a specific group of
specialty care physicians with whom he or she works and trusts. By
referring only to a select group of specialists, your primary care
physician is better able to ensure that you receive quality care.

You may select your primary care physician from the Medical Group
Physicians or from a contracted Affiliated Community Physicians
practicing in their own offices all over town. The Medical Group
physicians provide care at Kaiser Permanente medical centers in our
service area. An Affiliated Community Physician provides care in his or
her own medical office. Your primary care physician can be a family
practitioner, internist, or pediatrician. Adults should select an
internal medicine or family practice physician. Parents can choose a
pediatric or family practice physician for their children, or a family
practice physician can be selected for the entire family. To learn how
to choose or change a primary care physician, please call our Member
Services Department at 404/261-2590 (locally), 800/ 611-1811 (long
distance), or 800/255-0056 (TTY number).

If you wish to be treated by a physician at a Kaiser Permanente medical
center or by another Affiliated Community Physician, you should select
that individual as your new primary care physician before scheduling
treatment.

If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
Your primary care physician will provide most of your health care, or
give you a referral to see a specialist.

[]{#specialtycare .anchor}**Specialty care** Your primary care physician
will refer you to a specialist for needed care. When you receive a
referral from your primary care physician, you must return to the
primary care physician after the consultation, unless your primary care
physician authorized a certain number of visits without additional
referrals. The primary care physician must provide or authorize all
follow-up care. Do not go to the specialist for return visits unless
your primary care physician gives you a referral. However, you may see a
gynecologist, a dermatologist, an optometrist, or our mental health and
substance abuse Plan providers without a referral.

Here are other things you should know about specialty care:

Keep in mind that your primary care physician choice determines which
specialists are available to you. Your primary care physician has an
established relationship with a specific group of specialty care
doctors. By referring only to a certain group of specialists, your
primary care physician is better able to ensure that you receive quality
care.

-   If you need to see a specialist frequently because of a chronic,
    complex, or serious medical condition, your primary care physician
    will develop a treatment plan that allows you to see your specialist
    for a certain number of visits without additional referrals. Your
    primary care physician will use our criteria when creating your
    treatment plan.

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

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

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

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

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

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

[]{#hospitalcare .anchor}**Hospital care** Your Plan primary care
physician or specialist will make necessary hospital arrangements and
supervise your care. This includes admission to a skilled nursing or
other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call
our Member Services Department immediately at 404/261-2590. If you are
new to the FEHB Program, we will arrange for you to receive care.

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

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

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

```{=html}
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```
-   The 92^nd^ day after you become a member of this Plan,

whichever happens first.

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

[]{#circumstancesbeyondourcontrol .anchor}**Circumstances beyond our**
Under certain extraordinary circumstances, such as natural disasters, we

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

[]{#servicerequiringour .anchor}**Service requiring our** Your primary
care physician has authority to refer you for most services.

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

We call this review and approval process preauthorization. Your
physician must obtain preauthorization for the following services:

-   All inpatient hospital care services (this does not apply to
    emergency admissions)

-   Skilled nursing care benefits

-   Inpatient mental health or substance abuse services

-   Inpatient rehabilitation therapy services or programs

-   Organ and tissue transplants

-   Bariatric surgery

-   Infertility procedures

-   Outpatient procedures and services:

-   Ambulatory Surgery

-   Biofeedback or other pain management treatment

-   Botox injections

-   Comprehensive outpatient rehabilitation facility services

-   Cryosurgery of the prostate

-   Dialysis

-   Durable medical equipment, and orthopedic and prosthetic devices

-   Epidural steroid injections

-   HBO treatment

-   Home Health Care

-   Hospice care

-   Human Growth Hormone

-   Implantable cardiac defibrillators (AICD)

-   Intrathecal and epidural infusion pumps

-   Lithotripsy

-   PET Scans

-   Prostate seed implants

-   Speech therapy, physical therapy, occupational therapy

-   Spinal cord stimulation

-   Any request for non-Plan provider

  -----------------------------------------------------------------------
  Section 4. []{#yourcostsforcoveredservices .anchor}Your costs for
  covered services
  -----------------------------------------------------------------------

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

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

[]{#copayments .anchor}**Copayments** A copayment is a fixed amount of
money you pay to the provider, facility, pharmacy, etc., when you
receive services.

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

> []{#deductable .anchor}**Deductible** We do not have a deductible.

[]{#coinsurance .anchor}**Coinsurance** Coinsurance is the percentage of
our allowance that you must pay for certain services you receive.

Example: In our Plan, you pay 50% of our allowance for infertility
services and 20% of our allowance for durable medical equipment.

> []{#feeswhenyoufailto .anchor}**Fees when you fail to** If you do not
> pay your copayment or coinsurance at the time you receive
>
> **make your copayment** services, we will bill you. You will be
> required to pay a \$20 charge for
>
> **or coinsurance** each bill sent for unpaid services.

[]{#yourcatastrophicprotection .anchor}**Your catastrophic protection**
After your copayments and coinsurance total \$2,000 per person or
\$6,000

**out-of-pocket maximum** per family enrollment in any calendar year,
you do not have to pay any

**for copayments and coinsurance** more for covered services. However,
copayments or coinsurance for the following services do not count toward
your catastrophic protection out-of-pocket maximum, and you must
continue to pay copayments or coinsurance for these services as
described in this brochure:

-   prescription drugs

-   durable medical equipment

-   external prosthetic and orthotic devices

-   the \$25 charge for follow-up or continuing care outside the
    service\
    area

-   chiropractic services

-   dental services

-   any non-FEHB benefits

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

+-----------------------------------------------------------------------+
| Section 5. []{#benefits .anchor}Benefits \-- []{#overview             |
| .anchor}OVERVIEW                                                      |
|                                                                       |
| ***(See page 10 for how our benefits changed this year and page 78    |
| 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
404/261-2590 or at our website at
[http://members.kaiserpermanente.org](http://members.kaiserpermanente.org/).

(a) Medical services and supplies provided by physicians and other
    health care professionals 17-30

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 31-35

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

(c) Services provided by a hospital or other facility, and ambulance
    services 36-39

+---------------------------------+------------------------------------+
| Inpatient hospital              | Skilled nursing care benefits      |
|                                 |                                    |
| Outpatient hospital or          | Hospice care                       |
| ambulatory surgical center      |                                    |
|                                 | Ambulance                          |
+---------------------------------+------------------------------------+

(d) Emergency services/accidents 40-42

+---------------------------------+------------------------------------+
| Emergency within our service    | Ambulance                          |
| area                            |                                    |
|                                 |                                    |
| Emergency outside our service   |                                    |
| area                            |                                    |
+---------------------------------+------------------------------------+

(e) Mental health and substance abuse benefits 43-45

(f) Prescription drug benefits 46-49

(g) Special features 50-52

+---------------------------------+------------------------------------+
| Flexible benefits option        | Centers of excellence              |
|                                 |                                    |
| 24 hour nurse line              | Travel benefit                     |
|                                 |                                    |
| Services for deaf and hearing   | Smoking cessation                  |
| impaired                        |                                    |
|                                 | Services from other Kaiser         |
| High risk pregnancies           | Permanente plans                   |
+---------------------------------+------------------------------------+

(h) Dental benefits 53-54

(i) Non-FEHB benefits available to Plan members 55

Summary of benefits 78

+---+---+-------------------------------------+----------------+---+---+---+
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| a |   |                                     |                |   |   |   |
| l |   |                                     |                |   |   |   |
| s |   |                                     |                |   |   |   |
| * |   |                                     |                |   |   |   |
| * |   |                                     |                |   |   |   |
+---+---+-------------------------------------+----------------+---+---+---+
|   | * | **Here are some important things to |                | * |   |   |
|   | * | keep in mind about these            |                | * |   |   |
|   | I | benefits:**                         |                | I |   |   |
|   | * |                                     |                | * |   |   |
|   | * | -   Please remember that all        |                | * |   |   |
|   |   |     benefits are subject to the     |                |   |   |   |
|   | * |     definitions, limitations, and   |                | * |   |   |
|   | * |     exclusions in this brochure and |                | * |   |   |
|   | M |     we cover them only when we      |                | M |   |   |
|   | * |     determine they are medically    |                | * |   |   |
|   | * |     necessary.                      |                | * |   |   |
|   |   |                                     |                |   |   |   |
|   | * | -   Plan physicians must provide or |                | * |   |   |
|   | * |     arrange your care.              |                | * |   |   |
|   | P |                                     |                | P |   |   |
|   | * | -   Be sure to read Section 4,      |                | * |   |   |
|   | * |     *Your costs for covered         |                | * |   |   |
|   |   |     services,* for valuable         |                |   |   |   |
|   | * |     information about how cost      |                | * |   |   |
|   | * |     sharing works. Also read        |                | * |   |   |
|   | O |     Section 9 about coordinating    |                | O |   |   |
|   | * |     benefits with other coverage,   |                | * |   |   |
|   | * |     including with Medicare.        |                | * |   |   |
|   |   |                                     |                |   |   |   |
|   | * | -   We have no calendar year        |                | * |   |   |
|   | * |     deductible.                     |                | * |   |   |
|   | R |                                     |                | R |   |   |
|   | * | ```{=html}                          |                | * |   |   |
|   | * | <!-- -->                            |                | * |   |   |
|   |   | ```                                 |                |   |   |   |
|   | * | -   You must get PREAUTHORIZATION   |                | * |   |   |
|   | * |     for some MEDICAL procedures.    |                | * |   |   |
|   | T |     please refer to the             |                | T |   |   |
|   | * |     preauthorization shown in       |                | * |   |   |
|   | * |     Section 3 to be sure which      |                | * |   |   |
|   |   |     services and supplies require   |                |   |   |   |
|   | * |     preauthorization.               |                | * |   |   |
|   | * |                                     |                | * |   |   |
|   | A | -   Note: Instead of a \$15 charge, |                | A |   |   |
|   | * |     you pay only \$10 if you enroll |                | * |   |   |
|   | * |     in our Medicare+Choice Plan and |                | * |   |   |
|   |   |     assign your Medicare benefits   |                |   |   |   |
|   | * |     to the Plan.                    |                | * |   |   |
|   | * |                                     |                | * |   |   |
|   | N |                                     |                | N |   |   |
|   | * |                                     |                | * |   |   |
|   | * |                                     |                | * |   |   |
|   |   |                                     |                |   |   |   |
|   | * |                                     |                | * |   |   |
|   | * |                                     |                | * |   |   |
|   | T |                                     |                | T |   |   |
|   | * |                                     |                | * |   |   |
|   | * |                                     |                | * |   |   |
+---+---+-------------------------------------+----------------+---+---+---+
| > |   |                                     | **You pay**    |   |   |   |
|   |   |                                     |                |   |   |   |
| * |   |                                     |                |   |   |   |
| * |   |                                     |                |   |   |   |
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+---+---+-------------------------------------+----------------+---+---+---+
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+---+---+-------------------------------------+----------------+---+---+---+
| > |   |                                     | \$15 per       |   |   |   |
|   |   |                                     | office visit   |   |   |   |
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+---+---+-------------------------------------+----------------+---+---+---+

*Preventive care, adult -- continued on next page*

G

+---------------------------------------------+------------------------+
| **Preventive care, adult** *(continued)*    | **You pay**            |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| *Physical exams required for:*              |                        |
|                                             |                        |
| -   *Obtaining or continuing employment*    |                        |
|                                             |                        |
| -   *Participating in employee programs*    |                        |
|                                             |                        |
| -   *Insurance or licensing*                |                        |
|                                             |                        |
| -   *Court order required for parole or     |                        |
|     probation*                              |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Attending schools*                     |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Travel*                                |                        |
+---------------------------------------------+------------------------+
| ######### Preventive care, children         |                        |
+---------------------------------------------+------------------------+
| -   Childhood immunizations recommended by  | Nothing                |
|     the American Academy of Pediatrics      |                        |
|                                             |                        |
| -   Well-child preventive care visits (up   |                        |
|     to 2 years of age)                      |                        |
+---------------------------------------------+------------------------+
| -   Services, such as:                      | \$15 per office visit  |
|                                             |                        |
| ---Eye screenings to determine the need for |                        |
| vision correction                           |                        |
|                                             |                        |
| > ---Hearing screenings to determine the    |                        |
| > need for hearing correction               |                        |
|                                             |                        |
| -   Examinations done on the day of         |                        |
|     immunizations                           |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Well-child care charges for routine     |                        |
|     examinations, and care (age 2 and over) |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| *Physical exams required for:*              |                        |
|                                             |                        |
| -   *Obtaining or continuing employment*    |                        |
|                                             |                        |
| -   *Participating in employee programs*    |                        |
|                                             |                        |
| -   *Insurance or licensing*                |                        |
|                                             |                        |
| -   *Court order required for parole or     |                        |
|     probation*                              |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Attending schools or camp*             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Travel*                                |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######### Maternity care                    | **You pay**            |
+---------------------------------------------+------------------------+
| > Complete maternity (obstetrical) care,    | Nothing                |
| > such as:                                  |                        |
|                                             |                        |
| -   Prenatal care                           |                        |
|                                             |                        |
| -   Delivery                                |                        |
|                                             |                        |
| -   Postnatal care                          |                        |
|                                             |                        |
| Note: Here are some things to keep in mind: |                        |
|                                             |                        |
| -   You do not need to precertify your      |                        |
|     normal delivery.                        |                        |
|                                             |                        |
| -   You may remain in the hospital up to 48 |                        |
|     hours after a regular delivery and 96   |                        |
|     hours after a cesarean delivery. Your   |                        |
|     Plan physician will extend your         |                        |
|     inpatient stay if medically necessary.  |                        |
|                                             |                        |
| -   We cover routine nursery care of the    |                        |
|     newborn child during the covered        |                        |
|     portion of the mother's maternity stay. |                        |
|     We will cover other care of an infant   |                        |
|     who requires non-routine treatment only |                        |
|     if we cover the infant under a Self and |                        |
|     Family enrollment.                      |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   We pay hospitalization and surgeon      |                        |
|     services (delivery) the same as for     |                        |
|     illness and injury. See Section 5(c)    |                        |
|     for hospital benefits and Section 5(b)  |                        |
|     for surgery benefits*.*                 |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Routine sonograms to determine fetal   |                        |
|     age, size, or sex*                      |                        |
+---------------------------------------------+------------------------+
| ######### Family planning                   |                        |
+---------------------------------------------+------------------------+
| Family planning services, including:        | \$15 per office visit  |
|                                             |                        |
| -   Voluntary sterilization (See Surgical   |                        |
|     procedures Section 5(b))                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Information on birth control            |                        |
|                                             |                        |
| > Note: We cover surgically implanted       |                        |
| > contraceptives, diaphragms, injectable    |                        |
| > contraceptive drugs, intrauterine devices |                        |
| > (IUDs), and diaphragms under your         |                        |
| > prescription drug benefit.                |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | > *All charges*        |
|                                             |                        |
| -   *Reversal of voluntary surgical         |                        |
|     sterilization*                          |                        |
|                                             |                        |
| -   *Genetic counseling*                    |                        |
+---------------------------------------------+------------------------+
| ######### Infertility services              | **You pay**            |
+---------------------------------------------+------------------------+
| > Diagnosis and treatment of involuntary    | 50% of our allowance   |
| > infertility                               |                        |
|                                             |                        |
| -   Artificial insemination:                |                        |
|                                             |                        |
| > ---intravaginal insemination (IVI)        |                        |
| >                                           |                        |
| > ---intracervical insemination (ICI)       |                        |
| >                                           |                        |
| > ---intrauterine insemination (IUI)        |                        |
|                                             |                        |
| -   Fertility drugs                         |                        |
|                                             |                        |
| > Note: We cover injectable fertility drugs |                        |
| > under medical benefits and oral fertility |                        |
| > drugs under the prescription drug         |                        |
| > benefits.                                 |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| > *These exclusions apply to fertile as     |                        |
| > well as infertile individuals or          |                        |
| > couples:*                                 |                        |
|                                             |                        |
| -   *Assisted reproductive technology (ART) |                        |
|     procedures, such as:*                   |                        |
|                                             |                        |
| > ---*in vitro fertilization*               |                        |
| >                                           |                        |
| > ---*embryo transfer and gamete            |                        |
| > intrafallopian transfer (GIFT)*           |                        |
|                                             |                        |
| -   *Services and supplies related to       |                        |
|     excluded ART procedures*                |                        |
|                                             |                        |
| -   *Semen or eggs, and services and        |                        |
|     supplies related to their procurement   |                        |
|     and storage*                            |                        |
|                                             |                        |
| > *Note: Infertility services are not       |                        |
| > available when either member of the       |                        |
| > family has been voluntarily surgically    |                        |
| > sterilized.*                              |                        |
+---------------------------------------------+------------------------+
| ######### Allergy care                      |                        |
+---------------------------------------------+------------------------+
| > Testing and treatment                     | \$15 per office visit  |
+---------------------------------------------+------------------------+
| > Allergy injections                        | \$5 per office visit   |
+---------------------------------------------+------------------------+
| > Allergy serum                             | Nothing                |
+---------------------------------------------+------------------------+
| *Not covered:*                              | > *All charges*        |
|                                             |                        |
| -   *Provocative food testing*              |                        |
|                                             |                        |
| -   *Sublingual allergy desensitization*    |                        |
+---------------------------------------------+------------------------+
| ######### Treatment therapies               | **You pay**            |
+---------------------------------------------+------------------------+
| -   Chemotherapy and radiation therapy      | \$15 per office visit  |
|                                             |                        |
| > Note: We limit high dose chemotherapy in  |                        |
| > association with autologous bone marrow   |                        |
| > transplants to those transplants listed   |                        |
| > under Section 5(b), Organ/tissue          |                        |
| > transplants.                              |                        |
|                                             |                        |
| -   Respiratory and inhalation therapy      |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Intravenous (IV)/Infusion Therapy --    |                        |
|     Home IV and antibiotic therapy          |                        |
|                                             |                        |
| > Note: We cover growth hormone therapy     |                        |
| > (GHT) under the prescription drug         |                        |
| > benefit.                                  |                        |
|                                             |                        |
| -   Dialysis -- hemodialysis and peritoneal |                        |
|     dialysis                                |                        |
|                                             |                        |
| > Note: We waive dialysis office visit      |                        |
| > charges if you enroll in Medicare Part B  |                        |
| > and assign your Medicare benefits to us.  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Chemotherapy supported by a bone       |                        |
|     marrow transplant or with stem cell     |                        |
|     support, for any diagnosis not listed   |                        |
|     as covered*                             |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ##                                          | **You pay**            |
| ####### Physical and occupational therapies |                        |
+---------------------------------------------+------------------------+
| > If, in the judgment of a Plan physician,  | > \$15 per outpatient  |
| > significant improvement is achievable     | > visit                |
| > within a two-month period, two            | >                      |
| > consecutive months of therapy per         | > Nothing for          |
| > condition:                                | > inpatient            |
|                                             |                        |
| -   Physical therapy by qualified physical  |                        |
|     therapists to restore bodily function   |                        |
|     when you have a total or partial loss   |                        |
|     of bodily function due to illness or    |                        |
|     injury                                  |                        |
|                                             |                        |
| -   Occupational therapy by occupational    |                        |
|     therapists to assist you in achieving   |                        |
|     and maintaining self-care and improved  |                        |
|     functioning in other activities of      |                        |
|     daily life                              |                        |
|                                             |                        |
| > Note: If you have not received 20 or more |                        |
| > outpatient visits within the two-month    |                        |
| > period that started with your first visit |                        |
| > to a therapist, we may continue your      |                        |
| > therapy for up to 20 outpatient visits    |                        |
| > per therapy per condition.                |                        |
|                                             |                        |
| -   Cardiac rehabilitation following a      |                        |
|     heart transplant, bypass surgery, or a  |                        |
|     myocardial infarction is provided for   |                        |
|     up to 12 weeks or 36 visits             |                        |
|                                             |                        |
| -   Comprehensive outpatient rehabilitation |                        |
|     facility services are provided up to    |                        |
|     two months per condition. Outpatient    |                        |
|     rehabilitation, including diagnostic    |                        |
|     and restorative services, providing a   |                        |
|     program of physical, speech,            |                        |
|     occupational, respiratory therapy,      |                        |
|     social and psychological services, and  |                        |
|     other items and services that are       |                        |
|     medically necessary for rehabilitation. |                        |
|     The two month limit applies to all      |                        |
|     inpatient and outpatient comprehensive  |                        |
|     rehabilitation services you may receive |                        |
|     for the same condition.                 |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Long-term physical therapy or          |                        |
|     occupational therapy*                   |                        |
|                                             |                        |
| -   *Exercise programs*                     |                        |
|                                             |                        |
| -   *Cognitive rehabilitation programs*     |                        |
|                                             |                        |
| -   *Vocational rehabilitation programs*    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Therapies done primarily for education |                        |
|     purposes*                               |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######### Speech therapy                    | **You pay**            |
+---------------------------------------------+------------------------+
| Two consecutive months of therapy per       | \$15 per outpatient    |
| condition:                                  | visit                  |
|                                             |                        |
| -   Speech therapy by speech therapists     | Nothing for inpatient  |
|     when medically necessary                |                        |
|                                             |                        |
| > Note: If you have not received 20 or more |                        |
| > outpatient visits within the two-month    |                        |
| > period that started with your first visit |                        |
| > to a therapist, we may continue your      |                        |
| > therapy for up to 20 outpatient visits    |                        |
| > per therapy per condition.                |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
| >                                           |                        |
| > *Speech therapy that is not medically     |                        |
| > necessary such as:*                       |                        |
|                                             |                        |
| -   *Therapy for educational placement or   |                        |
|     other educational purposes*             |                        |
|                                             |                        |
| -   *Training or therapy to improve         |                        |
|     articulation in the absence of injury,  |                        |
|     illness, or medical condition affecting |                        |
|     articulation*                           |                        |
|                                             |                        |
| -   *Therapy for tongue thrust in the       |                        |
|     absence of swallowing problems*         |                        |
|                                             |                        |
| -   *Voice therapy for occupation or        |                        |
|     performing arts*                        |                        |
+---------------------------------------------+------------------------+
| ######### Hearing                           |                        |
| services (testing, treatment, and supplies) |                        |
+---------------------------------------------+------------------------+
| -   Hearing test to determine the need for  | \$15 per office visit  |
|     hearing correction                      |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Hearing testing for children through    |                        |
|     age 17 (see Preventive care, children)  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *All other hearing tests*               |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Hearing aids, tests to determine their |                        |
|     effectiveness, and examinations for     |                        |
|     them*                                   |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######### Vision                            | **You pay**            |
| services (testing, treatment, and supplies) |                        |
+---------------------------------------------+------------------------+
| -   Eye refractions for eyeglasses (to      | > \$15 per office      |
|     provide written lens prescription)      | > visit                |
+---------------------------------------------+------------------------+
| -   Diagnosis and treatment of diseases of  | > \$15 per office      |
|     the eye                                 | > visit                |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Corrective eyeglasses and frames or    |                        |
|     contact lenses (including the           |                        |
|     examination and fitting of contact      |                        |
|     lenses)*                                |                        |
|                                             |                        |
| -   *Refractions for contact lenses*        |                        |
|                                             |                        |
| -   *Eye exercises, orthoptics, and visual  |                        |
|     training*                               |                        |
|                                             |                        |
| -   *Radial keratotomy and other refractive |                        |
|     surgery*                                |                        |
|                                             |                        |
| -   *Any eye surgery solely for the purpose |                        |
|     of correcting refractive defects of the |                        |
|     eye, such as nearsightedness (myopia),  |                        |
|     farsightedness (hyperopia), and         |                        |
|     astigmatism*                            |                        |
|                                             |                        |
| -   *Low vision aids*                       |                        |
+---------------------------------------------+------------------------+
| ######### Foot care                         |                        |
+---------------------------------------------+------------------------+
| > Routine foot care when you are under      | \$15 per office visit  |
| > active treatment for a metabolic or       |                        |
| > peripheral vascular disease, such as      |                        |
| > diabetes.                                 |                        |
| >                                           |                        |
| > Note: See orthopedic and prosthetic       |                        |
| > devices for information on podiatric shoe |                        |
| > inserts.                                  |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Cutting, trimming or removal of corns, |                        |
|     calluses, or the free edge of toenails, |                        |
|     and similar routine treatment of        |                        |
|     conditions of the foot, except as       |                        |
|     stated above*                           |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Treatment of weak, strained, or flat   |                        |
|     feet or bunions or spurs; and of any    |                        |
|     instability, imbalance, or subluxation  |                        |
|     of the foot (unless the treatment is by |                        |
|     open cutting surgery)*                  |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######### Orthopedic and prosthetic devices | **You pay**            |
+---------------------------------------------+------------------------+
| External prosthetic and orthotic devices,   | 20% of our allowance   |
| such as:                                    |                        |
|                                             |                        |
| -   Ostomy and urological supplies          |                        |
|                                             |                        |
| -   Artificial limbs and eyes; stump hose   |                        |
|                                             |                        |
| -   Braces                                  |                        |
|                                             |                        |
| -   Therapeutic shoes required for          |                        |
|     conditions associated with diabetes     |                        |
|                                             |                        |
| -   Externally worn breast prostheses and   |                        |
|     surgical bras, including necessary      |                        |
|     replacements, following a mastectomy    |                        |
|                                             |                        |
| -   Scoliosis braces                        |                        |
|                                             |                        |
| -   Lenses following cataract removal       |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Corrective orthopedic appliances for    |                        |
|     non-dental treatment of                 |                        |
|     temporomandibular joint (TMJ) pain      |                        |
|     dysfunction syndrome                    |                        |
+---------------------------------------------+------------------------+
| -   Internal prosthetic devices, such as    | Nothing                |
|     artificial joints, pacemakers,          |                        |
|     intraocular lens following cataract     |                        |
|     removal, cochlear implants, and         |                        |
|     surgically implanted breast implant     |                        |
|     following mastectomy.                   |                        |
|                                             |                        |
| > Note: See Section 5(b) for coverage of    |                        |
| > the surgery to insert the device.         |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Orthopedic and corrective shoes*       |                        |
|                                             |                        |
| -   *Arch supports*                         |                        |
|                                             |                        |
| -   *Foot orthotics*                        |                        |
|                                             |                        |
| -   *Heel pads and heel cups*               |                        |
|                                             |                        |
| -   *Lumbosacral supports*                  |                        |
|                                             |                        |
| -   *Corsets, trusses, elastic stockings,   |                        |
|     support hose, and other supportive      |                        |
|     devices*                                |                        |
|                                             |                        |
| -   *Devices, equipment, supplies, and      |                        |
|     prosthetics related to the treatment of |                        |
|     sexual dysfunction*                     |                        |
|                                             |                        |
| -   *External and internally implanted      |                        |
|     hearing aids*                           |                        |
|                                             |                        |
| -   *Experimental or research equipment*    |                        |
+---------------------------------------------+------------------------+
| ######### Durable medical equipment (DME)   | **You pay**            |
+---------------------------------------------+------------------------+
| Covered DME items include:                  | 20% of our allowance   |
|                                             |                        |
| -   Hospital beds                           |                        |
|                                             |                        |
| -   Wheelchairs, except motorized           |                        |
|                                             |                        |
| -   Crutches                                |                        |
|                                             |                        |
| -   Walkers                                 |                        |
|                                             |                        |
| -   Infant apnea monitors                   |                        |
|                                             |                        |
| -   Oxygen-dispensing equipment             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Oxygen                                  |                        |
|                                             |                        |
| > Note: We decide whether to rent or        |                        |
| > purchase the equipment, and we select the |                        |
| > vendor. We will repair the equipment      |                        |
| > without charge, unless the repair is due  |                        |
| > to loss or misuse. You must return the    |                        |
| > equipment to us or pay us the fair market |                        |
| > price of the equipment when it is no      |                        |
| > longer prescribed.                        |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Motorized wheel chairs*                |                        |
|                                             |                        |
| -   *Comfort, convenience, or luxury        |                        |
|     equipment or features*                  |                        |
|                                             |                        |
| -   *Exercise or hygiene equipment*         |                        |
|                                             |                        |
| -   *Non-medical items such as sauna baths  |                        |
|     or elevators*                           |                        |
|                                             |                        |
| -   *Modifications to your home or car*     |                        |
|                                             |                        |
| -   *Devices for testing blood or other     |                        |
|     body substances*                        |                        |
|                                             |                        |
| -   *Electronic monitors of bodily          |                        |
|     functions, except apnea monitors and    |                        |
|     blood glucose monitors*                 |                        |
|                                             |                        |
| -   *Disposable supplies*                   |                        |
|                                             |                        |
| -   *Replacement of lost equipment*         |                        |
|                                             |                        |
| -   *Repair, adjustments, or replacements   |                        |
|     necessitated by misuse*                 |                        |
|                                             |                        |
| -   *More than one piece of durable medical |                        |
|     equipment serving essentially the same  |                        |
|     function, except for replacements other |                        |
|     than those necessitated by misuse or    |                        |
|     loss*                                   |                        |
|                                             |                        |
| -   *Spare or alternate use equipment*      |                        |
|                                             |                        |
| -   *Devices, equipment, supplies, and      |                        |
|     prosthetics for the treatment of sexual |                        |
|     dysfunction disorders*                  |                        |
|                                             |                        |
| -   *External and internally implanted      |                        |
|     hearing aids*                           |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Experimental or research equipment*    |                        |
+---------------------------------------------+------------------------+
| ######### Home health services              | **You pay**            |
+---------------------------------------------+------------------------+
| If you are homebound and reside in the      | Nothing                |
| service area:                               |                        |
|                                             |                        |
| -   You may receive home health services of |                        |
|     nurses and health aides, physical or    |                        |
|     occupational therapists, and speech and |                        |
|     language pathologists                   |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Services include oxygen therapy,        |                        |
|     intravenous therapy, and medications    |                        |
|                                             |                        |
| > Note: Your Plan physician will            |                        |
| > periodically review the program for       |                        |
| > continuing appropriateness and need.      |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Nursing care requested by, or for the  |                        |
|     convenience of, the patient or the      |                        |
|     patient's family*                       |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Home care primarily for personal       |                        |
|     assistance that does not include a      |                        |
|     medical component and is not            |                        |
|     diagnostic, therapeutic, or             |                        |
|     rehabilitative*                         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Custodial care*                        |                        |
|                                             |                        |
| -   *Care that the Medical Director of the  |                        |
|     Medical Group or his/her designee       |                        |
|     determines may be appropriately         |                        |
|     provided in a Plan facility, skilled    |                        |
|     nursing facility, or other facility we  |                        |
|     designate and we provide or offer to    |                        |
|     provide that care in one of these       |                        |
|     facilities*                             |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Services outside our service area*     |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| ######## Chiropractic                       | **You pay**            |
+---------------------------------------------+------------------------+
| > Chiropractic services up to 30 visits per | \$15 per office visit  |
| > calendar year, for the following          |                        |
| > services:                                 |                        |
|                                             |                        |
| -   Evaluation and management of            |                        |
|     musculoskeletal disorders               |                        |
|                                             |                        |
| -   Routine chiropractic X-rays provided in |                        |
|     the chiropractor's office (not to       |                        |
|     exceed 4 views)                         |                        |
|                                             |                        |
| -   Chiropractic adjustments                |                        |
|                                             |                        |
| -   Appropriate therapies (e.g., hot and    |                        |
|     cold packs) not to exceed 2 per visit   |                        |
|                                             |                        |
| > Note: You may see a chiropractor without  |                        |
| > referral from your Plan physician.        |                        |
| > Services must be provided from our list   |                        |
| > of Participating Chiropractors. Please    |                        |
| > contact us to get the list.               |                        |
+---------------------------------------------+------------------------+
| ## Not covered:                             | *All charges*          |
|                                             |                        |
| -   *Vitamins and supplements*              |                        |
|                                             |                        |
| -   *Vax-D*                                 |                        |
|                                             |                        |
| -   *Structural supports*                   |                        |
|                                             |                        |
| -   *Massage therapies*                     |                        |
|                                             |                        |
| -   *Maintenance/preventative care*         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Acupuncture therapy*                   |                        |
|                                             |                        |
| -   *Physical, speech, and occupational     |                        |
|     therapy provided by a chiropractor*     |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Neurological testing, unless           |                        |
|     authorized by your primary care         |                        |
|     physician*                              |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Laboratory and pathology services,     |                        |
|     unless authorized by your primary care  |                        |
|     physician*                              |                        |
+---------------------------------------------+------------------------+
| ######## Alternative treatments             |                        |
+---------------------------------------------+------------------------+
| > No benefit                                | > *All charges*        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| #### **Educational classes and programs**   | **You pay**            |
+---------------------------------------------+------------------------+
| > Training in self-care and preventive care | > \$15 per office      |
|                                             | > visit                |
+---------------------------------------------+------------------------+
| > Health education publications and         | > Nothing              |
| > education about how to use our services   |                        |
| > and supplies                              |                        |
+---------------------------------------------+------------------------+
| > General health education not addressed to | > Charges vary (\$0 to |
| > a specific condition, as well as Lamaze   | > \$50)                |
| > classes and weight control classes        |                        |
+---------------------------------------------+------------------------+
| > Quit Smart Smoking Cessation Program      | > Nothing              |
| >                                           |                        |
| > This program includes six sessions with   |                        |
| > one follow up session, lectures, a quit   |                        |
| > smoking kit, discussions and relaxation   |                        |
| > techniques, a patented realistic          |                        |
| > cigarette substitute, and vouchers for    |                        |
| > nicotine patches                          |                        |
+---------------------------------------------+------------------------+
| > Any member who is enrolled and attends    | > \$5                  |
| > the quit smart smoking cessation program  |                        |
| > is eligible to receive nicotine patches   |                        |
| > (with voucher) at a Plan pharmacy         |                        |
+---------------------------------------------+------------------------+
| > Note: This information is a summary of    |                        |
| > services available. Please call us at     |                        |
| > 404/261-2590 for availability and         |                        |
| > location of these classes.                |                        |
+---------------------------------------------+------------------------+

+---+---+-------------------------------------+----------------+---+---+
| * |   |                                     |                |   |   |
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| * |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
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| s |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
|   | * | > **Here are some important things  |                | * |   |
|   | * | > to keep in mind about these       |                | * |   |
|   | I | > benefits:**                       |                | I |   |
|   | * |                                     |                | * |   |
|   | * | -   Please remember that all        |                | * |   |
|   |   |     benefits are subject to the     |                |   |   |
|   | * |     definitions, limitations, and   |                | * |   |
|   | * |     exclusions in this brochure and |                | * |   |
|   | M |     we cover them only when we      |                | M |   |
|   | * |     determine they are medically    |                | * |   |
|   | * |     necessary.                      |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Plan physicians must provide or |                | * |   |
|   | * |     arrange your care.              |                | * |   |
|   | P |                                     |                | P |   |
|   | * | -   Be sure to read Section 4,      |                | * |   |
|   | * |     *Your costs for covered         |                | * |   |
|   |   |     services,* for valuable         |                |   |   |
|   | * |     information about how cost      |                | * |   |
|   | * |     sharing works. Also read        |                | * |   |
|   | O |     Section 9 about coordinating    |                | O |   |
|   | * |     benefits with other coverage,   |                | * |   |
|   | * |     including with Medicare.        |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   We do not have a calendar year  |                | * |   |
|   | * |     deductible.                     |                | * |   |
|   | R |                                     |                | R |   |
|   | * | -   YouR PHYSICIAN must get         |                | * |   |
|   | * |     PREAUTHORIZATION for some       |                | * |   |
|   |   |     surgical procedures. please     |                |   |   |
|   | * |     refer to the preauthorization   |                | * |   |
|   | * |     shown in Section 3 to be sure   |                | * |   |
|   | T |     which services and surgeries    |                | T |   |
|   | * |     require preauthorization.       |                | * |   |
|   | * |                                     |                | * |   |
|   |   | ```{=html}                          |                |   |   |
|   | * | <!-- -->                            |                | * |   |
|   | * | ```                                 |                | * |   |
|   | A | -   The amounts listed below are    |                | A |   |
|   | * |     for the charges billed by a     |                | * |   |
|   | * |     physician or other health care  |                | * |   |
|   |   |     professional for your surgical  |                |   |   |
|   | * |     care. Look in Section 5(c) for  |                | * |   |
|   | * |     charges associated with the     |                | * |   |
|   | N |     facility (i.e., hospital,       |                | N |   |
|   | * |     surgical center, etc.).         |                | * |   |
|   | * |                                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | T |                                     |                | T |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | **You pay**    |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| B |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
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| f |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| D |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| S |   |                                     |                |   |   |
| u |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| g |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| l |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
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| d |   |                                     |                |   |   |
| u |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
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| s |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| A |   |                                     | > \$15 per     |   |   |
| c |   |                                     | > office visit |   |   |
| o |   |                                     | > for          |   |   |
| m |   |                                     | > outpatient   |   |   |
| p |   |                                     | > services     |   |   |
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| e |   |                                     | > \$50 for     |   |   |
| h |   |                                     | > outpatient   |   |   |
| e |   |                                     | > surgery and  |   |   |
| n |   |                                     | > procedures   |   |   |
| s |   |                                     | >              |   |   |
| i |   |                                     | > Nothing for  |   |   |
| v |   |                                     | > inpatient    |   |   |
| e |   |                                     | > services     |   |   |
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| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| S |   |                                     |                |   |   |
| u |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| g |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| l |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| d |   |                                     |                |   |   |
| u |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| - |   |                                     |                |   |   |
| - |   |                                     |                |   |   |
| - |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| u |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| d |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| x |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| g |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+

+---------------------------------------------+------------------------+
| > **Surgical procedures** *(continued)*     | **You pay**            |
+---------------------------------------------+------------------------+
| -   Voluntary sterilization (e.g., Tubal    | > \$15 per office      |
|     ligation, Vasectomy)                    | > visit for outpatient |
|                                             | > services             |
| -   Surgically implanted time-release       | >                      |
|     contraceptive drugs and intrauterine    | > Nothing for          |
|     devices (IUDs). Note: Drugs and devices | > inpatient services   |
|     are covered under Section 5(f)          |                        |
|                                             |                        |
| -   Other implanted time-release drugs      |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Treatment of burns                      |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Reversal of voluntary sterilization*   |                        |
|                                             |                        |
| -   *Routine foot care; see Foot care*      |                        |
+---------------------------------------------+------------------------+
| ######### Reconstructive surgery            |                        |
+---------------------------------------------+------------------------+
| -   Surgery to correct a functional defect  | > \$15 per office      |
|                                             | > visit for outpatient |
| -   Surgery to correct a condition caused   | > services             |
|     by injury or illness if:                | >                      |
|                                             | > Nothing for          |
| > ---the condition produced a major effect  | > inpatient services   |
| > on the member's appearance; and           |                        |
| >                                           |                        |
| > ---the condition can reasonably be        |                        |
| > expected to be corrected by such surgery  |                        |
|                                             |                        |
| -   Surgery to correct a condition that     |                        |
|     existed at or from birth and is a       |                        |
|     significant deviation from the common   |                        |
|     form or norm. Examples of congenital    |                        |
|     anomalies are protruding ear            |                        |
|     deformities, cleft lip, cleft palate,   |                        |
|     birthmarks, web fingers, and toes.      |                        |
|                                             |                        |
| -   Treatment of port wine stains on the    |                        |
|     face of members 18 years or younger     |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   All stages of breast reconstruction     |                        |
|     surgery following a mastectomy, such    |                        |
|     as:                                     |                        |
|                                             |                        |
| > ---surgery to produce a symmetrical       |                        |
| > appearance on the other breast;           |                        |
| >                                           |                        |
| > ---treatment of any physical              |                        |
| > complications, such as lymphedemas; and   |                        |
| >                                           |                        |
| > ---breast prostheses and surgical bras    |                        |
| > and replacements (see Prosthetic devices) |                        |
| >                                           |                        |
| > Note: If you need a mastectomy, you may   |                        |
| > choose to have this procedure performed   |                        |
| > on an inpatient basis and remain in the   |                        |
| > hospital up to 48 hours after the         |                        |
| > procedure.                                |                        |
+---------------------------------------------+------------------------+

*Reconstructive surgery -- continued on next page*

+---------------------------------------------+------------------------+
| > **Reconstructive surgery** *(continued)*  | > **You pay**          |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Cosmetic surgery -- any surgical       |                        |
|     procedure (or any portion of a          |                        |
|     procedure) performed primarily to       |                        |
|     change physical appearance through      |                        |
|     change in bodily form, except repair of |                        |
|     accidental injury*                      |                        |
|                                             |                        |
| -   *Surgeries related to sex               |                        |
|     transformation*                         |                        |
+---------------------------------------------+------------------------+
| > **Oral and maxillofacial surgery**        |                        |
+---------------------------------------------+------------------------+
| > Oral surgical procedures, limited to:     | > \$15 per office      |
|                                             | > visit for outpatient |
| -   Reduction of fractures of the jaws or   | > services             |
|     facial bones                            | >                      |
|                                             | > Nothing for          |
| -   Surgical correction of cleft lip, cleft | > inpatient services   |
|     palate, or severe functional            |                        |
|     malocclusion                            |                        |
|                                             |                        |
| -   Removal of stones from salivary ducts   |                        |
|                                             |                        |
| -   Excision of leukoplakia or malignancies |                        |
|                                             |                        |
| -   Excision of cysts and incision of       |                        |
|     abscesses when done as independent      |                        |
|     procedures                              |                        |
|                                             |                        |
| -   Other surgical procedures that do not   |                        |
|     involve the teeth or their supporting   |                        |
|     structures                              |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Oral implants and transplants*         |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Procedures that involve the teeth or   |                        |
|     their supporting structures (such as    |                        |
|     the periodontal membrane, gingiva, and  |                        |
|     alveolar bone)*                         |                        |
|                                             |                        |
| -   *Shortening of the mandible or maxillae |                        |
|     for cosmetic purposes and correction of |                        |
|     malocclusion*                           |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Organ/tissue transplants**              | > **You pay**          |
+---------------------------------------------+------------------------+
| > Limited to:                               | > \$15 per office      |
|                                             | > visit for outpatient |
| -   Allogeneic (donor) bone marrow          | > services             |
|                                             | >                      |
| -   Autologous tandem                       | > Nothing for          |
|                                             | > inpatient services   |
| -   Autologous bone marrow transplants      |                        |
|     (autologous stem cell and peripheral    |                        |
|     stem cell support) for the following    |                        |
|     conditions: acute lymphocytic or        |                        |
|     non-lymphocytic leukemia; advanced      |                        |
|     Hodgkin\'s lymphoma; advanced           |                        |
|     non-Hodgkin\'s lymphoma; advanced       |                        |
|     neuroblastoma; breast cancer; multiple  |                        |
|     myeloma; epithelial ovarian cancer; and |                        |
|     testicular, mediastinal,                |                        |
|     retroperitoneal and ovarian germ cell   |                        |
|     tumors                                  |                        |
|                                             |                        |
| -   Cornea                                  |                        |
|                                             |                        |
| -   Heart                                   |                        |
|                                             |                        |
| -   Heart/lung                              |                        |
|                                             |                        |
| -   Intestinal transplants (small           |                        |
|     intestine) and the small intestine with |                        |
|     the liver or small intestine with       |                        |
|     multiple organs such as the liver,      |                        |
|     stomach, and pancreas                   |                        |
|                                             |                        |
| -   Kidney                                  |                        |
|                                             |                        |
| -   Kidney/pancreas                         |                        |
|                                             |                        |
| -   Liver                                   |                        |
|                                             |                        |
| -   Lung: Single --Double                   |                        |
|                                             |                        |
| -   Pancreas                                |                        |
|                                             |                        |
| -   Stem cell                               |                        |
|                                             |                        |
| > Limited Benefits - 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        |                        |
| > Plan-designated center of excellence and  |                        |
| > if approved by the Plan's medical         |                        |
| > director in accordance with the Plan's    |                        |
| > protocols                                 |                        |
| >                                           |                        |
| > Note: We cover related medical and        |                        |
| > hospital expenses of the donor when we    |                        |
| > cover your transplant.                    |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | > *All charges*        |
|                                             |                        |
| -   *Donor screening tests and donor search |                        |
|     expenses, except those performed for    |                        |
|     the actual donor*                       |                        |
|                                             |                        |
| -   *Implants of non-human or artificial    |                        |
|     organs*                                 |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Transplants not listed as covered*     |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| > **Anesthesia**                            | **You pay**            |
+---------------------------------------------+------------------------+
| > Professional services provided in:        | Nothing                |
|                                             |                        |
| -   Hospital (inpatient)                    |                        |
|                                             |                        |
| -   Hospital outpatient department          |                        |
|                                             |                        |
| -   Ambulatory surgical center              |                        |
|                                             |                        |
| -   Office                                  |                        |
+---------------------------------------------+------------------------+

+----+---+-----------------------------------+--------------+---+-----+---+
| >  |   |                                   |              |   |     |   |
|  * |   |                                   |              |   |     |   |
| *S |   |                                   |              |   |     |   |
| ec |   |                                   |              |   |     |   |
| ti |   |                                   |              |   |     |   |
| on |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  5 |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
| (c |   |                                   |              |   |     |   |
| ). |   |                                   |              |   |     |   |
| ** |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  [ |   |                                   |              |   |     |   |
| ]{ |   |                                   |              |   |     |   |
| #s |   |                                   |              |   |     |   |
| er |   |                                   |              |   |     |   |
| vi |   |                                   |              |   |     |   |
| ce |   |                                   |              |   |     |   |
| sp |   |                                   |              |   |     |   |
| ro |   |                                   |              |   |     |   |
| vi |   |                                   |              |   |     |   |
| de |   |                                   |              |   |     |   |
| db |   |                                   |              |   |     |   |
| ya |   |                                   |              |   |     |   |
| ho |   |                                   |              |   |     |   |
| sp |   |                                   |              |   |     |   |
| it |   |                                   |              |   |     |   |
| al |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
| .a |   |                                   |              |   |     |   |
| nc |   |                                   |              |   |     |   |
| ho |   |                                   |              |   |     |   |
| r} |   |                                   |              |   |     |   |
| ** |   |                                   |              |   |     |   |
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| rv |   |                                   |              |   |     |   |
| ic |   |                                   |              |   |     |   |
| es |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
| pr |   |                                   |              |   |     |   |
| ov |   |                                   |              |   |     |   |
| id |   |                                   |              |   |     |   |
| ed |   |                                   |              |   |     |   |
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| by |   |                                   |              |   |     |   |
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| >  |   |                                   |              |   |     |   |
|  o |   |                                   |              |   |     |   |
| th |   |                                   |              |   |     |   |
| er |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  f |   |                                   |              |   |     |   |
| ac |   |                                   |              |   |     |   |
| il |   |                                   |              |   |     |   |
| it |   |                                   |              |   |     |   |
| y, |   |                                   |              |   |     |   |
| ** |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  * |   |                                   |              |   |     |   |
| *a |   |                                   |              |   |     |   |
| nd |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  a |   |                                   |              |   |     |   |
| mb |   |                                   |              |   |     |   |
| ul |   |                                   |              |   |     |   |
| an |   |                                   |              |   |     |   |
| ce |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
| se |   |                                   |              |   |     |   |
| rv |   |                                   |              |   |     |   |
| ic |   |                                   |              |   |     |   |
| es |   |                                   |              |   |     |   |
| ** |   |                                   |              |   |     |   |
+----+---+-----------------------------------+--------------+---+-----+---+
|    | * | > **Here are some important       |              | * |     |   |
|    | * | > things to remember about these  |              | * |     |   |
|    | I | > benefits:**                     |              | I |     |   |
|    | * |                                   |              | * |     |   |
|    | * | -   Please remember that all      |              | * |     |   |
|    |   |     benefits are subject to the   |              |   |     |   |
|    | * |     definitions, limitations, and |              | * |     |   |
|    | * |     exclusions in this brochure   |              | * |     |   |
|    | M |     and we cover them only when   |              | M |     |   |
|    | * |     we determine they are         |              | * |     |   |
|    | * |     medically necessary.          |              | * |     |   |
|    |   |                                   |              |   |     |   |
|    | * | -   Plan physicians must provide  |              | * |     |   |
|    | * |     or arrange your care and you  |              | * |     |   |
|    | P |     must be hospitalized in a     |              | P |     |   |
|    | * |     Plan facility.                |              | * |     |   |
|    | * |                                   |              | * |     |   |
|    |   | -   We do not have a calendar     |              |   |     |   |
|    | * |     year deductible.              |              | * |     |   |
|    | * |                                   |              | * |     |   |
|    | O | -   Be sure to read Section 4,    |              | O |     |   |
|    | * |     *Your costs for covered       |              | * |     |   |
|    | * |     services,* for valuable       |              | * |     |   |
|    |   |     information about how cost    |              |   |     |   |
|    | * |     sharing works. Also read      |              | * |     |   |
|    | * |     Section 9 about coordinating  |              | * |     |   |
|    | R |     benefits with other coverage, |              | R |     |   |
|    | * |     including with Medicare.      |              | * |     |   |
|    | * |                                   |              | * |     |   |
|    |   | -   The amounts listed below are  |              |   |     |   |
|    | * |     for the charges billed by the |              | * |     |   |
|    | * |     facility (i.e., hospital or   |              | * |     |   |
|    | T |     surgical center) or ambulance |              | T |     |   |
|    | * |     service for your surgery or   |              | * |     |   |
|    | * |     care. Any costs associated    |              | * |     |   |
|    |   |     with the professional charge  |              |   |     |   |
|    | * |     (i.e., physicians, etc.) are  |              | * |     |   |
|    | * |     covered in Sections 5(a) or   |              | * |     |   |
|    | A |     (b).                          |              | A |     |   |
|    | * |                                   |              | * |     |   |
|    | * | -   **YouR PHYSICIAN must get     |              | * |     |   |
|    |   |     PREAUTHORIZATION for ALL      |              |   |     |   |
|    | * |     NON-EMERGENCY INPATIENT       |              | * |     |   |
|    | * |     HOSPITAL CARE SERVICES        |              | * |     |   |
|    | N |     (except for Maternity         |              | N |     |   |
|    | * |     stays).** please refer to the |              | * |     |   |
|    | * |     preauthorization shown in     |              | * |     |   |
|    |   |     Section 3 to see which        |              |   |     |   |
|    | * |     services require              |              | * |     |   |
|    | * |     preauthorization.             |              | * |     |   |
|    | T |                                   |              | T |     |   |
|    | * |                                   |              | * |     |   |
|    | * |                                   |              | * |     |   |
+----+---+-----------------------------------+--------------+---+-----+---+
| >  |   |                                   | **You pay**  |   |     |   |
|  * |   |                                   |              |   |     |   |
| *B |   |                                   |              |   |     |   |
| en |   |                                   |              |   |     |   |
| ef |   |                                   |              |   |     |   |
| it |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  D |   |                                   |              |   |     |   |
| es |   |                                   |              |   |     |   |
| cr |   |                                   |              |   |     |   |
| ip |   |                                   |              |   |     |   |
| ti |   |                                   |              |   |     |   |
| on |   |                                   |              |   |     |   |
| ** |   |                                   |              |   |     |   |
+----+---+-----------------------------------+--------------+---+-----+---+
| #  |   |                                   | ########     |   |     |   |
| ## |   |                                   |              |   |     |   |
| ## |   |                                   |              |   |     |   |
| ## |   |                                   |              |   |     |   |
| #  |   |                                   |              |   |     |   |
| In |   |                                   |              |   |     |   |
| pa |   |                                   |              |   |     |   |
| ti |   |                                   |              |   |     |   |
| en |   |                                   |              |   |     |   |
| t  |   |                                   |              |   |     |   |
| ho |   |                                   |              |   |     |   |
| sp |   |                                   |              |   |     |   |
| it |   |                                   |              |   |     |   |
| al |   |                                   |              |   |     |   |
+----+---+-----------------------------------+--------------+---+-----+---+
| >  |   |                                   | > \$250 per  |   |     |   |
| Ro |   |                                   | > admission  |   |     |   |
| om |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  a |   |                                   |              |   |     |   |
| nd |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
| bo |   |                                   |              |   |     |   |
| ar |   |                                   |              |   |     |   |
| d, |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
| su |   |                                   |              |   |     |   |
| ch |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  a |   |                                   |              |   |     |   |
| s: |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
| -  |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
|  W |   |                                   |              |   |     |   |
| ar |   |                                   |              |   |     |   |
| d, |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
| se |   |                                   |              |   |     |   |
| mi |   |                                   |              |   |     |   |
| pr |   |                                   |              |   |     |   |
| iv |   |                                   |              |   |     |   |
| at |   |                                   |              |   |     |   |
| e, |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
| or |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
|  i |   |                                   |              |   |     |   |
| nt |   |                                   |              |   |     |   |
| en |   |                                   |              |   |     |   |
| si |   |                                   |              |   |     |   |
| ve |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
| ca |   |                                   |              |   |     |   |
| re |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
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| co |   |                                   |              |   |     |   |
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| od |   |                                   |              |   |     |   |
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| ns |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
| -  |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
|  G |   |                                   |              |   |     |   |
| en |   |                                   |              |   |     |   |
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| al |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
|    |   |                                   |              |   |     |   |
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| ur |   |                                   |              |   |     |   |
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|    |   |                                   |              |   |     |   |
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|    |   |                                   |              |   |     |   |
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|    |   |                                   |              |   |     |   |
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| ca |   |                                   |              |   |     |   |
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| ed |   |                                   |              |   |     |   |
| ic |   |                                   |              |   |     |   |
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| ce |   |                                   |              |   |     |   |
| ss |   |                                   |              |   |     |   |
| ar |   |                                   |              |   |     |   |
| y, |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  y |   |                                   |              |   |     |   |
| ou |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  p |   |                                   |              |   |     |   |
| ay |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  t |   |                                   |              |   |     |   |
| he |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
| ad |   |                                   |              |   |     |   |
| di |   |                                   |              |   |     |   |
| ti |   |                                   |              |   |     |   |
| on |   |                                   |              |   |     |   |
| al |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
| ch |   |                                   |              |   |     |   |
| ar |   |                                   |              |   |     |   |
| ge |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  a |   |                                   |              |   |     |   |
| bo |   |                                   |              |   |     |   |
| ve |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  t |   |                                   |              |   |     |   |
| he |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  s |   |                                   |              |   |     |   |
| em |   |                                   |              |   |     |   |
| ip |   |                                   |              |   |     |   |
| ri |   |                                   |              |   |     |   |
| va |   |                                   |              |   |     |   |
| te |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
| ro |   |                                   |              |   |     |   |
| om |   |                                   |              |   |     |   |
| >  |   |                                   |              |   |     |   |
|  r |   |                                   |              |   |     |   |
| at |   |                                   |              |   |     |   |
| e. |   |                                   |              |   |     |   |
+----+---+-----------------------------------+--------------+---+-----+---+

*Inpatient hospital -- continued on next page*

+--------------------------------------------+-------------------------+
| #### **Inpatient hospital** *(continued)*  | **You pay**             |
+--------------------------------------------+-------------------------+
| #### Othe                                  | > \$250 per admission   |
| r hospital services and supplies, such as: |                         |
|                                            |                         |
| -   Operating, recovery, maternity, and    |                         |
|     other treatment rooms                  |                         |
|                                            |                         |
| -   Prescribed drugs and medicines         |                         |
|                                            |                         |
| -   Diagnostic laboratory tests and X-rays |                         |
|                                            |                         |
| -   Administration of blood and blood      |                         |
|     products                               |                         |
|                                            |                         |
| -   Blood or blood plasma. The collection  |                         |
|     and storage of autologous blood for    |                         |
|     elective surgery is covered when       |                         |
|     authorized by a Plan physician         |                         |
|                                            |                         |
| -   Dressings, splints, casts, and sterile |                         |
|     tray services                          |                         |
|                                            |                         |
| -   Medical supplies and equipment,        |                         |
|     including oxygen                       |                         |
|                                            |                         |
| -   Anesthetics, including nurse           |                         |
|     anesthetist services                   |                         |
|                                            |                         |
| -   Take-home items                        |                         |
|                                            |                         |
| -   Medical supplies, appliances, medical  |                         |
|     equipment, and any covered items       |                         |
|     billed by a hospital for use at home   |                         |
|                                            |                         |
| > Note: You may receive covered hospital   |                         |
| > services for certain dental procedures   |                         |
| > if a Plan physician determines you need  |                         |
| > to be hospitalized for reasons unrelated |                         |
| > to the dental procedure. The conditions  |                         |
| > for which we will provide                |                         |
| > hospitalization include hemophilia and   |                         |
| > heart disease. The need for anesthesia,  |                         |
| > by itself, is not such a condition.      |                         |
+--------------------------------------------+-------------------------+
| #### *Not covered:*                        | > *All charges*         |
|                                            |                         |
| -   *Personal comfort items, such as       |                         |
|     telephone, television, barber          |                         |
|     services, guest meals, and beds*       |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   *Private nursing care*                 |                         |
|                                            |                         |
| -   *Any inpatient dental procedures,      |                         |
|     except as shown above and in Section   |                         |
|     5(h) under dental benefits*            |                         |
|                                            |                         |
| -   *Cord blood procurement and storage    |                         |
|     for possible future need or for a      |                         |
|     yet-to-be determined member recipient* |                         |
+--------------------------------------------+-------------------------+
| ######### Outpati                          | #### **You pay**        |
| ent hospital or ambulatory surgical center |                         |
+--------------------------------------------+-------------------------+
| -   Operating, recovery, and other         | \$50 per surgery        |
|     treatment rooms                        |                         |
|                                            |                         |
| -   Prescribed drugs and medicines         |                         |
|                                            |                         |
| -   Diagnostic laboratory tests, X-rays,   |                         |
|     and pathology services                 |                         |
|                                            |                         |
| -   Administration of blood, blood plasma, |                         |
|     and other biologicals                  |                         |
|                                            |                         |
| -   Blood and blood plasma                 |                         |
|                                            |                         |
| -   Pre-surgical testing                   |                         |
|                                            |                         |
| -   Dressings, casts, and sterile tray     |                         |
|     services                               |                         |
|                                            |                         |
| -   Medical supplies, including oxygen     |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Anesthetics and anesthesia service     |                         |
+--------------------------------------------+-------------------------+
| ######## *Not covered:*                    | ######## *All charges*  |
|                                            |                         |
| -   *Cord blood procurement and storage    |                         |
|     for possible future need or for a      |                         |
|     yet-to-be determined member recipient* |                         |
+--------------------------------------------+-------------------------+
| ######## Skilled nursing care benefits     | ########                |
+--------------------------------------------+-------------------------+
| > Up to 100 days per calendar year when    | > Nothing               |
| > full-time skilled nursing care is        |                         |
| > necessary and confinement in a skilled   |                         |
| > nursing facility is medically            |                         |
| > appropriate. We cover the following:     |                         |
|                                            |                         |
| -   Physician and nursing services         |                         |
|                                            |                         |
| -   Room and board                         |                         |
|                                            |                         |
| -   Medical social services                |                         |
|                                            |                         |
| -   Blood, blood products, and their       |                         |
|     administration                         |                         |
|                                            |                         |
| -   Durable medical equipment ordinarily   |                         |
|     furnished by a skilled nursing         |                         |
|     facility, including oxygen-dispensing  |                         |
|     equipment and oxygen                   |                         |
|                                            |                         |
| -   Respiratory therapy                    |                         |
|                                            |                         |
| -   Biological supplies                    |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Medical supplies                       |                         |
+--------------------------------------------+-------------------------+
| > *Not covered:*                           | *All charges*           |
|                                            |                         |
| -   *Custodial care in an intermediate     |                         |
|     care facility*                         |                         |
|                                            |                         |
| -   *Custodial care*                       |                         |
+--------------------------------------------+-------------------------+
| #### **Hospice care**                      | ######## You pay        |
+--------------------------------------------+-------------------------+
| > Supportive and palliative care for a     | Nothing                 |
| > terminally ill member:                   |                         |
|                                            |                         |
| -   You must reside in the service area    |                         |
|                                            |                         |
| -   Services are provided in the home      |                         |
|                                            |                         |
| -   Services are provided in a Plan        |                         |
|     approved hospice facility              |                         |
|                                            |                         |
| > Services include inpatient care,         |                         |
| > outpatient care, and family counseling.  |                         |
| > A Plan physician must certify that you   |                         |
| > have a terminal illness, with a life     |                         |
| > expectancy of approximately six months   |                         |
| > or less.                                 |                         |
| >                                          |                         |
| > Note: Hospice is a program for caring    |                         |
| > for the terminally ill that emphasizes   |                         |
| > supportive services, such as home care   |                         |
| > and pain control, rather than curative   |                         |
| > care of the terminal illness. A person   |                         |
| > who is terminally ill may elect to       |                         |
| > receive hospice benefits. These          |                         |
| > palliative and supportive services       |                         |
| > include nursing care, medical social     |                         |
| > services, physician services, and        |                         |
| > short-term inpatient care for pain       |                         |
| > control and acute and chronic symptom    |                         |
| > management. We also provide counseling   |                         |
| > and bereavement services for the         |                         |
| > individual and family members, and       |                         |
| > therapy for purposes of symptom control  |                         |
| > to enable the person to continue life    |                         |
| > with as little disruption as possible.   |                         |
| > If you make a hospice election, you are  |                         |
| > not entitled to receive other health     |                         |
| > care services that are related to the    |                         |
| > terminal illness. If you have made a     |                         |
| > hospice election, you may revoke that    |                         |
| > election at any time, and your standard  |                         |
| > health benefits will be covered.         |                         |
+--------------------------------------------+-------------------------+
| > *Not covered:*                           | > *All charges*         |
|                                            |                         |
| -   *Private duty nursing (independent     |                         |
|     nursing)*                              |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   *Homemaker services*                   |                         |
+--------------------------------------------+-------------------------+
| ######## Ambulance                         | ########                |
+--------------------------------------------+-------------------------+
| -   Local professional ambulance service   | > \$75 per trip         |
|     when ordered or authorized by a Plan   |                         |
|     physician                              |                         |
+--------------------------------------------+-------------------------+
| > *Not covered:*                           | > *All charges*         |
|                                            |                         |
| -   *Transports that we determine are not  |                         |
|     medically necessary*                   |                         |
+--------------------------------------------+-------------------------+

+---+---+-------------------------------------+-----------+---+---+---+---+
| # |   |                                     |           |   |   |   |   |
| # |   |                                     |           |   |   |   |   |
| # |   |                                     |           |   |   |   |   |
| # |   |                                     |           |   |   |   |   |
| # |   |                                     |           |   |   |   |   |
|   |   |                                     |           |   |   |   |   |
| S |   |                                     |           |   |   |   |   |
| e |   |                                     |           |   |   |   |   |
| c |   |                                     |           |   |   |   |   |
| t |   |                                     |           |   |   |   |   |
| i |   |                                     |           |   |   |   |   |
| o |   |                                     |           |   |   |   |   |
| n |   |                                     |           |   |   |   |   |
|   |   |                                     |           |   |   |   |   |
| 5 |   |                                     |           |   |   |   |   |
|   |   |                                     |           |   |   |   |   |
| ( |   |                                     |           |   |   |   |   |
| d |   |                                     |           |   |   |   |   |
| ) |   |                                     |           |   |   |   |   |
| . |   |                                     |           |   |   |   |   |
|   |   |                                     |           |   |   |   |   |
| E |   |                                     |           |   |   |   |   |
| m |   |                                     |           |   |   |   |   |
| e |   |                                     |           |   |   |   |   |
| r |   |                                     |           |   |   |   |   |
| g |   |                                     |           |   |   |   |   |
| e |   |                                     |           |   |   |   |   |
| n |   |                                     |           |   |   |   |   |
| c |   |                                     |           |   |   |   |   |
| y |   |                                     |           |   |   |   |   |
|   |   |                                     |           |   |   |   |   |
| s |   |                                     |           |   |   |   |   |
| e |   |                                     |           |   |   |   |   |
| r |   |                                     |           |   |   |   |   |
| v |   |                                     |           |   |   |   |   |
| i |   |                                     |           |   |   |   |   |
| c |   |                                     |           |   |   |   |   |
| e |   |                                     |           |   |   |   |   |
| s |   |                                     |           |   |   |   |   |
| / |   |                                     |           |   |   |   |   |
| a |   |                                     |           |   |   |   |   |
| c |   |                                     |           |   |   |   |   |
| c |   |                                     |           |   |   |   |   |
| i |   |                                     |           |   |   |   |   |
| d |   |                                     |           |   |   |   |   |
| e |   |                                     |           |   |   |   |   |
| n |   |                                     |           |   |   |   |   |
| t |   |                                     |           |   |   |   |   |
| s |   |                                     |           |   |   |   |   |
+---+---+-------------------------------------+-----------+---+---+---+---+
|   | * | > Here are some important things to |           | * | # |   |   |
|   | * | > keep in mind about these          |           | * | # |   |   |
|   | I | > benefits:                         |           | I | # |   |   |
|   | * |                                     |           | * | # |   |   |
|   | * | -   Please remember that all        |           | * | # |   |   |
|   |   |     benefits are subject to the     |           |   |   |   |   |
|   | * |     definitions, limitations, and   |           | * |   |   |   |
|   | * |     exclusions in this brochure and |           | * |   |   |   |
|   | M |     we cover them only when we      |           | M |   |   |   |
|   | * |     determine they are medically    |           | * |   |   |   |
|   | * |     necessary.                      |           | * |   |   |   |
|   |   |                                     |           |   |   |   |   |
|   | * | -   We do not have a calendar year  |           | * |   |   |   |
|   | * |     deductible.                     |           | * |   |   |   |
|   | P |                                     |           | P |   |   |   |
|   | * | ```{=html}                          |           | * |   |   |   |
|   | * | <!-- -->                            |           | * |   |   |   |
|   |   | ```                                 |           |   |   |   |   |
|   | * | -   Be sure to read Section 4,      |           | * |   |   |   |
|   | * |     *Your costs for covered         |           | * |   |   |   |
|   | O |     services,* for valuable         |           | O |   |   |   |
|   | * |     information about how cost      |           | * |   |   |   |
|   | * |     sharing works. Also read        |           | * |   |   |   |
|   |   |     Section 9 about coordinating    |           |   |   |   |   |
|   | * |     benefits with other coverage,   |           | * |   |   |   |
|   | * |     including with Medicare.        |           | * |   |   |   |
|   | R |                                     |           | R |   |   |   |
|   | * | #####                               |           | * |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   |   |                                     |           |   |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | T |                                     |           | T |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   |   |                                     |           |   |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | A |                                     |           | A |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   |   |                                     |           |   |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | N |                                     |           | N |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   |   |                                     |           |   |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | T |                                     |           | T |   |   |   |
|   | * |                                     |           | * |   |   |   |
|   | * |                                     |           | * |   |   |   |
+---+---+-------------------------------------+-----------+---+---+---+---+
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| n |   |                                      |              |   |   |   |
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| f |   |                                      |              |   |   |   |
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| t |   |                                      |              |   |   |   |
| s |   |                                      |              |   |   |   |
| * |   |                                      |              |   |   |   |
| * |   |                                      |              |   |   |   |
+---+---+--------------------------------------+--------------+---+---+---+
|   | * | > **Here are some important things   |              | * | # |   |
|   | * | > to keep in mind about these        |              | * | # |   |
|   | I | > benefits:**                        |              | I | # |   |
|   | * |                                      |              | * | # |   |
|   | * | -   Please remember that all         |              | * | # |   |
|   |   |     benefits are subject to the      |              |   |   |   |
|   | * |     definitions, limitations, and    |              | * |   |   |
|   | * |     exclusions in this brochure and  |              | * |   |   |
|   | M |     we cover them only when we       |              | M |   |   |
|   | * |     determine they are clinically    |              | * |   |   |
|   | * |     appropriate to treat your        |              | * |   |   |
|   |   |     condition.                       |              |   |   |   |
|   | * |                                      |              | * |   |   |
|   | * | ```{=html}                           |              | * |   |   |
|   | P | <!-- -->                             |              | P |   |   |
|   | * | ```                                  |              | * |   |   |
|   | * | -   Plan physicians must provide or  |              | * |   |   |
|   |   |     arrange your care.               |              |   |   |   |
|   | * |                                      |              | * |   |   |
|   | * | ```{=html}                           |              | * |   |   |
|   | O | <!-- -->                             |              | O |   |   |
|   | * | ```                                  |              | * |   |   |
|   | * | -   We have no calendar year         |              | * |   |   |
|   |   |     deductible.                      |              |   |   |   |
|   | * |                                      |              | * |   |   |
|   | * | ##### Be sure to read Section 4, *Yo |              | * |   |   |
|   | R | ur costs for covered services,* for  |              | R |   |   |
|   | * | valuable information about how cost  |              | * |   |   |
|   | * | sharing works. Also read Section 9 a |              | * |   |   |
|   |   | bout coordinating benefits with othe |              |   |   |   |
|   | * | r coverage, including with Medicare. |              | * |   |   |
|   | * |                                      |              | * |   |   |
|   | T |                                      |              | T |   |   |
|   | * |                                      |              | * |   |   |
|   | * |                                      |              | * |   |   |
|   |   |                                      |              |   |   |   |
|   | * |                                      |              | * |   |   |
|   | * |                                      |              | * |   |   |
|   | A |                                      |              | A |   |   |
|   | * |                                      |              | * |   |   |
|   | * |                                      |              | * |   |   |
|   |   |                                      |              |   |   |   |
|   | * |                                      |              | * |   |   |
|   | * |                                      |              | * |   |   |
|   | N |                                      |              | N |   |   |
|   | * |                                      |              | * |   |   |
|   | * |                                      |              | * |   |   |
|   |   |                                      |              |   |   |   |
|   | * |                                      |              | * |   |   |
|   | * |                                      |              | * |   |   |
|   | T |                                      |              | T |   |   |
|   | * |                                      |              | * |   |   |
|   | * |                                      |              | * |   |   |
+---+---+--------------------------------------+--------------+---+---+---+
| * |   |                                      | **You pay**  |   |   |   |
| * |   |                                      |              |   |   |   |
| B |   |                                      |              |   |   |   |
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| * |   |                                      |              |   |   |   |
+---+---+--------------------------------------+--------------+---+---+---+
| # |   |                                      | ###          |   |   |   |
| # |   |                                      |              |   |   |   |
| # |   |                                      |              |   |   |   |
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+---+---+--------------------------------------+--------------+---+---+---+
| > |   |                                      | ### Your     |   |   |   |
|   |   |                                      | cost sharing |   |   |   |
| W |   |                                      |  responsibil |   |   |   |
| e |   |                                      | ities are no |   |   |   |
| > |   |                                      |  greater tha |   |   |   |
|   |   |                                      | n for other  |   |   |   |
| c |   |                                      | illnesses or |   |   |   |
| o |   |                                      |  conditions. |   |   |   |
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|   |   |                                      |              |   |   |   |
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| f |   |                                      |              |   |   |   |
|   |   |                                      |              |   |   |   |
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| r |   |                                      |              |   |   |   |
| . |   |                                      |              |   |   |   |
+---+---+--------------------------------------+--------------+---+---+---+

*Mental health and substance abuse benefits -- continued on next page*

+--------------------------------------------+-------------------------+
| **Mental health and substance abuse        | > **You pay**           |
| benefits** *(continued)*                   |                         |
+--------------------------------------------+-------------------------+
| > Diagnosis and treatment of psychiatric,  | > \$15 per office visit |
| > mental illness, or disorders of          | > for individual        |
| > children, adolescents, and adults.       | > therapy               |
| > Services include:                        | >                       |
|                                            | > \$7 per office visit  |
| -   Diagnostic evaluation                  | > for group therapy     |
|                                            |                         |
| -   Crisis intervention and stabilization  |                         |
|     for acute episodes                     |                         |
|                                            |                         |
| -   Psychological testing to determine the |                         |
|     appropriate psychiatric treatment      |                         |
|                                            |                         |
| -   Outpatient psychiatric treatment       |                         |
|     (including individual and group        |                         |
|     therapy visits)                        |                         |
|                                            |                         |
| -   Medication evaluation and management   |                         |
|                                            |                         |
| Diagnosis and treatment of alcoholism and  |                         |
| drug abuse. Services include:              |                         |
|                                            |                         |
| -   Detoxification (medical management of  |                         |
|     withdrawal from the substance)         |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Treatment and counseling (including    |                         |
|     individual and group therapy visits)   |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Rehabilitative care                    |                         |
|                                            |                         |
| > Notes:                                   |                         |
|                                            |                         |
| -   You may see an outpatient mental       |                         |
|     health or substance abuse provider     |                         |
|     without a referral from your primary   |                         |
|     care physician. See Section 3*, How    |                         |
|     you get care* for information about    |                         |
|     services requiring our prior approval. |                         |
|                                            |                         |
| ```{=html}                                 |                         |
| <!-- -->                                   |                         |
| ```                                        |                         |
| -   Your mental health or substance abuse  |                         |
|     provider will develop a treatment plan |                         |
|     to assist you in improving or          |                         |
|     maintaining your condition and         |                         |
|     functional level, or to prevent        |                         |
|     relapse and will determine which       |                         |
|     diagnostic and treatment services are  |                         |
|     appropriate for you.                   |                         |
+--------------------------------------------+-------------------------+

*Mental health and substance abuse benefits -- continued on next page*

+--------------------------------------------+---+-------------------------+
| ### **Mental health an                     |   | > **You pay**           |
| d substance abuse benefits** *(continued)* |   |                         |
+--------------------------------------------+---+-------------------------+
| -   Inpatient mental health and substance  | # |                         |
|     abuse care                             | # |                         |
|                                            | # |                         |
| -   Hospital alternative services, such as | # |                         |
|     partial hospitalization and intensive  | # |                         |
|     outpatient psychiatric treatment       | # |                         |
|     programs                               | # |                         |
|                                            |   |                         |
| ## Note: All inpatient admissions and ho   | \ |                         |
| spital alternative services treatment prog | $ |                         |
| rams require approval by a Plan physician. | 2 |                         |
|                                            | 5 |                         |
|                                            | 0 |                         |
|                                            |   |                         |
|                                            | p |                         |
|                                            | e |                         |
|                                            | r |                         |
|                                            |   |                         |
|                                            | a |                         |
|                                            | d |                         |
|                                            | m |                         |
|                                            | i |                         |
|                                            | s |                         |
|                                            | s |                         |
|                                            | i |                         |
|                                            | o |                         |
|                                            | n |                         |
+--------------------------------------------+---+-------------------------+
| ## Not covered:                            | > |                         |
|                                            |   |                         |
| -   *Care that is not clinically           | * |                         |
|     appropriate for the treatment of your  | A |                         |
|     condition*                             | l |                         |
|                                            | l |                         |
| -   *Services we have not approved*        | > |                         |
|                                            |   |                         |
| -   *Intelligence, IQ, aptitude ability,   | c |                         |
|     learning disorders, or interest        | h |                         |
|     testing not necessary to determine the | a |                         |
|     appropriate treatment of a psychiatric | r |                         |
|     condition*                             | g |                         |
|                                            | e |                         |
| -   *Evaluation or therapy on court order  | s |                         |
|     or as a condition of parole or         | * |                         |
|     probation, or otherwise required by    |   |                         |
|     the criminal justice system, unless    |   |                         |
|     determined by a Plan physician to be   |   |                         |
|     medically necessary and appropriate*   |   |                         |
|                                            |   |                         |
| -   *Services that are custodial in        |   |                         |
|     nature*                                |   |                         |
|                                            |   |                         |
| -   *Services rendered or billed by a      |   |                         |
|     school or a member of its staff*       |   |                         |
|                                            |   |                         |
| ```{=html}                                 |   |                         |
| <!-- -->                                   |   |                         |
| ```                                        |   |                         |
| -   *Services provided under a federal,    |   |                         |
|     state, or local government program*    |   |                         |
|                                            |   |                         |
| ```{=html}                                 |   |                         |
| <!-- -->                                   |   |                         |
| ```                                        |   |                         |
| -   *Psychoanalysis or psychotherapy       |   |                         |
|     credited toward earning a degree or    |   |                         |
|     furtherance of education or training   |   |                         |
|     regardless of diagnosis or symptoms*   |   |                         |
+--------------------------------------------+---+-------------------------+

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

+----+---+---+-------------------------------------------------+---+-------+
| *  |   |   |                                                 |   |       |
| *S |   |   |                                                 |   |       |
| ec |   |   |                                                 |   |       |
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| ts |   |   |                                                 |   |       |
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| r} |   |   |                                                 |   |       |
| ** |   |   |                                                 |   |       |
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| es |   |   |                                                 |   |       |
| cr |   |   |                                                 |   |       |
| ip |   |   |                                                 |   |       |
| ti |   |   |                                                 |   |       |
| on |   |   |                                                 |   |       |
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| ** |   |   |                                                 |   |       |
+----+---+---+-------------------------------------------------+---+-------+
|    |   | * | > **Here are some important things to keep in   | * |       |
|    |   | * | > mind about these benefits:**                  | * |       |
|    |   | I |                                                 | I |       |
|    |   | * | -   We cover prescribed drugs and medications,  | * |       |
|    |   | * |     as described in the chart beginning on the  | * |       |
|    |   |   |     next page.                                  |   |       |
|    |   | * |                                                 | * |       |
|    |   | * | -   Please remember that all benefits are       | * |       |
|    |   | M |     subject to the definitions, limitations,    | M |       |
|    |   | * |     and exclusions in this brochure and we      | * |       |
|    |   | * |     cover them only when we determine they are  | * |       |
|    |   |   |     medically necessary.                        |   |       |
|    |   | * |                                                 | * |       |
|    |   | * | -   We have no calendar year deductible.        | * |       |
|    |   | P |                                                 | P |       |
|    |   | * | -   Your physician must get preauthorization    | * |       |
|    |   | * |     for certain drugs. Certain prescription     | * |       |
|    |   |   |     drugs require approval prior to dispensing. |   |       |
|    |   | * |     The list of prescription drugs that require | * |       |
|    |   | * |     preauthorization is subject to periodic     | * |       |
|    |   | O |     review and modification. If you would like  | O |       |
|    |   | * |     to know if a drug requires preauthorization | * |       |
|    |   | * |     you may contact our Member Services         | * |       |
|    |   |   |     Department at 404/261-2590.                 |   |       |
|    |   | * |                                                 | * |       |
|    |   | * | ```{=html}                                      | * |       |
|    |   | R | <!-- -->                                        | R |       |
|    |   | * | ```                                             | * |       |
|    |   | * | -   Be sure to read Section 4, *Your costs for  | * |       |
|    |   |   |     covered services,* for valuable information |   |       |
|    |   | * |     about how cost sharing works. Also read     | * |       |
|    |   | * |     Section 9 about coordinating benefits with  | * |       |
|    |   | T |     other coverage, including with Medicare.    | T |       |
|    |   | * |                                                 | * |       |
|    |   | * |                                                 | * |       |
|    |   |   |                                                 |   |       |
|    |   | * |                                                 | * |       |
|    |   | * |                                                 | * |       |
|    |   | A |                                                 | A |       |
|    |   | * |                                                 | * |       |
|    |   | * |                                                 | * |       |
|    |   |   |                                                 |   |       |
|    |   | * |                                                 | * |       |
|    |   | * |                                                 | * |       |
|    |   | N |                                                 | N |       |
|    |   | * |                                                 | * |       |
|    |   | * |                                                 | * |       |
|    |   |   |                                                 |   |       |
|    |   | * |                                                 | * |       |
|    |   | * |                                                 | * |       |
|    |   | T |                                                 | T |       |
|    |   | * |                                                 | * |       |
|    |   | * |                                                 | * |       |
+----+---+---+-------------------------------------------------+---+-------+
| >  |   |   |                                                 |   |       |
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| pa |   |   |                                                 |   |       |
| rt |   |   |                                                 |   |       |
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|  4 |   |   |                                                 |   |       |
| 04 |   |   |                                                 |   |       |
| /2 |   |   |                                                 |   |       |
| 61 |   |   |                                                 |   |       |
| -2 |   |   |                                                 |   |       |
| 59 |   |   |                                                 |   |       |
| 0. |   |   |                                                 |   |       |
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| >  |   |   |                                                 |   |       |
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| >  |   |   |                                                 |   |       |
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| >  |   |   |                                                 |   |       |
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| nd |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
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| >  |   |   |                                                 |   |       |
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| me |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
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| di |   |   |                                                 |   |       |
| ci |   |   |                                                 |   |       |
| ne |   |   |                                                 |   |       |
| s, |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| su |   |   |                                                 |   |       |
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| >  |   |   |                                                 |   |       |
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| >  |   |   |                                                 |   |       |
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| ho |   |   |                                                 |   |       |
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| eq |   |   |                                                 |   |       |
| ui |   |   |                                                 |   |       |
| ri |   |   |                                                 |   |       |
| ng |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
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| al |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
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| dl |   |   |                                                 |   |       |
| in |   |   |                                                 |   |       |
| g, |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
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| ru |   |   |                                                 |   |       |
| gs |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
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| mi |   |   |                                                 |   |       |
| ni |   |   |                                                 |   |       |
| st |   |   |                                                 |   |       |
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| >  |   |   |                                                 |   |       |
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| ui |   |   |                                                 |   |       |
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| al |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
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| es |   |   |                                                 |   |       |
| si |   |   |                                                 |   |       |
| on |   |   |                                                 |   |       |
| al |   |   |                                                 |   |       |
| s, |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| hi |   |   |                                                 |   |       |
| gh |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
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| st |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| dr |   |   |                                                 |   |       |
| ug |   |   |                                                 |   |       |
| s, |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
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| gs |   |   |                                                 |   |       |
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| eq |   |   |                                                 |   |       |
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| >  |   |   |                                                 |   |       |
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| ri |   |   |                                                 |   |       |
| ge |   |   |                                                 |   |       |
| ra |   |   |                                                 |   |       |
| ti |   |   |                                                 |   |       |
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| >  |   |   |                                                 |   |       |
|  a |   |   |                                                 |   |       |
| nd |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
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| nt |   |   |                                                 |   |       |
| ro |   |   |                                                 |   |       |
| ll |   |   |                                                 |   |       |
| ed |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| me |   |   |                                                 |   |       |
| di |   |   |                                                 |   |       |
| ca |   |   |                                                 |   |       |
| ti |   |   |                                                 |   |       |
| on |   |   |                                                 |   |       |
| s, |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  a |   |   |                                                 |   |       |
| re |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  n |   |   |                                                 |   |       |
| ot |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  a |   |   |                                                 |   |       |
| va |   |   |                                                 |   |       |
| il |   |   |                                                 |   |       |
| ab |   |   |                                                 |   |       |
| le |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  t |   |   |                                                 |   |       |
| hr |   |   |                                                 |   |       |
| ou |   |   |                                                 |   |       |
| gh |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  m |   |   |                                                 |   |       |
| ai |   |   |                                                 |   |       |
| l- |   |   |                                                 |   |       |
| or |   |   |                                                 |   |       |
| de |   |   |                                                 |   |       |
| r. |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| We |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  p |   |   |                                                 |   |       |
| ay |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  a |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| hi |   |   |                                                 |   |       |
| gh |   |   |                                                 |   |       |
| er |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
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| ev |   |   |                                                 |   |       |
| el |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| of |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| be |   |   |                                                 |   |       |
| ne |   |   |                                                 |   |       |
| fi |   |   |                                                 |   |       |
| ts |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| wh |   |   |                                                 |   |       |
| en |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  y |   |   |                                                 |   |       |
| ou |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  u |   |   |                                                 |   |       |
| se |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  a |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| Pl |   |   |                                                 |   |       |
| an |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  m |   |   |                                                 |   |       |
| ed |   |   |                                                 |   |       |
| ic |   |   |                                                 |   |       |
| al |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
| of |   |   |                                                 |   |       |
| fi |   |   |                                                 |   |       |
| ce |   |   |                                                 |   |       |
| >  |   |   |                                                 |   |       |
|  p |   |   |                                                 |   |       |
| ha |   |   |                                                 |   |       |
| rm |   |   |                                                 |   |       |
| ac |   |   |                                                 |   |       |
| y. |   |   |                                                 |   |       |
+----+---+---+-------------------------------------------------+---+-------+
|    | - |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
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|    |   |   |                                                 |   |       |
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|    | a |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
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|    | f |   |                                                 |   |       |
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|    | l |   |                                                 |   |       |
|    | a |   |                                                 |   |       |
|    | r |   |                                                 |   |       |
|    | y |   |                                                 |   |       |
|    | . |   |                                                 |   |       |
|    | * |   |                                                 |   |       |
|    | * |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
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|    |   |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    | a |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    |   |   |                                                 |   |       |
|    | f |   |                                                 |   |       |
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|    | . |   |                                                 |   |       |
+----+---+---+-------------------------------------------------+---+-------+

*Prescription drug benefits begin on the next page.*

+---------------------------------------------+------------------------+
| > **Benefit Description**                   | > **You pay**          |
+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      |                        |
+---------------------------------------------+------------------------+
| > We cover the following medications and    | \$10 per prescription  |
| > supplies prescribed by a Plan physician   | or refill if obtained  |
| > and obtained from a Plan pharmacy or      | at a Plan medical      |
| > through our mail order program:           | office pharmacy        |
|                                             |                        |
| -   Drugs for which a prescription is       | \$16 per prescription  |
|     required by law                         | or refill if obtained  |
|                                             | at a Plan              |
| -   Diabetic supplies such as glucose test  | participating          |
|     strips (Chemstrip^®^), Dextrostix^®^,   | community pharmacy     |
|     sugar test tape, sugar test tablets,    |                        |
|     acetone test tablets                    |                        |
|                                             |                        |
| -   Inhalers                                |                        |
|                                             |                        |
| -   Spacer devices                          |                        |
|                                             |                        |
| -   Compounded dermatological preparation   |                        |
|     prepared by a pharmacist                |                        |
|                                             |                        |
| -   Oral contraceptive drugs                |                        |
|                                             |                        |
| -   Diaphragms                              |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Growth hormone therapy (GHT) -- for     |                        |
|     treatment of children with Turner's     |                        |
|     syndrome or classical growth hormone    |                        |
|     deficiency                              |                        |
+---------------------------------------------+------------------------+
| -   Insulin                                 | \$10 per vial or       |
|                                             | refill if obtained at  |
|                                             | a Plan medical office  |
|                                             | pharmacy               |
|                                             |                        |
|                                             | \$16 per vial or       |
|                                             | refill if obtained at  |
|                                             | a Plan participating   |
|                                             | community pharmacy     |
+---------------------------------------------+------------------------+
| -   Disposable needles and syringes for the | Nothing                |
|     administration of covered medications   |                        |
|                                             |                        |
| -   Intravenous fluids and medications for  |                        |
|     home use                                |                        |
|                                             |                        |
| -   Amino acid-modified products used to    |                        |
|     treat congenital errors of amino acid   |                        |
|     metabolism                              |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Post-surgical immunosuppressant         |                        |
|     outpatient drugs required as a result   |                        |
|     of a covered transplant                 |                        |
+---------------------------------------------+------------------------+
| -   Implanted time release drugs, including | \$10 times the number  |
|     contraceptive drugs                     | of months the drug is  |
|                                             | expected to be         |
| ```{=html}                                  | effective, not to      |
| <!-- -->                                    | exceed \$200           |
| ```                                         |                        |
| -   Injectable contraceptive drugs          |                        |
|                                             |                        |
| -   Topical contraceptives                  |                        |
|                                             |                        |
| > Note: We do not refund any portion of     |                        |
| > your copayment if you request removal of  |                        |
| > the implanted drug time-release           |                        |
| > medication before the end of its expected |                        |
| > life.                                     |                        |
+---------------------------------------------+------------------------+
| -   Intrauterine devices                    | \$50 per device        |
+---------------------------------------------+------------------------+

> *Covered medications and supplies -- continued on next page*

+---------------------------------------------+------------------------+
| > **Covered medications and supplies**      | > **You pay**          |
| > *(continued)*                             |                        |
+---------------------------------------------+------------------------+
| -   Drugs for covered infertility           | 50% of our allowance   |
|     treatments                              |                        |
|                                             |                        |
| -   Drugs for sexual dysfunction            |                        |
|                                             |                        |
| > Note: Drugs to treat sexual dysfunction   |                        |
| > have dispensing limitations. Contact us   |                        |
| > for details.                              |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Drugs and supplies for cosmetic        |                        |
|     purposes*                               |                        |
|                                             |                        |
| -   *Vitamins and nutritional supplements   |                        |
|     that can be purchased without a         |                        |
|     prescription*                           |                        |
|                                             |                        |
| -   *Nonprescription drugs*                 |                        |
|                                             |                        |
| -   *Prescription drugs for which there is  |                        |
|     a nonprescription equivalent available* |                        |
|                                             |                        |
| -   *Drugs obtained at a non-Plan pharmacy; |                        |
|     except for out-of-area emergencies*     |                        |
|                                             |                        |
| -   *Medical supplies such as dressings and |                        |
|     antiseptics*                            |                        |
|                                             |                        |
| -   *Any packaging other than the           |                        |
|     dispensing pharmacy's standard          |                        |
|     packaging*                              |                        |
|                                             |                        |
| -   *Drugs to enhance athletic performance* |                        |
|                                             |                        |
| -   *Drugs related to non-covered           |                        |
|     infertility services*                   |                        |
|                                             |                        |
| -   *Contraceptive devices, except          |                        |
|     diaphragms and intrauterine devices*    |                        |
|                                             |                        |
| -   *Smoking cessation drugs and            |                        |
|     medications, including nicotine         |                        |
|     patches*                                |                        |
|                                             |                        |
| -   *Drugs for non-covered services*        |                        |
|                                             |                        |
| -   *Packaging of prescription medications  |                        |
|     is limited to Plan standard packaging;  |                        |
|     special packaging is not covered*       |                        |
|                                             |                        |
| -   *Replacement of lost, stolen, or        |                        |
|     damaged drugs and accessories*          |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Infant formulas, except for amino      |                        |
|     acid-modified products noted above*     |                        |
|                                             |                        |
| -   *Drugs available without a prescription |                        |
|     or for which there is a nonprescription |                        |
|     equivalent available, except those      |                        |
|     listed on the Plan\'s formulary and     |                        |
|     prescribed by a Plan physician*         |                        |
|                                             |                        |
| -   *Drugs to shorten the duration of the   |                        |
|     common cold*                            |                        |
+---------------------------------------------+------------------------+

+----------------------+-----------------------------------------------+
| > Section 5 (g).     |                                               |
| >                    |                                               |
|  []{#specialfeatures |                                               |
| > .anchor}Special    |                                               |
| > features           |                                               |
+----------------------+-----------------------------------------------+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| >                    | Under the flexible benefits option, we        |
| []{#flexiblebenefits | determine the most effective way to provide   |
| > .anchor}**Flexible | services.                                     |
| > benefits option**  |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other treatments as a less     |
|                      |     costly alternative benefit                |
|                      |                                               |
|                      | -   We review alternative treatments on an    |
|                      |     ongoing basis                             |
|                      |                                               |
|                      | -   By approving an alternative treatment, we |
|                      |     cannot guarantee you will get it in the   |
|                      |     future                                    |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     treatment is solely ours, and we may      |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits                 |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative treatments is not subject to  |
|                      |     OPM review under the disputed claims      |
|                      |     process                                   |
+----------------------+-----------------------------------------------+
| > []{#hournurseline  | For any of your health concerns, 24 hours a   |
| > .anchor}**24 hour  | day, 7 days a week, you may call 404/365-0966 |
| > nurse line**       | (locally) or 800/611-1811 (long distance) and |
|                      | talk with a registered nurse who will discuss |
|                      | treatment options and answer your health      |
|                      | questions.                                    |
+----------------------+-----------------------------------------------+
| >                    | Our hearing and speech impaired TYY number    |
|  []{#servicesfordeaf | is: 800/255-0056.                             |
| > .anchor}**Services |                                               |
| > for deaf and       |                                               |
| > hearing impaired** |                                               |
+----------------------+-----------------------------------------------+
| > []{                | **Comprehensive Maternity Program.** The goal |
| #highriskpregnancies | is to significantly reduce the incident of    |
| > .anchor}**High     | pre-term deliveries and low birth weight      |
| > risk pregnancies** | babies by prompt interventions utilizing a    |
|                      | multidisciplinary team approach.              |
|                      |                                               |
|                      | All women receiving prenatal care are         |
|                      | assessed at the first provider visit (ideally |
|                      | during the first trimester) for factors       |
|                      | associated with high-risk pregnancy. Risk     |
|                      | scoring systems are based on a combination of |
|                      | past medical history (particularly            |
|                      | reproductive history), current pregnancy      |
|                      | events, personal habits during pregnancy, and |
|                      | demographic risks.                            |
|                      |                                               |
|                      | Although risk scoring can identify some       |
|                      | individuals at risk during pregnancy, no      |
|                      | scoring system is so effective that those at  |
|                      | risk may be safely ignored. Therefore,        |
|                      | ongoing assessment must be done for all       |
|                      | patients for symptoms and risk factors for    |
|                      | pre-term birth.                               |
|                      |                                               |
|                      | We are not able to implement any aspect of    |
|                      | our maternity benefits on a \"mandatory\"     |
|                      | basis. However, because copayments are waived |
|                      | for all prenatal and one postnatal visit, we  |
|                      | have a 99% compliance with the recommended    |
|                      | course of treatment.                          |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| > []{                | The Centers of Excellence program began in    |
| #centersofexcellence | Fall 1987. As new technologies proliferate    |
| > .anchor}**Centers  | and become the standard of care, Kaiser       |
| > of excellence**    | Permanente refers members to contracted       |
|                      | \"centers of excellence\" for certain         |
|                      | specialized medical procedures.               |
|                      |                                               |
|                      | We have developed a network of Centers of     |
|                      | Excellence for organ transplantation, which   |
|                      | consists of medical facilities that have met  |
|                      | stringent criteria for quality care in        |
|                      | specific procedures. A national clinical and  |
|                      | administrative team has developed guidelines  |
|                      | for site selection, site visit protocol,      |
|                      | volume and survival criteria for evaluation,  |
|                      | and selection of facilities. The institutions |
|                      | have a record of positive outcomes and        |
|                      | exceptional standards of quality.             |
+----------------------+-----------------------------------------------+
| > []{#travelbenefit  | Kaiser Permanente's travel benefits for       |
| > .anchor}**Travel   | Federal employees provide you with outpatient |
| > benefit**          | follow-up or continuing medical care when you |
|                      | are temporarily outside your home service     |
|                      | area by more than 100 miles and outside of    |
|                      | any other Kaiser Permanente service area.     |
|                      | These benefits are in addition to your        |
|                      | emergency and urgent care benefits and        |
|                      | include:                                      |
|                      |                                               |
|                      | -   Outpatient follow-up care necessary to    |
|                      |     complete a course of treatment after a    |
|                      |     covered emergency. Services include       |
|                      |     removal of stitches, a catheter, or a     |
|                      |     cast                                      |
|                      |                                               |
|                      | -   Outpatient continuing care for covered    |
|                      |     services for conditions diagnosed and     |
|                      |     treated within the previous 90 days by a  |
|                      |     Kaiser Permanente health care provider or |
|                      |     affiliated Plan provider. Services        |
|                      |     include dialysis and prescription drug    |
|                      |     monitoring                                |
|                      |                                               |
|                      | -   You pay \$25 for each follow-up or        |
|                      |     continuing care office visit. We deduct   |
|                      |     this amount from the payment we make to   |
|                      |     you                                       |
|                      |                                               |
|                      | -   We pay no more than \$1200 each calendar  |
|                      |     year                                      |
|                      |                                               |
|                      | -   For more information about this benefit   |
|                      |     call the Travel Benefit Information Line  |
|                      |     at 800/390-3509                           |
|                      |                                               |
|                      | -   File claims as shown on page 57.          |
|                      |                                               |
|                      | *The following are not included in your       |
|                      | travel benefits coverage:*                    |
|                      |                                               |
|                      | -   *Non-emergency hospitalization*           |
|                      |                                               |
|                      | -   *Infertility treatments*                  |
|                      |                                               |
|                      | -   *Medical and hospital costs resulting     |
|                      |     from a normal full-term delivery of a     |
|                      |     baby outside the service area*            |
|                      |                                               |
|                      | -   *Transplants*                             |
|                      |                                               |
|                      | -   *DME*                                     |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   *Prescription drugs*                      |
|                      |                                               |
|                      | -   *Home health services*                    |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| >                    | Kaiser Permanente offers smoking cessation    |
| []{#smokingcessation | classes as described under Educational        |
| > .anchor}**Smoking  | classes and programs in Section 5(a). In      |
| > cessation**        | addition to the classes we also offer the     |
|                      | following:                                    |
|                      |                                               |
|                      | -   Free brochures                            |
|                      |                                               |
|                      | -   Bookmark listing of smoking cessation     |
|                      |     resources                                 |
|                      |                                               |
|                      | -   Quarterly smoking cessation resource      |
|                      |     outreach mailings to all identified       |
|                      |     smokers                                   |
|                      |                                               |
|                      | -   Smoking cessation self-help booklet for   |
|                      |     pregnant women                            |
|                      |                                               |
|                      | -   Smoking cessation brochure for teens      |
|                      |                                               |
|                      | > For more information or to order any of the |
|                      | > above materials please call our Member      |
|                      | > Services Department at 404/261-2590.        |
+----------------------+-----------------------------------------------+
| > [                  | > When you visit the service area of another  |
| ]{#servicesfromother | > Kaiser Permanente plan, you are entitled to |
| > .anchor}**Services | > receive virtually all the benefits          |
| > from other Kaiser  | > described in this brochure (including our   |
| > Permanente plans** | > mail order prescription program) at any     |
|                      | > Kaiser Permanente medical office or medical |
|                      | > center. You must pay the charges or         |
|                      | > copayments imposed by the Kaiser Permanente |
|                      | > Plan you are visiting, with the exception   |
|                      | > of mail order prescriptions which are       |
|                      | > administered by your home Plan. You will    |
|                      | > have to pay the copayments or other charges |
|                      | > imposed by the Plan you are visiting. If    |
|                      | > the Plan you are visiting has a benefit     |
|                      | > that differs from the benefits of this      |
|                      | > Plan, you are not entitled to receive that  |
|                      | > benefit.                                    |
|                      | >                                             |
|                      | > Some services covered by this Plan, such as |
|                      | > artificial reproductive services and the    |
|                      | > services of specialized rehabilitation      |
|                      | > facilities, will not be covered if you      |
|                      | > receive them in other Kaiser Permanente     |
|                      | > service areas. If a benefit is limited to a |
|                      | > specific number of visits or days, you are  |
|                      | > entitled to receive only the number of      |
|                      | > visits or days covered by this Plan.        |
|                      | >                                             |
|                      | > If you are seeking routine, non-emergent,   |
|                      | > or non-urgent services, you should call the |
|                      | > Kaiser Permanente Membership Services       |
|                      | > department in that service area and request |
|                      | > an appointment. You may obtain routine      |
|                      | > follow-up or continuing care from these     |
|                      | > plans, even when you have obtained the      |
|                      | > original services in our service area. If   |
|                      | > you require emergency services as the       |
|                      | > result of unexpected or unforeseen illness  |
|                      | > that requires immediate attention, you      |
|                      | > should go directly to the nearest Kaiser    |
|                      | > Permanente facility to receive care.        |
|                      | >                                             |
|                      | > At the time you register for services, you  |
|                      | > will be asked to pay the charges required   |
|                      | > by the local Plan.                          |
|                      | >                                             |
|                      | > If you wish to obtain more information      |
|                      | > about the benefits available to you from a  |
|                      | > Kaiser Permanente Plan in an area you       |
|                      | > visit, please call our Member Services      |
|                      | > Department at 404/261-2590 or 800/611-1811. |
+----------------------+-----------------------------------------------+

+---+---+---------------------------+-------------------------+---+----+
| > |   |                           |                         |   |    |
|   |   |                           |                         |   |    |
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| i |   |                           |                         |   |    |
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| n |   |                           |                         |   |    |
| > |   |                           |                         |   |    |
|   |   |                           |                         |   |    |
| 5 |   |                           |                         |   |    |
| > |   |                           |                         |   |    |
|   |   |                           |                         |   |    |
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| ) |   |                           |                         |   |    |
| . |   |                           |                         |   |    |
| > |   |                           |                         |   |    |
|   |   |                           |                         |   |    |
| [ |   |                           |                         |   |    |
| ] |   |                           |                         |   |    |
| { |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
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| n |   |                           |                         |   |    |
| t |   |                           |                         |   |    |
| a |   |                           |                         |   |    |
| l |   |                           |                         |   |    |
| b |   |                           |                         |   |    |
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| n |   |                           |                         |   |    |
| e |   |                           |                         |   |    |
| f |   |                           |                         |   |    |
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| t |   |                           |                         |   |    |
| s |   |                           |                         |   |    |
| > |   |                           |                         |   |    |
|   |   |                           |                         |   |    |
| . |   |                           |                         |   |    |
| a |   |                           |                         |   |    |
| n |   |                           |                         |   |    |
| c |   |                           |                         |   |    |
| h |   |                           |                         |   |    |
| o |   |                           |                         |   |    |
| r |   |                           |                         |   |    |
| } |   |                           |                         |   |    |
| D |   |                           |                         |   |    |
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| n |   |                           |                         |   |    |
| t |   |                           |                         |   |    |
| a |   |                           |                         |   |    |
| l |   |                           |                         |   |    |
| > |   |                           |                         |   |    |
|   |   |                           |                         |   |    |
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| i |   |                           |                         |   |    |
| t |   |                           |                         |   |    |
| s |   |                           |                         |   |    |
+---+---+---------------------------+-------------------------+---+----+
|   | * | > **Here are some         |                         | * |    |
|   | * | > important things to     |                         | * |    |
|   | I | > keep in mind about      |                         | I |    |
|   | * | > these benefits:**       |                         | * |    |
|   | * |                           |                         | * |    |
|   |   | -   Please remember that  |                         |   |    |
|   | * |     all benefits are      |                         | * |    |
|   | * |     subject to the        |                         | * |    |
|   | M |     definitions,          |                         | M |    |
|   | * |     limitations, and      |                         | * |    |
|   | * |     exclusions in this    |                         | * |    |
|   |   |     brochure and we pay   |                         |   |    |
|   | * |     them only when we     |                         | * |    |
|   | * |     determine they are    |                         | * |    |
|   | P |     medically necessary.  |                         | P |    |
|   | * |                           |                         | * |    |
|   | * | ```{=html}                |                         | * |    |
|   |   | <!-- -->                  |                         |   |    |
|   | * | ```                       |                         | * |    |
|   | * | -   Plan dentists must    |                         | * |    |
|   | O |     provide or arrange    |                         | O |    |
|   | * |     your care. Call       |                         | * |    |
|   | * |     Member Services for a |                         | * |    |
|   |   |     list of participating |                         |   |    |
|   | * |     dentists.             |                         | * |    |
|   | * |                           |                         | * |    |
|   | R | -   We have no calendar   |                         | R |    |
|   | * |     year deductible.      |                         | * |    |
|   | * |                           |                         | * |    |
|   |   | -   We cover              |                         |   |    |
|   | * |     hospitalization for   |                         | * |    |
|   | * |     dental procedures     |                         | * |    |
|   | T |     only when a nondental |                         | T |    |
|   | * |     physical impairment   |                         | * |    |
|   | * |     exists which makes    |                         | * |    |
|   |   |     hospitalization       |                         |   |    |
|   | * |     necessary to          |                         | * |    |
|   | * |     safeguard the health  |                         | * |    |
|   | A |     of the patient. See   |                         | A |    |
|   | * |     Section 5(c) for      |                         | * |    |
|   | * |     inpatient hospital    |                         | * |    |
|   |   |     benefits. We do not   |                         |   |    |
|   | * |     cover the dental      |                         | * |    |
|   | * |     procedure except as   |                         | * |    |
|   | N |     described below.      |                         | N |    |
|   | * |                           |                         | * |    |
|   | * | ```{=html}                |                         | * |    |
|   |   | <!-- -->                  |                         |   |    |
|   | * | ```                       |                         | * |    |
|   | * | -   Be sure to read       |                         | * |    |
|   | T |     Section 4, *Your      |                         | T |    |
|   | * |     costs for covered     |                         | * |    |
|   | * |     services,* for        |                         | * |    |
|   |   |     valuable information  |                         |   |    |
|   |   |     about how cost        |                         |   |    |
|   |   |     sharing works. Also   |                         |   |    |
|   |   |     read Section 9 about  |                         |   |    |
|   |   |     coordinating benefits |                         |   |    |
|   |   |     with other coverage,  |                         |   |    |
|   |   |     including with        |                         |   |    |
|   |   |     Medicare.             |                         |   |    |
+---+---+---------------------------+-------------------------+---+----+
| # |   |                           | **You pay**             |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
|   |   |                           |                         |   |    |
| D |   |                           |                         |   |    |
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| n |   |                           |                         |   |    |
| t |   |                           |                         |   |    |
| a |   |                           |                         |   |    |
| l |   |                           |                         |   |    |
|   |   |                           |                         |   |    |
| B |   |                           |                         |   |    |
| e |   |                           |                         |   |    |
| n |   |                           |                         |   |    |
| e |   |                           |                         |   |    |
| f |   |                           |                         |   |    |
| i |   |                           |                         |   |    |
| t |   |                           |                         |   |    |
| s |   |                           |                         |   |    |
+---+---+---------------------------+-------------------------+---+----+
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
| # |   |                           |                         |   |    |
|   |   |                           |                         |   |    |
| A |   |                           |                         |   |    |
| c |   |                           |                         |   |    |
| c |   |                           |                         |   |    |
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| l |   |                           |                         |   |    |
|   |   |                           |                         |   |    |
| i |   |                           |                         |   |    |
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| j |   |                           |                         |   |    |
| u |   |                           |                         |   |    |
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|   |   |                           |                         |   |    |
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| n |   |                           |                         |   |    |
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| f |   |                           |                         |   |    |
| i |   |                           |                         |   |    |
| t |   |                           |                         |   |    |
+---+---+---------------------------+-------------------------+---+----+
| # |   |                           | > 50% of the first      |   |    |
| # |   |                           | > \$1,000 of covered    |   |    |
| # |   |                           | > charges (that is, up  |   |    |
| # |   |                           | > to \$500) per         |   |    |
| # |   |                           | > accident; all charges |   |    |
| # |   |                           | > thereafter            |   |    |
| # |   |                           | >                       |   |    |
| # |   |                           | > The Maximum Benefit   |   |    |
| # |   |                           | > Amount we will pay is |   |    |
|   |   |                           | > \$500 per accident.   |   |    |
| W |   |                           |                         |   |    |
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|   |   |                           |                         |   |    |
| 3 |   |                           |                         |   |    |
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| d |   |                           |                         |   |    |
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| r |   |                           |                         |   |    |
| y |   |                           |                         |   |    |
| . |   |                           |                         |   |    |
+---+---+---------------------------+-------------------------+---+----+

+-----------------------------------+----------------------------------+
| ######### Other dental benefits   | **You Pay**                      |
+-----------------------------------+----------------------------------+
| > We cover non-surgical treatment | 50% of our allowance             |
| > of temporomandibular joint      |                                  |
| > dysfunction (TMJ), including    |                                  |
| > splints and appliances          |                                  |
+-----------------------------------+----------------------------------+
| > The following preventive dental | \$14 per office visit            |
| > services are covered when       |                                  |
| > provided by a participating     |                                  |
| > Plan dentist:                   |                                  |
|                                   |                                  |
| -   Oral examinations twice a     |                                  |
|     year                          |                                  |
|                                   |                                  |
| ```{=html}                        |                                  |
| <!-- -->                          |                                  |
| ```                               |                                  |
| -   Dental prophylaxis (cleaning) |                                  |
|     twice a year                  |                                  |
|                                   |                                  |
| -   Topical application of        |                                  |
|     fluoride twice a year         |                                  |
|                                   |                                  |
| -   Bitewing X-ray twice a year   |                                  |
|                                   |                                  |
| -   Full mouth series X-rays once |                                  |
|     every three years             |                                  |
|                                   |                                  |
| > Note: You receive a 10%         |                                  |
| > discount from the Plan          |                                  |
| > dentist's usual and customary   |                                  |
| > fee schedule for all other      |                                  |
| > dental care.                    |                                  |
+-----------------------------------+----------------------------------+
| > General anesthesia and          | Nothing                          |
| > associated hospital or          |                                  |
| > ambulatory surgery facility     |                                  |
| > charges in conjunction with     |                                  |
| > dental care are covered for     |                                  |
| > persons:                        |                                  |
|                                   |                                  |
| -   7 years of age or younger     |                                  |
|                                   |                                  |
| -   Who are developmentally       |                                  |
|     disabled                      |                                  |
|                                   |                                  |
| -   Who are not able to have      |                                  |
|     dental care under local       |                                  |
|     anesthesia due to a           |                                  |
|     neurological or medically     |                                  |
|     compromising condition        |                                  |
|                                   |                                  |
| -   Who have sustained extensive  |                                  |
|     facial or dental trauma       |                                  |
+-----------------------------------+----------------------------------+
| > Extraction of teeth to prepare  | \$50 per office visit            |
| > the jaw for radiation treatment |                                  |
| > of neoplastic disease           |                                  |
+-----------------------------------+----------------------------------+
| *Not covered*                     | *All charges*                    |
|                                   |                                  |
| -   *Other dental services not    |                                  |
|     specifically shown as         |                                  |
|     covered*                      |                                  |
+-----------------------------------+----------------------------------+

  -----------------------------------------------------------------------
  **Section 5 (i).** []{#nonfehbbenefits .anchor}**Non-FEHB benefits
  available to Plan members**

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

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

######### Expanded Dental Care

We are pleased to offer you and your family expanded dental coverage
through the American Dental Plan.

CompDent Corporation offers you dental health maintenance organization
benefits administered by American Dental Plan (ADP). You must choose a
primary care dentist from the list of ADP dentists that is most
convenient to you and your family. With ADP you have no claim forms to
worry about. ADP provides a full range of services such as: preventive,
restorative, endodontics, periodontics, prosthetics, and orthodontics.
Under this program, you pay discounted rates for all covered services.

######### Monthly Premium\*

###### Self Only \$ 12.74

Self & One Party \$ 23.30

Self & Two or More \$ 33.50

\*These rates are effective January 1, 2004, through December 31, 2004

######### How To Enroll

Please read the enclosed flyer for a summary of the expanded dental
plan. If you would like more information call 770/649-1506 or send an
e-mail to: brendajoiner@tds.net, and identify yourself as an Federal
employee interested in the Kaiser Permanente/CompDent expanded dental
care option.

You must pay the monthly premium by automatic monthly withdrawal from
your checking, savings, or credit union account or an annual charge to
your MasterCard or Visa.

######### SelfWise Program

As a Kaiser Permanente member, you're automatically enrolled in our
*SelfWise* Program. This program gives you easy access to products and
services you can use to enhance your health and improve your quality of
life. *SelfWise* offers discounted rates for chiropractic, accupressure,
and massage therapy services through our Complementary and Alternative
Medicine (CAM) program; discounted products and services from local
businesses and health clubs; vision care discounts, LASIK discounts,
competitively priced over-the-counter items at our Kaiser Permanente
Medical Center pharmacies; complete overseas travel vaccinations from
our international travel service, and much more.

Note: Keep in mind that these programs are discount programs. They are
not a part of your FEHP benefits. These discounted programs are made
available to all enrollees and family members who are members of Kaiser
Permanente.

For more information about our *SelfWise* Program or for a *SelfWise*
brochure, contact our Member Services Department at 404/261-2590.

+-----------------------------------------------------------------------+
| > Section 6. []{#generalexclusions .anchor}General exclusions --      |
| > things we don\'t cover                                              |
+-----------------------------------------------------------------------+

> The exclusions in this section apply to all benefits. **Although we
> may list a specific service as a benefit, we will not cover it unless
> your Plan physician determines it is medically necessary to prevent,
> diagnose, or treat your illness, disease, injury, or condition.**
>
> We do not cover the following:

-   Care by non-Plan providers except for authorized referrals or
    emergencies (see Section 5(d)), services under the Travel Benefit
    (see Section 5(g)), and services received from other Kaiser
    Permanente plans (see Section 5(g));

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

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

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

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

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

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

```{=html}
<!-- -->
```
-   Services, drugs, or supplies you receive from a provider or facility
    barred from the FEHB Program;

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

-   Services provided or arranged by criminal justice institutions for
    members confined therein.

  -----------------------------------------------------------------------
  Section 7. []{#filingaclaimforcoveredservices .anchor}Filing a claim
  for covered services

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

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

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

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

**benefits** must file on the form HCFA-1500, Health Insurance Claim
Form. Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 404/261-2590.

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

-   Covered member's name and ID number;

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

-   Dates you received the services or supplies;

-   Diagnosis;

-   Type of each service or supply;

-   The charge for each service or supply;

-   Follow up services rendered out-of-area

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

```{=html}
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```
-   Receipts, if you paid for your services.

> **Submit your claims to:**
>
> Kaiser Permanente
>
> Claims Administration
>
> P.O. Box 190849
>
> Atlanta, GA 31119-0849

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

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

  -----------------------------------------------------------------------
  Section 8. []{#thedisputedclaimsprocess .anchor}The disputed claims
  process

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

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

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) \(a\) Write to us within 6 months from the date of our       |
| * |     decision; and                                                |
| * |                                                                  |
|   | (b) \(b\) Send your request to us at: Kaiser Foundation Health   |
|   |     Plan of Georgia, Inc., Attention: Appeals Department, Nine   |
|   |     Piedmont Center, 3495 Piedmont Road, NE, Atlanta GA          |
|   |     30305-1736; and                                              |
|   |                                                                  |
|   | (c) \(c\) Include a statement about why you believe our initial  |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) \(d\) Include copies of documents that support your claim,   |
|   |     such as physicians\' letters, operative reports, bills,      |
|   |     medical records, and explanation of benefits (EOB) forms.    |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) \(a\) Pay the claim (or, if applicable, arrange for the      |
| * |     health care provider to give you the care); or               |
| * |                                                                  |
|   | (b) \(b\) Write to you and maintain our denial \-- go to step 4; |
|   |     or                                                           |
|   |                                                                  |
|   | (c) \(c\) Ask you or your provider for more information. If we   |
|   |     ask your provider, we will send you a copy of our request -- |
|   |     go to step 3.                                                |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us \-- if we did not       |
|   |     answer that request in some way within 30 days; or           |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: United States Office of Personnel Management,   |
|   | Insurance Services Programs, Health Insurance Group 3, 1900 E    |
|   | Street, NW, Washington, DC 20415-3630.                           |
+---+------------------------------------------------------------------+
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must 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 yet to your initial request for care or
    preauthorization/prior approval, then call us at 404/261-2590 and we
    will expedite our review; or

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

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

-   You may call OPM\'s Health Insurance Group 3 at 202/606-0755 between
    8 a.m. and 5 p.m. eastern time.

  -----------------------------------------------------------------------
  Section 9. []{#coordinatingbenefitswithothercoverage
  .anchor}Coordinating benefits with other coverage

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

[]{#whenyouhaveotherhealthcoverage .anchor}**When you have other health
coverage** You must tell us if you or a covered family member have
coverage under another group health plan or have automobile insurance
that pays health care expenses without regard to fault. This is called
\"double coverage.\"

When you have double coverage, one plan is the primary payer; it pays
benefits first. The other plan pays a reduced benefit as the secondary
payer. We, like other insurers, determine which coverage is primary
according to the National Association of Insurance Commissioners\'
Guidelines.

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

When we are the secondary payer, we will determine our allowance. After
the primary plan pays, we will pay what is left of our allowance, up to
or our regular benefit. We will not pay more than our allowance. If we
are the secondary payer, and you received your services from Plan
providers, we may bill the primary carrier.

-   []{#whatismedicare .anchor}**What is Medicare?** Medicare is a
    Health Insurance Program for:

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```
-   People 65 years of age and older.

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

```{=html}
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```
-   People with End-Stage Renal Disease (permanent kidney failure
    requiring dialysis or a transplant).

> Medicare has two parts:

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

```{=html}
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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 managed care plan you
> have.

-   **Should I enroll in Medicare?** The decision to enroll in Medicare
    is yours. We encourage you to apply

> for Medicare benefits 3 months before you turn age 65. It's easy. Just
> call the Social Security Administration toll-free number
> 1-800-772-1213 to set up an appointment to apply. If you do not apply
> for one or both Parts of Medicare, you can still be covered under the
> FEHB Program.
>
> If you can get premium-free Part A coverage, we advise you to enroll
> in it. Most Federal employees and annuitants are entitled to Medicare
> Part A at age 65 **without cost**. When you don't have to pay premiums
> for Medicare Part A, it makes good sense to obtain the coverage. It
> can reduce your out-of-pocket expenses as well as costs to the FEHB,
> which can help keep FEHB premiums down.
>
> Everyone is charged a premium for Medicare Part B coverage. The Social
> Security Administration can provide you with premium and benefit
> information. Review the information and decide if it makes sense for
> you to buy the Medicare Part B coverage.

**If you do enroll in** If you enroll in Medicare Part B, we require you
to assign your Medicare

**Medicare Part B** Part B benefits to the Plan or its services.

-   []{#theoriginalmedicareplan .anchor}**The Original Medicare Plan**
    The Original Medicare Plan (Original Medicare) is available
    everywhere

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

When you are enrolled in Original Medicare along with this Plan, you
still need to follow the rules in this brochure for us to cover your
care. We will not waive any of our copayments.

> **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.

```{=html}
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```
-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In most cases, your claim will be coordinated
    automatically and we will then provide secondary benefits for
    covered charges. You will not need to do anything. To find out if
    you need to do something to file your claim, call us at 404/233-3700
    (locally), 800/232-4404 (long distance) and 800/255-0056 (TTY line).

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

Medicare always makes the final determination as to whether they are the
primary payer. The following chart illustrates whether Medicare

or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is

critical that you tell us if you or a covered family member has Medicare
coverage so we can administer these requirements correctly.

+-----------------------------------------------------+------+---+---------+
| > **Primary Payer Chart**                           |      |   |         |
+-----------------------------------------------------+------+---+---------+
| **A. When you - or your covered spouse - are age 65 | *    |   |         |
| or over and have Medicare and you...**              | *The |   |         |
|                                                     | pri  |   |         |
|                                                     | mary |   |         |
|                                                     | p    |   |         |
|                                                     | ayer |   |         |
|                                                     | for  |   |         |
|                                                     | the  |   |         |
|                                                     | in   |   |         |
|                                                     | divi |   |         |
|                                                     | dual |   |         |
|                                                     | with |   |         |
|                                                     | Medi |   |         |
|                                                     | care |   |         |
|                                                     | is.  |   |         |
|                                                     | ..** |   |         |
+-----------------------------------------------------+------+---+---------+
|                                                     | **Me |   | **This  |
|                                                     | dica |   | Plan**  |
|                                                     | re** |   |         |
+-----------------------------------------------------+------+---+---------+
| 1)  Are an active employee with the Federal         |      |   |         |
|     government and**...**                           |      |   |         |
|                                                     |      |   |         |
|     -   You have FEHB coverage on your own or       |      |   |         |
|         through your spouse who is also an active   |      |   |         |
|         employee                                    |      |   |         |
+-----------------------------------------------------+------+---+---------+
| -   You have FEHB coverage through your spouse who  |      |   |         |
|     is an annuitant                                 |      |   |         |
+-----------------------------------------------------+------+---+---------+
| 2)  Are an annuitant and**...**                     |      |   |         |
|                                                     |      |   |         |
|     -   You have FEHB coverage on your own or       |      |   |         |
|         through your spouse who is also an          |      |   |         |
|         annuitant                                   |      |   |         |
+-----------------------------------------------------+------+---+---------+
| -   You have FEHB coverage through your spouse who  |      |   |         |
|     is an active employee                           |      |   |         |
+-----------------------------------------------------+------+---+---------+
| 3)  Are a reemployed annuitant with the Federal     | \*   |   |         |
|     government and your position is excluded from   |      |   |         |
|     the FEHB (your employing office will know if    |      |   |         |
|     this is the case)                               |      |   |         |
+-----------------------------------------------------+------+---+---------+
| 4)  Are a reemployed annuitant with the Federal     |      |   |         |
|     government and your position is not excluded    |      |   |         |
|     from the FEHB (your employing office will know  |      |   |         |
|     if this is the case) and**...**                 |      |   |         |
|                                                     |      |   |         |
|     -   You have FEHB coverage on your own or       |      |   |         |
|         through your spouse who is also an active   |      |   |         |
|         employee                                    |      |   |         |
+-----------------------------------------------------+------+---+---------+
| -   You have FEHB coverage through your spouse who  |      |   |         |
|     is an annuitant                                 |      |   |         |
+-----------------------------------------------------+------+---+---------+
| 5)  Are a Federal judge who retired under title 28, | #    |   |         |
|     U.S.C., or a Tax Court judge who retired under  | #### |   |         |
|     Section 7447 of title 26, U.S.C. (or if your    | # \* |   |         |
|     covered spouse is this type of judge)           |      |   |         |
+-----------------------------------------------------+------+---+---------+
| 6)  Are enrolled in Part B only, regardless of your | for  |   | for     |
|     employment status                               | Part |   | other   |
|                                                     | B    |   | s       |
|                                                     | serv |   | ervices |
|                                                     | ices |   |         |
+-----------------------------------------------------+------+---+---------+
| 7)  Are a former Federal employee receiving         | \*\* |   |         |
|     Workers' Compensation and the Office of         |      |   |         |
|     Workers' Compensation Programs has determined   |      |   |         |
|     that you are unable to return to duty)          |      |   |         |
+-----------------------------------------------------+------+---+---------+
| **B. When you or a covered family member...**       |      |   |         |
+-----------------------------------------------------+------+---+---------+
| ###### Have Medicare solely                         |      |   |         |
|  based on end stage renal disease (ESRD) and**...** |      |   |         |
|                                                     |      |   |         |
| ###### It is within the fi                          |      |   |         |
| rst 30 months of eligibility for or entitlement to  |      |   |         |
| Medicare due to ESRD (30-month coordination period) |      |   |         |
+-----------------------------------------------------+------+---+---------+
| -   It is beyond the 30-month coordination period   |      |   |         |
|     and you or a family member are still entitled   |      |   |         |
|     to Medicare due to ESRD                         |      |   |         |
+-----------------------------------------------------+------+---+---------+
| 1)  Become eligible for Medicare due to ESRD while  |      | f |         |
|     already a Medicare beneficiary and**...**       |      | o |         |
|                                                     |      | r |         |
| -   This Plan was the primary payer before          |      | 3 |         |
|     eligibility due to ESRD                         |      | 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. Are covered under the FEHB Spouse Equity       |      |   |         |
| provision as a former spouse**                      |      |   |         |
+-----------------------------------------------------+------+---+---------+

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

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

[]{#medicaremanagedcareplan .anchor}**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 our Medicare+Choice plan:** You may enroll in our
Medicare+Choice plan, Kaiser Permanente Senior Advantage, and also
remain enrolled in our FEHB Plan. There is no additional premium to
enroll in Senior Advantage. In this case, we waive or lower some of our
copayments and coinsurance for your FEHB and Medicare coverage. If you
would like information about our Medicare+Choice plan, please call
weekdays, 8:30 a.m. to 5:00 p.m., 404/233-3700 (locally), 800/232-4404
(long distance) and 800/255-0056 (TTY line). Your Kaiser Permanente
Senior Advantage-FEHBP benefits that we lowered or waived are:

+-----------------------------------------------------------------------+
| -   **Physician office visits**: \$10 copayment for                   |
|     physician/specialist visit                                        |
|                                                                       |
| -   **Preventive care**: \$10 copayment per visit for most adult      |
|     preventive care services; no copayment for mammograms             |
|                                                                       |
| -   **Routine physicals and hearing exams**: \$10 copayment per visit |
|                                                                       |
| -   **Inpatient hospital**: \$100 per admission                       |
|                                                                       |
| -   **Outpatient mental health and substance abuse**: \$10 copayment  |
|     per visit                                                         |
|                                                                       |
| -   **Prescriptions**:                                                |
|                                                                       |
| > ---\$5 for each generic/brand prescription obtained at a Plan       |
| > medical office pharmacy                                             |
| >                                                                     |
| > ---\$11 for each generic/brand prescription obtained at a Plan      |
| > participating community pharmacy                                    |
|                                                                       |
| -   **Dialysis**: no copayments                                       |
|                                                                       |
| -   **Durable medical equipment**: 20% of our allowance               |
|                                                                       |
| -   **Orthopedic and prosthetic devices**: 20% of our allowance       |
|                                                                       |
| -   **Vision Services**:                                              |
|                                                                       |
| > ---\$10 copayment for one routine eye exam each year                |
| >                                                                     |
| > ---Up to an allowance of \$100 for eyeglass lenses and frames;      |
| > cosmetic contact lenses and medically necessary contact lenses once |
| > every 24 months.                                                    |
| >                                                                     |
| > --- Up to an allowance of \$60 for single vision eyeglass or        |
| > contact lenses and \$90 for multifocal lenses for replacement       |
| > lenses for changes in prescription of at least .50 diopter within   |
| > 12 months                                                           |
| >                                                                     |
| > An allowance is applied toward the total expense of an item that is |
| > covered. If the cost of the item you select exceeds the allowance,  |
| > you will pay the difference. You may only use your allowance one    |
| > time, which is at the time you order your initial eyeglass lenses,  |
| > frames, or contact lenses.                                          |
|                                                                       |
| **You will also enjoy**:                                              |
|                                                                       |
| -   Health/Wellness Education: \$10 copayment for disease-specific    |
|     health education classes (costs may vary for wellness classes)    |
|                                                                       |
| -   No deductibles and virtually no paperwork                         |
|                                                                       |
| -   On-line access to health information and resources at our         |
|     award-winning members only website                                |
|                                                                       |
| -   Quarterly member communication in our \"Senior Outlook\" magazine |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Customized Senior Advantage new member orientation.               |
+-----------------------------------------------------------------------+

**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 if you use our Plan providers, but we will not lower or waive
any of our copayments or coinsurance. If you enroll in a Medicare+Choice
plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare+Choice plan so we can correctly
coordinate benefits with Medicare.

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

[]{#tricareandchampva .anchor}**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.

[]{#workerscompensation .anchor}**Workers' Compensation** We do not
cover services that:

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

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

[]{#medicaid .anchor}**Medicaid** When you have this Plan and Medicaid,
we pay first.

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

[]{#whenothergovernmentagencies .anchor}**When other Government
agencies** We do not cover services and supplies when a local, State,

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

[]{#whenothersareresponsible .anchor}**When others are responsible**
When you receive money to compensate you for medical or hospital care

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

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

  -----------------------------------------------------------------------
  Section 10. []{#definitionsoftermsweuseinthisbrochure
  .anchor}Definitions of terms we use in this brochure

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

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

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

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

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

**Custodial care** (1) Assistance with activities of daily living, for
example, walking, getting in and out of bed, dressing, feeding,
toileting, and taking medicine. (2) Care that can be performed safely
and effectively by people whom, in order to provide the care, do not
require medical licenses or certificates or the presence of a
supervising licensed nurse. Custodial care that lasts 90 days or more is
sometimes known as Long term care.

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

**Durable medical equipment** Durable medical equipment (DME) is
equipment that is intended for repeated use, medically necessary,
primarily and customarily used to serve a medical purpose, generally not
useful to a person who is not ill or injured, designed for prolonged
use, appropriate for use in the home, and serves a specific therapeutic
purpose in the treatment of an illness or injury.

**Experimental or**

**investigational services** We carefully evaluate whether a particular
therapy is safe and effective or offers a reasonable degree of promise
with respect to improving health outcomes. The primary source of
evidence about health outcomes of any intervention is peer-reviewed
medical or dental literature. When the service or supply, including a
drug: (1) has not been approved by the FDA; or (2) is the subject of a
new drug or new device application on file with the FDA; or (3) is part
of a Phase I or Phase II clinical trial, as the experimental or research
arm of a Phase III clinical trial; or is intended to evaluate the
safety, toxicity, or efficacy of the service; or (4) is available as the
result of a written protocol that evaluates the service\'s safety,
toxicity, or efficacy; or (5) is subject to the approval or review of an
Institutional Review Board; or (6) requires an informed consent that
describes the service as experimental or investigational; then this Plan
considers that service supply or drug to be experimental, and not
covered by the Plan.

**Group health coverage** Health care benefits that are available as a
result of your employment, or the employment of your spouse, and that
are offered by an employer or through membership in an employee
organization. Health care coverage may be insured or indemnity coverage,
self-insured or self-funded coverage, or coverage through health
maintenance organizations or other managed care plans. Health care
coverage purchased through membership in an organization is also \"group
health coverage.\"

**Medically necessary** All benefits need to be medically necessary in
order for them to be covered benefits. Generally, if your Plan physician
provides the service in accord with the terms of this brochure, it will
be considered medically necessary. However, some services are reviewed
in advance of your receiving them to determine if they are medically
necessary. When we review a service to determine if it is medically
necessary, a Plan physician will evaluate what would happen to you if
you do not receive the service. If not receiving the service would
adversely affect your health, it will be considered medically necessary.
The services must be a medically appropriate course of treatment for
your condition. If they are not medically necessary, we will not cover
the services. In case of emergency services, the services that you
received will be evaluated to determine if they were medically
necessary.

**Our allowance** The amount we use to determine your coinsurance. When
you receive services or supplies from Plan providers, it is the amount
that we set for the services or supplies if we were to charge for them.
When you receive services from non-Plan providers, we determine the
amount that we believe is usual and customary for the service or supply,
and compare it to the charges. Our allowance is based upon the
reasonableness of the charges. If the charges exceed what we believe is
reasonable, you may be responsible for the excess over our allowance in
addition to your coinsurance.

**Us/We** Us and we refer to Kaiser Foundation Health Plan of Georgia,
Inc.

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

  -----------------------------------------------------------------------
  Section 11. []{#fehbfacts .anchor}FEHB facts

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

[]{#nopreexistingcondition .anchor}**Coverage information**

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

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

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

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

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

-   When you may change your enrollment;

```{=html}
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-   How you can cover your family members;

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

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-   When your enrollment ends; and

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```
-   When the next open season for enrollment begins.

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

[]{#typesofcoverageavailable .anchor}**Types of coverage available**
Self Only coverage is for you alone. Self and Family coverage is for

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

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

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

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

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

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

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

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

-   if you are enrolled in an HMO that does not serve the area where the
    children live, your employing office will change your enrollment to
    Self and Family in the 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.

[]{#whenbenefitsand .anchor}**When benefits and** The benefits in this
brochure are effective on January 1. If you joined

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

[]{#whenyouretire .anchor}**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).

[]{#whenyoulosebenefits .anchor}**When you lose benefits**

[]{#whenfehbcoverageends .anchor}**When FEHB coverage ends** You will
receive an additional 31 days of coverage, for no additional premium,
when:

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

```{=html}
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```
-   You are a family member no longer eligible for coverage.

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

[]{#spouseequitycoverage .anchor}**Spouse equity coverage** If you are
divorced from a Federal employee or annuitant, you may not

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

[]{#temporarycontinuatuonofcoverage .anchor}**Temporary continuation**
If you leave Federal service, or if you lose coverage because you no

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

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

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

[]{#convertingto .anchor}**Converting to** You may convert to a non-FEHB
individual policy if:

**individual coverage**

-   Your coverage under TCC or the spouse equity law ends (if you
    canceled your coverage or did not pay your premium, you cannot
    convert);

```{=html}
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```
-   You decided not to receive coverage under TCC or the spouse equity
    law; or

```{=html}
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```
-   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.

[]{#gettingacertificateof .anchor}**Getting a Certificate of** The
Health Insurance Portability and Accountability Act of 1996

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

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

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

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

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

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

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

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

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

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

```{=html}
<!-- -->
```
-   **Enroll during Open Season** You **must make an election** to
    enroll in an FSA during the

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

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

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

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

**Who is eligible to enroll?** If you are a Federal employee eligible
for FEHB -- even if

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

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

> **contribute to my FSA?** 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.

-   **What can my HCFSA** Every FEHB health plan includes cost sharing
    features, such

> **pay for?** 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 15 and detailed throughout
> this brochure. Your HCFSA will reimburse you for such costs when they
> are for tax deductible medical care for you and your dependents that
> is NOT covered by this FEHB Plan or any other coverage that you have.
>
> Under this Plan, typical out-of-pocket expenses include: office visit
> copayments, prescription drug copayments, and durable medical
> equipment coinsurance.
>
> 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 website at
> <http://www.irs.gov/pub/irs-pdf/p502.pdf>. If you do not see your
> service or expense listed in Publication 502, please call a FSAFEDS
> Benefit Counselor at 1-877-FSAFEDS (372-3337), who will be able to
> answer your specific questions.

-   **Tax savings with an FSA** An FSA lets you allot money for eligible
    expenses ***before*** your

> agency deducts taxes from your paycheck. This means the amount of
> income that your taxes are based on will be lower, so your tax
> liability will also be lower. Without an FSA, you would still pay for
> these expenses, but you would do so using money remaining in your
> paycheck after Federal (and often state and local) taxes are deducted.
> The following chart illustrates a typical tax savings example:

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

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

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

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

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

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

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

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

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

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

> **deductions** if you receive reimbursement for them from your HCFSA
> or DCFSA. Below are some guidelines that may help you decide whether
> to participate in FSAFEDS.
>
> **Health care 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 exemption is not
> available on your Federal income tax return.

**Dependent care expenses** The DCFSA generally allows many families to
save more than

> they would with the Federal tax credit for dependent care expenses.
> Note that you may only be reimbursed from the DCFSA up to your current
> account balance. If you file a claim for more than your current
> balance, it will be held until additional payroll allotments have been
> added to your account.
>
> Visit [www.fsafeds.com](http://www.fsafeds.com/) and download the
> Dependent Care Tax Credit Worksheet from the Quick Links box to help
> you determine what is best for your situation. You may also wish to
> consult a tax professional for more details.

-   **Does it cost me anything** Probably not. While there is an
    administrative fee of \$4.00

> **to participate in FSAFEDS?** 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 website 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 website** 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-

**to request an application** 3557) or visit
[www.ltcfeds.com](http://www.ltcfeds.com/).

  -----------------------------------------------------------------------
  []{#index .anchor}**Index**

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

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

**A**ccidental injury 53

Allergy tests 21

Alternative treatment 29

Allogenetic (donor) bone marrow transplant 34

Ambulance 10, 39, 42

Anesthesia, 35, 37

**B**iopsies 31

Blood and blood plasma 37, 38

Breast cancer screening 18

**C**asts 37

Centers of excellence 51

Changes for 2004 10

Chemotherapy 22

Chiropractic 29

Cholesterol tests 18

Coinsurance 15, 66

Colorectal cancer screening 18

Congenital anomalies 31

Contraceptive devices and drugs 10, 32, 48

Coordination of benefits 60

Covered providers 11

Crutches 27

**D**eaf and hearing impaired

service 50

Deductible 15, 66

Dental care 53-54

Diagnostic services 17-18, 37-38, 43-44

Disputed claims review 58-59

Donor expenses (transplants) 34

Dressings 37, 38

Durable medical equipment (DME) 14, 27, 38, 63, 66

**E**ducational classes and programs 30

Effective date of enrollment 68

Emergency 10, 40-41

Experimental or investigational 56, 66

Eyeglasses 25, 63

**F**amily planning 20

Fecal occult blood test 18

Flexible benefits options 50

**G**eneral Exclusions 56

**H**earing services 24

Home health services 14, 28

Hospice care 14, 39

Hospital 14, 36-38

**I**mmunizations 19

Infertility 21

Inpatient Hospital Benefits 10, 36-37, 63

Insulin 48

**L**aboratory and pathological

> services 18, 37, 38

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

Mail Order Prescription Drugs 46

Mammograms 18, 63

Maternity Benefits 20, 50

Medicaid 64-65

Medically necessary 67

Medicare 60-64

Mental Conditions/Substance Abuse Benefits 10, 14, 43-45

**N**eurological testing 29

Newborn care 17, 20

Non-FEHB Benefits 55

Nurse

-   Nurse Anesthetist 37

-   Nurse Practitioner 11

-   Registered Nurse 50

    Nursery charges 20

    **O**bstetrical care 20

    Occupational therapy 23, 28

    Ocular injury 25

    Oral and maxillofacial surgery 33

    Orthopedic devices 14, 26, 63

Ostomy supplies 26

Out-of-pocket expenses 10, 15, 78

Oxygen 27, 28, 37-38

**P**ap test 18

Physical examination 18, 19, 63

Physical therapy 23

Precertification 14

Preventive care, adult 18-19

Preventive care, children 19

Preventive services 18-19

Prior approval 14

Prostate cancer screening 18

Prosthetic devices 26, 63

Psychotherapy 45

**R**adiation therapy 22

Renal dialysis 22, 66

Room and board 36, 38

**S**econd surgical opinion 17

Services from other Kaiser Permanente Plans 52

Skilled nursing care benefits 14, 38

Smoking cessation 10, 30, 49, 52

Speech therapy 14, 24

Splints 37, 54

Sterilization procedures 20, 32

Subrogation 65

Substance abuse 43-45

Surgery 10, 31-32

-   Anesthesia 35, 37-38

```{=html}
<!-- -->
```
-   Oral 33

-   Outpatient 10, 38

-   Reconstructive 32-33

    Syringes 48

    **T**emporary continuation of coverage 70-71

    Transplants 14, 34, 51

Travel benefit 51

Treatment therapies 22

**U**rological supplies 26

**V**ision services 25, 63

**W**ell child care 19

Wheelchairs 27

Workers' compensation 62

**X**-rays 18, 29, 37-38, 54

**24** hour nurse line 50

  -----------------------------------------------------------------------
  []{#summaryofbenefits .anchor}**Summary of benefits for Kaiser
  Foundation Health Plan of Georgia, Inc. -- 2004**

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

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

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

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

+-------------------------------------------+----------------------+---+
| **Benefits**                              | **You Pay**          | * |
|                                           |                      | * |
|                                           |                      | P |
|                                           |                      | a |
|                                           |                      | g |
|                                           |                      | e |
|                                           |                      | * |
|                                           |                      | * |
+-------------------------------------------+----------------------+---+
| Medical services provided by physicians:  | \$15 per office      | > |
|                                           | visit                |   |
| -   Diagnostic and treatment services     |                      | 1 |
|     provided in the office                |                      | 7 |
+-------------------------------------------+----------------------+---+
| Services provided by a hospital:          | > \$250 per          | > |
|                                           | > admission          |   |
| -   Inpatient                             | >                    | 3 |
|                                           | > \$50 per surgery   | 6 |
| -   Outpatient                            |                      | > |
|                                           |                      | > |
|                                           |                      |   |
|                                           |                      | 3 |
|                                           |                      | 8 |
+-------------------------------------------+----------------------+---+
| Emergency benefits:                       | > \$75 per visit     | > |
|                                           | >                    |   |
| -   In-area                               | > \$75 per visit     | 4 |
|                                           |                      | 0 |
| -   Out-of-area                           |                      | > |
|                                           |                      | > |
|                                           |                      |   |
|                                           |                      | 4 |
|                                           |                      | 0 |
+-------------------------------------------+----------------------+---+
| Mental health and substance abuse         | > Regular cost       | > |
| treatment:                                | > sharing            |   |
|                                           |                      | 4 |
|                                           |                      | 3 |
+-------------------------------------------+----------------------+---+
| Prescription drugs                        | > \$10 per           | > |
|                                           | > prescription if    |   |
|                                           | > obtained at a Plan | 4 |
|                                           | > medical office     | 6 |
|                                           | > pharmacy;          |   |
|                                           | >                    |   |
|                                           | > \$16 per           |   |
|                                           | > prescription if    |   |
|                                           | > obtained at a Plan |   |
|                                           | > participating      |   |
|                                           | > community pharmacy |   |
+-------------------------------------------+----------------------+---+
| Dental Care                               | > Various copayments | > |
|                                           | > based on procedure |   |
|                                           | > rendered           | 5 |
|                                           |                      | 3 |
+-------------------------------------------+----------------------+---+
| Vision Care                               | > Refractions; \$15  | > |
|                                           | > per office visit   |   |
|                                           |                      | 2 |
|                                           |                      | 5 |
+-------------------------------------------+----------------------+---+
| Special features: Flexible benefits       |                      | > |
| option; 24 hour nurse line; Services for  |                      |   |
| deaf and hearing impaired; High risk      |                      | 5 |
| pregnancies; Centers of excellence;       |                      | 0 |
| Travel benefit; Smoking cessation;        |                      |   |
| Services from other Kaiser Permanente     |                      |   |
| Plans                                     |                      |   |
+-------------------------------------------+----------------------+---+
| Protection against catastrophic costs     | > Nothing after      | > |
|                                           | > \$2,000/Self Only  |   |
| (your catastrophic protection             | > or \$6,000/Family  | 1 |
| out-of-pocket maximum)                    | > enrollment per     | 5 |
|                                           | > year               |   |
|                                           | >                    |   |
|                                           | > Some costs do not  |   |
|                                           | > count toward this  |   |
|                                           | > protection         |   |
+-------------------------------------------+----------------------+---+

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

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

[]{#rateinformation .anchor}**2004 Rate Information for**

**Kaiser Foundation Health Plan of Georgia, Inc.**

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

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

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

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

  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------
  **Self Only**   **F81**   **\$96.40**    **\$32.13**   **\$208.86**   **\$69.62**    **\$114.07**   **\$14.46**

  **Self and      **F82**   **\$244.73**   **\$81.58**   **\$530.26**   **\$176.75**   **\$289.60**   **\$36.71**
  Family**                                                                                            
  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------