APWU Health Plan![](media/image1.png){width="1.1756944444444444in"
height="0.5256944444444445in"}

**[http://www.apwuhp.com]{.underline}**

**2004**

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**A fee-for-service plan**

**and**

**A consumer-driven plan**

**with preferred provider organizations**

**Sponsored and administered by: American Postal Workers Union,
AFL-CIO**

**Who may enroll in this Plan:** All Federal and Postal Service
employees and\
annuitants who are eligible to enroll in the FEHB Program may become
members\
of this Plan. To enroll, you must be, or must become, a member of the
American\
Postal Workers Union, AFL-CIO.

**To become a member or associate member:** All active Postal Service
bargaining unit employees must be, or must become, dues-paying members
of the APWU, except where exempt by law. In item 1 of Part B of your
registration form, enter the number of your APWU Local immediately after
the name of this Plan.

If you are a non-postal employee/annuitant, you will automatically
become an associate member of APWU upon enrollment in the APWU Health
Plan.

Annuitants (retirees) may enroll in this Plan.

**Membership dues:** \$35 per year for an associate membership. APWU
will bill new associate members for the annual dues when it receives
notice of enrollment. APWU will also bill continuing associate members
for the annual membership. Active and retired Postal Service employee's
membership dues vary by APWU local.

**Enrollment codes for this Plan:**

**471 High Option - Self Only**

**472 High Option - Self and Family**

#####  474 Consumer-driven Option - Self Only

**475 Consumer-driven Option - Self and Family**

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> Dear Federal Employees Health Benefits Program Participant:
>
> I am pleased to present this 2004 Federal Employees Health Benefits
> (FEHB) Program plan brochure. The brochure describes the benefits this
> plan offers you for 2004. Because benefits vary from year to year, you
> should review your plan's brochure every Open Season -- especially
> Section 2, which explains how the plan changed.
>
> It takes a lot of information to help a consumer make wise healthcare
> decisions. The information in this brochure, our FEHB Guide, and our
> web-based resources, make it easier than ever to get information about
> plans, to compare benefits and to read customer service satisfaction
> ratings for the national and local plans that may be of interest. Just
> click on [www.opm.gov/insure](http://www.opm.gov/insure)!
>
> The FEHB Program continues to be an enviable national model that
> offers exceptional choice, and uses private-sector competition to keep
> costs reasonable, ensure high-quality care, and spur innovation. The
> Program, which began in 1960, is sound and has stood the test of time.
> It enjoys one of the highest levels of customer satisfaction of any
> healthcare program in the country.
>
> I continue to take aggressive steps to keep the FEHB Program on the
> cutting edge of employer-sponsored health benefits. We demand
> cost-effective quality care from our FEHB carriers and we have
> encouraged Federal agencies and departments to pay the full FEHB
> health benefit premium for their employees called to active duty in
> the Reserve and National Guard so they can continue FEHB coverage for
> themselves and their families. Our carriers have also responded to my
> request to help our members to be prepared by making additional
> supplies of medications available for emergencies as well as call-up
> situations and you can help by getting an Emergency Preparedness Guide
> at www.opm.gov. OPM's *HealthierFeds* campaign is another way the
> carriers are working with us to ensure Federal employees and retirees
> are informed on healthy living and best-treatment strategies. You can
> help to contain healthcare costs and keep premiums down by living a
> healthy life style.
>
> Open Season is your opportunity to review your choices and to become
> an educated consumer to meet your healthcare needs. Use this brochure,
> the FEHB Guide, and the web resources to make your choice an informed
> one. Finally, if you know someone interested in Federal employment,
> refer them to www.usajobs.opm.gov.
>
> Sincerely,

![](media/image6.png){width="2.5833333333333335in"
height="0.7291666666666666in"}

> Kay Coles James
>
> Director

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height="1.0354166666666667in"}
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height="0.9208333333333333in"}

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

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

Privacy Complaints

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

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  Table of Contents
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Introduction 5

Plain Language 5

Stop Health Care Fraud! 5

Preventing medical mistakes 6

Section 1. Facts about this fee-for-service plan 8

Section 2. How we change for 2004 10

Section 3. How you get care 11

Identification cards 11

Where you get covered care 11

Covered providers 11

Covered facilities 11

What you must do to get covered care 12

How to get approval for 13

Your hospital stay (precertification) 13

-   Radiology/Imaging Procedures 14

Other services 15

Section 4. Your costs for covered services 16

Copayments 16

Deductible 16

Coinsurance 16

Member Responsibility 17

Differences between our allowance and the bill 17

Your catastrophic protection out-of-pocket maximum 18

When Government facilities bill us 19

If we overpay you 19

When you are age 65 or over and you do **not** have Medicare 20

When you have Medicare 21

Should I enroll in Medicare? 21

Section 5. High Option Benefits 22

Overview 22

(a) Medical services and supplies provided by physicians and other
    health care professionals 23

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

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

(d) Emergency services/accidents 39

(e) Mental health and substance abuse benefits 41

(f) Prescription drug benefits 43

(g) Special features 46

-   Flexible benefits option 46

-   24 hour nurse line 46

-   Services for deaf and hearing impaired 46

-   Wellness benefit 46

-   Disease management program 46

-   Review and reward program 46

(h) Dental benefits 47

(i) Non-FEHB benefits available to Plan members 48

Section 6. Consumer-driven Option Benefits 49

Overview 49

\(a\) In-network preventive care 50

\(b\) Personal Care Account (PCA) 52

\(c\) Traditional health coverage 54

\(d\) Health tools and resources 74

Section 7. General exclusions --- things we don't cover 75

Section 8. Filing a claim for covered services 76

Section 9. The disputed claims process 78

Section 10. Coordinating benefits with other coverage 80

When you have other health coverage 80

What is Medicare? 80

> Medicare + Choice 83

TRICARE and CHAMPVA 83

Workers' Compensation 83

Medicaid 84

When other Government agencies are responsible for your care 84

When others are responsible for injuries 84

Section 11. Definitions of terms we use in this brochure 85

Section 12. FEHB facts 88

Coverage information 88

No pre-existing condition limitation 88

Where you get information about enrolling in the FEHB Program 88

Types of coverage available for you and your family 88

Children's Equity Act 89

When benefits and premiums start 89

When you retire 90

When you lose benefits 90

-   When FEHB coverage ends 90

-   Spouse equity coverage 90

-   Temporary Continuation of Coverage (TCC) 90

-   Converting to individual coverage 90

-   Getting a Certificate of Group Health Plan Coverage 90

Two new Federal Programs complement FEHB benefits 92

> The Federal Flexible Spending Account Program -- *FSAFEDS* 92
>
> The Federal Long Term Care Insurance Program 95

Index 96

Summary of benefits -- High Option 99

Summary of benefits -- Consumer-driven Option 100

Rates Back Cover

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  Introduction

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This brochure describes the benefits of APWU Health Plan under our
contract (CS 1370) with the United States Office of Personnel
Management, as authorized by the Federal Employees Health Benefits law.
This plan is underwritten by the American Postal Workers Union, AFL-CIO.
The address for the APWU Health Plan administrative office is:

**APWU Health Plan**

**P.O. Box 3279**

**Silver Spring, MD 20918**

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 at the end of this brochure.

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  Plain Language

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

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

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

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

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

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  Stop Health Care Fraud!

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

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at 800/222-APWU
    and explain the situation.

-   If we do not resolve the issue:

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

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

-   Your child age 22 (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.

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  Preventing medical mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

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

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

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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

    Want more information on patient safety?

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

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

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

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

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

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

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

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

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

**We also have Preferred Provider Organizations (PPO**) Our
fee-for-service plans offer services through PPO networks. When you use
our network providers, you will receive covered services at reduced
cost. APWU Health Plan is solely responsible for the selection of PPO
providers in your area. The PPO networks for the High Option and the
Consumer-driven Option are different.

**High Option PPO Network:** Contact APWU Health Plan at 800/222-APWU to
request a High Option PPO directory. You can also go to our Web page,
which you can reach through the FEHB website,
[www.opm.gov/insure](http://www.opm.gov/insure). If you need assistance
in identifying a participating provider or to verify their continued
participation, call the Plan's PPO administrator for your state:
Alliance PPO, Inc. 800/342-3289 for providers in the District of
Columbia, Maryland, Virginia and West Virginia; Beech Street
800/923-3248 for providers in Arkansas, California, Florida, Montana,
Nebraska, Nevada, New Mexico, Ohio, Oklahoma, Pennsylvania, South
Carolina, Washington and Wisconsin; First Health 800/447-1704 for
providers in Alaska, Hawaii, Idaho, Iowa, Kansas, Massachusetts,
Mississippi, New Hampshire, North Carolina, North Dakota, Oregon, Puerto
Rico, Rhode Island, South Dakota, Utah, Vermont and Wyoming; MagnaCare
888/211-8704 for providers in New Jersey; MultiPlan 800/672-2140 for
providers in Arizona, Connecticut, Louisiana and New York; MedNet
800/556-1144 for providers in Maine; Private Healthcare Systems (PHCS)
800/661-7563 for providers in Alabama, Colorado, Delaware, Georgia,
Illinois, Indiana, Kentucky, Michigan, Missouri, Tennessee and Texas;
PreferredOne 800/451-9597 for providers in Minnesota; or V.I. Equicare
340/774-5779 for providers in the U.S. Virgin Islands. For mental
conditions/substance abuse providers (all states), call ValueOptions
toll-free 888/700-7965.

**Consumer-driven Option PPO Network:** If you need assistance
identifying a participating provider or to verify their continued
participation, call the Plan\'s Consumer-driven Option administrator,
Definity Health of St. Louis Park, MN, at 866/833-3463 or you can go to
their Web page,
[www.definityhealth.com](http://www.definityhealth.com/), User ID:
**APWUHP** Password: **HPINFO** for a full nationwide online provider
directory. Printed provider directories are **not** available.

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

How we pay providers

PPO Providers: Allowable benefits are based upon charges and discounts
which we or our PPO administrators have negotiated with participating
providers. PPO provider charges are always within our plan allowance.

Non-PPO providers: We determine our allowance for covered charges by
using health care charge data prepared by the Health Insurance
Association of America (HIAA) or other credible sources, including our
own data, when necessary. We apply this charge data under the High
Option at the 70^th^ percentile and under the Consumer-driven Option at
the 80^th^ percentile.

**Your Rights**

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

-   Spectera/CARE Programs, is the major subcontractor performing
    hospital precertification, continued stay review and case management
    for the High Option. The American Accreditation HealthCare
    Commission/URAC has accredited them for Health Utilization
    Management since 1993 and they received Case Management
    Certification in 2003.

-   PreferredOne Administrative Services, Inc. performs hospital
    precertification, continued stay review and case management for High
    Option members in the State of Minnesota only. The American
    Accreditation HealthCare Commission/URAC has accredited them for
    Health Utilization Management since 1993, Health Network
    w/Credentialing and Health Plan since 2000.

-   ValueOptions performs hospital precertification, continued stay
    review and outpatient prior authorization for mental
    health/substance abuse services. The American Accreditation
    HealthCare Commission/URAC has accredited them for Health
    Utilization Management since 1992.

-   Alliance PPO, which provides preferred provider networks in
    specified states, has received a Credentialing Certification from
    the National Committee for Quality Assurance (NCQA) for compliance
    against the NCQA\'s 2000 Standards for Certification in
    Credentialing.

-   PHCS, which provides preferred provider networks in specific states,
    has Credentialing Certification from the National Committee for
    Quality Assurance (NCQA) and Health Network and Credentialing
    Certification from the American Accreditation HealthCare
    Commission/URAC.

-   The American Postal Workers Union Health Plan is a not-for-profit
    Voluntary Employee's Beneficiary Association (VEBA) formed in 1972.

-   We meet applicable State and Federal licensing and accreditation
    requirements for fiscal solvency, confidentiality and transfer of
    medical records.

If you want more information about us, call 800/222-APWU, or write to
APWU Health Plan, P.O. Box 3279, Silver Spring, MD 20918. You may also
contact us by fax at 301/622-5712 or visit our Web site at
[www.apwuhp.com]{.underline}.

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

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Do not rely on these change descriptions; this page is not an official
statement of benefits. For that, go to Sections 5 and 6 Benefits. Also,
we edited and clarified language throughout the brochure; any language
change not shown here is a clarification that does not change benefits.

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program -- *FSAFEDS* and the Federal Long Term Care Insurance
    Program. See page 92.

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

-   We added information regarding enrolling in Medicare. See page 21.

-   We revised the Medicare Primary Payer Chart. See page 82.

**Changes to this Plan**

**High Option**

-   Your share of the Postal premium will increase by 8.2% for Self Only
    or 8.0% for Self & Family.

-   Your share of the non-Postal premium will increase by 9.3% for Self
    Only or 9.3% for Self and Family.

-   You now pay an \$18 copay per visit to a PPO physician. Previously,
    you paid \$15.

-   You now pay an \$18 copay per in-network visit for mental conditions
    and substance abuse. Previously, you paid \$15.

-   The non-PPO calendar year deductible is now \$500 per person with a
    maximum of \$1,000 per family. Previously, this annual deductible
    was \$350 per person with a maximum of \$700 per family.

-   If you are using non-PPO providers, your catastrophic protection
    out-of-pocket maximum is \$10,000 for either a Self Only or a Self
    and Family enrollment. The limit was previously \$8,000.

-   For prescription drugs, you now pay an \$8 copay for generic drugs
    obtained from a network pharmacy for either Medicare or
    non-Medicare. Last year, you paid \$7.

-   For prescription drugs, there is now an \$8 minimum for brand name
    drugs obtained from a network pharmacy for either Medicare or
    non-Medicare. Last year, the minimum was \$5.

-   For prescription drugs, you now pay 50% with an \$8 minimum for
    prescription drugs obtained from a non-network pharmacy for either
    Medicare or non-Medicare. Last year, you paid 45% and there was no
    minimum.

-   For prescription drugs, you now pay a \$12 copay for generic drugs
    obtained through Network Mail Order for either Medicare or
    non-Medicare. Last year, you paid \$10.

-   For prescription drugs, you now pay 25% for brand name drugs
    obtained through Network Mail Order for either Medicare or
    non-Medicare. Last year, you paid 20%.

-   For prescription drugs, there is now a \$12 minimum for brand name
    drugs obtained through Network Mail Order for either Medicare or
    non-Medicare. Last year, the minimum was \$5.

-   We now cover Osteoporosis screening, once every two years, for women
    age 65 or older under Preventive Care, adult.

-   If you don't use a Plan-designated transplant facility, covered
    benefits for kidney transplants is now limited to \$50,000.
    Previously, a \$100,000 maximum was allowed.

-   We now require prior approval of certain outpatient radiological
    procedures, specifically CAT/CT/MRI/MRA/NC/PET scans.

-   For Inpatient hospital benefits, the non-PPO per admission
    deductible is now \$300. Previously, it was \$200 per admission.

-   We have changed PPO networks in the following states: Alabama,
    Arizona, Arkansas, Colorado, Connecticut, Delaware, Georgia,
    Illinois, Indiana, Kentucky, Louisiana, Michigan, Missouri, Montana,
    Nebraska, Nevada, New Jersey, New Mexico, Pennsylvania, South
    Carolina, Tennessee, Texas and Wisconsin.

**Consumer-driven Option**

-   Your share of the Postal premium will increase by 5.8% for Self Only
    or decrease by 1.0% for Self & Family.

-   Your share of the non-Postal premium will increase by 6.9% for Self
    Only or 5.1% for Self and Family.

-   We now cover Osteoporosis screening, once every two years, for women
    age 65 or over under In-network Preventive Care.

-   We have changed or added PPO networks in the following states:
    Illinois, Iowa, Nebraska, Ohio, Oklahoma, Wisconsin and Wyoming.

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

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

+----------------------+-----------------------------------------------+
| **Identification     | We will send you an identification (ID) card  |
| cards**              | when you enroll. You should carry your ID     |
|                      | card with you at all times. You must show it  |
|                      | whenever you receive services from a Plan     |
|                      | provider, or fill a prescription at a Plan    |
|                      | pharmacy. Until you receive your ID card, use |
|                      | your copy of the Health Benefits Election     |
|                      | Form, SF-2809, your health benefits           |
|                      | enrollment confirmation (for annuitants), or  |
|                      | your Employee Express confirmation letter.    |
|                      |                                               |
|                      | If you do not receive your ID card within 30  |
|                      | days after the effective date of your         |
|                      | enrollment, or if you need replacement cards, |
|                      | contact us as follows:                        |
|                      |                                               |
|                      | -   **High Option:** Call us at 800/222-APWU  |
|                      |     or write to us at P.O. Box 3279, Silver   |
|                      |     Spring, MD 20918 or through our Web site  |
|                      |     at                                        |
|                      |     [[www.apwu                                |
|                      | hp.com]{.underline}](http://www.apwuhp.com/). |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   **Consumer-driven Option:** Call Definity |
|                      |     Health at 866/833-3463 or request         |
|                      |     replacement cards through the Web site at |
|                      |     [[www.definity](                          |
|                      | http://www.definity/)health.com]{.underline}. |
+----------------------+-----------------------------------------------+
| **Where you get      | You can get care from any "covered provider"  |
| covered care**       | or "covered facility." How much we pay -- and |
|                      | you pay -- depends on the type of covered     |
|                      | provider or facility you use. If you use our  |
|                      | preferred providers, you will pay less.       |
+----------------------+-----------------------------------------------+
| -   **Covered        | > We consider the following to be covered     |
|     providers**      | > providers when they perform services within |
|                      | > the scope of their license or               |
|                      | > certification:                              |
|                      |                                               |
|                      | 1.  Doctor -- A licensed doctor of medicine   |
|                      |     (M.D.), a licensed doctor of osteopathy   |
|                      |     (D.O.), a licensed doctor of podiatry     |
|                      |     (D.P.M.), or, for certain specified       |
|                      |     services covered by this Plan, a licensed |
|                      |     dentist, licensed chiropractor, or        |
|                      |     licensed clinical psychologist practicing |
|                      |     within the scope of the license.          |
|                      |                                               |
|                      | 2.  Alternate Provider -- Alternate providers |
|                      |     are covered when performing certain       |
|                      |     specified services covered by this Plan   |
|                      |     and when such treatment is within the     |
|                      |     scope of the provider's license.          |
|                      |     Alternate providers are limited to        |
|                      |     licensed physical occupational and speech |
|                      |     therapists licensed physician's           |
|                      |     assistants; Registered Nurses (R.N.);     |
|                      |     Licensed Practical Nurses (L.P.N.);       |
|                      |     Licensed Vocational Nurses (L.V.N.); and  |
|                      |     Certified Registered Nurse Anesthetists   |
|                      |     (C.R.N.A.).                               |
|                      |                                               |
|                      | 3.  Other covered providers include a         |
|                      |     qualified clinical psychologist, clinical |
|                      |     social worker, optometrist, audiologist,  |
|                      |     nurse midwife nurse practitioner          |
|                      |     /clinical specialist, and nursing school  |
|                      |     administered clinic. For purposes of this |
|                      |     FEHB brochure, the term "doctor" includes |
|                      |     all of these providers when the services  |
|                      |     are performed within the scope of their   |
|                      |     license or certification.                 |
|                      |                                               |
|                      | > **Medically underserved areas.** Note: We   |
|                      | > cover any licensed medical practitioner for |
|                      | > any covered service performed within the    |
|                      | > scope of that license in states OPM         |
|                      | > determines are "medically underserved." For |
|                      | > 2004, the states are: Alabama, Idaho,       |
|                      | > Kentucky, Louisiana, Maine, Mississippi,    |
|                      | > Missouri, Montana, New Mexico,\             |
|                      | > North Dakota, South Carolina, South Dakota, |
|                      | > Texas, Utah, West Virginia, and Wyoming.    |
+----------------------+-----------------------------------------------+
| -   **Covered        | Covered facilities include:                   |
|     facilities**     |                                               |
|                      | -   Freestanding ambulatory facility\         |
|                      |     \                                         |
|                      |     An out-of-hospital facility such as a     |
|                      |     medical, cancer, dialysis, or surgical    |
|                      |     center or clinic, and licensed outpatient |
|                      |     facilities accredited by the Joint        |
|                      |     Commission on Accreditation of Healthcare |
|                      |     Organizations for treatment of substance  |
|                      |     abuse.                                    |
+----------------------+-----------------------------------------------+
| -   **Covered        | -   Hospital                                  |
|     facilities       |                                               |
|     *(Continued)***  | 1)  An institution which is accredited as a   |
|                      |     hospital under the Hospital Accreditation |
|                      |     Program of the Joint Commission on        |
|                      |     Accreditation of Healthcare               |
|                      |     Organizations, or                         |
|                      |                                               |
|                      | 2)  Any other institution which is operated   |
|                      |     pursuant to law, under the supervision of |
|                      |     a staff of doctors and twenty-four hour a |
|                      |     day nursing service, and which is         |
|                      |     primarily engaged in providing:           |
|                      |                                               |
|                      |     a.  general inpatient care and treatment  |
|                      |         of sick and injured persons through   |
|                      |         medical, diagnostic and major         |
|                      |         surgical facilities, all of which     |
|                      |         must be provided on its premises or   |
|                      |         under its control, or                 |
|                      |                                               |
|                      |     b.  specialized inpatient medical care    |
|                      |         and treatment of sick or injured      |
|                      |         persons through medical and           |
|                      |         diagnostic facilities (including      |
|                      |         X-ray and laboratory) on its          |
|                      |         premises, under its control, or       |
|                      |         through a written agreement with a    |
|                      |         hospital (as defined above) or with a |
|                      |         specialized provider of those         |
|                      |         facilities.                           |
|                      |                                               |
|                      | > The term "hospital" shall not include a     |
|                      | > skilled nursing facility, a convalescent    |
|                      | > nursing home or institution or part thereof |
|                      | > which 1) is used principally as a           |
|                      | > convalescent facility, rest facility,       |
|                      | > residential treatment center, nursing       |
|                      | > facility or facility for the aged or 2)     |
|                      | > furnishes primarily domiciliary or          |
|                      | > custodial care, including training in the   |
|                      | > routines of daily living.                   |
+----------------------+-----------------------------------------------+
| **What you must do   | It depends on the kind of care you want to    |
| to\                  | receive. You can go to any provider you want, |
| get covered care**   | but we must approve some care in advance.     |
+----------------------+-----------------------------------------------+
| **Transitional       | **Specialty care:** If you have a chronic or  |
| care**               | disabling condition and                       |
|                      |                                               |
|                      | -   lose access to your specialist because we |
|                      |     drop out of the Federal Employees Health  |
|                      |     Benefits (FEHB) Program and you enroll in |
|                      |     another FEHB Plan, or                     |
|                      |                                               |
|                      | -   lose access to your PPO specialist        |
|                      |     because we terminate our contract with    |
|                      |     your specialist for other than cause,     |
|                      |                                               |
|                      | you may be able to continue seeing your       |
|                      | specialist and receiving any PPO benefits for |
|                      | up to 90 days after you receive notice of the |
|                      | change. Contact us or, if we drop out of the  |
|                      | Program, contact your new plan.               |
|                      |                                               |
|                      | If you are in the second or third trimester   |
|                      | of pregnancy and you lose access to your      |
|                      | specialist based on the above circumstances,  |
|                      | you can continue to see your specialist and   |
|                      | any PPO benefits continue until the end of    |
|                      | your postpartum care, even if it is beyond    |
|                      | the 90 days.                                  |
+----------------------+-----------------------------------------------+
| **Hospital care**    | We pay for covered services from the          |
|                      | effective date of your enrollment. However,   |
|                      | if you are in the hospital when your          |
|                      | enrollment in our High Option begins, call    |
|                      | our customer service department immediately   |
|                      | at 800/222-APWU. For the Consumer-driven      |
|                      | Option, please call Definity Health at        |
|                      | 866/833-3463.                                 |
+----------------------+-----------------------------------------------+
|                      | If you changed from another FEHB plan to us,  |
|                      | your former plan will pay for the hospital    |
|                      | stay until:                                   |
|                      |                                               |
|                      | -   You are discharged, not merely moved to   |
|                      |     an alternative care center; or            |
|                      |                                               |
|                      | -   The day your benefits from your former    |
|                      |     plan run out; or                          |
|                      |                                               |
|                      | -   The 92nd day after you become a member of |
|                      |     this Plan, whichever happens first        |
|                      |                                               |
|                      | These provisions apply only to the benefits   |
|                      | of the hospitalized person. If your plan      |
|                      | terminates participation in the FEHB in whole |
|                      | or in part, or if OPM orders an enrollment    |
|                      | change, this continuation of coverage         |
|                      | provision does not apply. In such case, the   |
|                      | hospitalized family member's benefits under   |
|                      | the new plan begin on the effective date of   |
|                      | enrollment.                                   |
+----------------------+-----------------------------------------------+
| **How to Get         |                                               |
| Approval for...**    |                                               |
+----------------------+-----------------------------------------------+
| -   **Your hospital  | **Precertification** is the process by which  |
|     stay**           | -- prior to your inpatient hospital admission |
|                      | -- we evaluate the medical necessity of your  |
|                      | proposed stay and the number of days required |
|                      | to treat your condition. Unless we are misled |
|                      | by the information given to us, we won't      |
|                      | change our decision on medical necessity.     |
|                      |                                               |
|                      | In most cases, your physician or hospital     |
|                      | will take care of precertification. Because   |
|                      | you are still responsible for ensuring that   |
|                      | we are asked to precertify your care, you     |
|                      | should always ask your physician or hospital  |
|                      | whether they have contacted us.               |
+----------------------+-----------------------------------------------+
| **Warning**          | We will reduce our benefits for the inpatient |
|                      | hospital stay by \$500 if no one contacts us  |
|                      | for precertification. If the stay is not      |
|                      | medically necessary, we will not pay any      |
|                      | benefits.                                     |
+----------------------+-----------------------------------------------+
| **How to precertify  | -   High Option: You, your representative,    |
| an\                  |     your doctor, or your hospital must call   |
| admission**          |     Spectera/CARE at 800/580-8771 at least 48 |
|                      |     hours before admission. In Minnesota,     |
|                      |     call PreferredOne at 800/451-9597 to      |
|                      |     precertify. These numbers are available   |
|                      |     24 hours every day.                       |
|                      |                                               |
|                      | -   Consumer-driven Option: You, your         |
|                      |     representative, your doctor, or your      |
|                      |     hospital must call Definity Health at     |
|                      |     866/333-4648 at least 48 hours before     |
|                      |     admission. This number is available 24    |
|                      |     hours every day.                          |
|                      |                                               |
|                      | -   If you have an emergency admission due to |
|                      |     a condition that you reasonably believe   |
|                      |     puts your life in danger or could cause   |
|                      |     serious damage to bodily function, you,   |
|                      |     your representative, the doctor, or the   |
|                      |     hospital must telephone the above number  |
|                      |     48 hours following the day of the         |
|                      |     emergency admission, even if you have     |
|                      |     been discharged from the hospital.        |
|                      |                                               |
|                      | -   Provide the following information:        |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Enrollee's name and Plan identification   |
|                      |     number                                    |
|                      |                                               |
|                      | -   Patient's name, birth date, and phone     |
|                      |     number                                    |
|                      |                                               |
|                      | -   Reason for hospitalization, proposed      |
|                      |     treatment, or surgery                     |
|                      |                                               |
|                      | -   Name and phone number of admitting doctor |
|                      |                                               |
|                      | -   Name of hospital or facility; and         |
|                      |                                               |
|                      | -   Number of planned days of confinement     |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   We will then tell the doctor and/or       |
|                      |     hospital the number of approved inpatient |
|                      |     days and we will send written             |
|                      |     confirmation of our decision to you, your |
|                      |     doctor, and the hospital.                 |
+----------------------+-----------------------------------------------+
| **Maternity care**   | You do not need to precertify a maternity     |
|                      | admission for a routine delivery. However, if |
|                      | your medical condition requires you to stay   |
|                      | more than 48 hours after a vaginal delivery   |
|                      | or 96 hours after a cesarean section, then    |
|                      | your physician or the hospital must contact   |
|                      | us for precertification of additional days.   |
|                      | Further, if your baby stays after you are     |
|                      | discharged, then your physician or the        |
|                      | hospital must contact us for precertification |
|                      | of additional days for your baby.             |
+----------------------+-----------------------------------------------+
| **If your hospital   | **High Option:** If your hospital stay \--    |
| stay\                | including for maternity care \-- needs to be  |
| needs to be          | extended, you, your representative, your      |
| extended**           | doctor or the hospital must ask us to approve |
|                      | the additional days by calling Spectera/CARE  |
|                      | at 800/580-8771 or in Minnesota, call         |
|                      | PreferredOne at 800/451-9597.                 |
|                      |                                               |
|                      | **Consumer-driven Option:** If your hospital  |
|                      | stay -- including for maternity care - needs  |
|                      | to be extended, you, your representative,     |
|                      | your doctor or the hospital must ask us to    |
|                      | approve the additional days by calling        |
|                      | Definity Health at 866/333-4648.              |
+----------------------+-----------------------------------------------+
| **What happens when  | -   If no one contacted us, we will decide    |
| you\                 |     whether the hospital stay was medically   |
| do not follow the    |     necessary.                                |
| precertification     |                                               |
| rules**              | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   If we determine that the stay was         |
|                      |     medically necessary, we will pay the      |
|                      |     inpatient charges, less the \$500         |
|                      |     penalty.                                  |
+----------------------+-----------------------------------------------+
| > **What happens     | -   If we determine that it was not medically |
| > when you\          |     necessary for you to be an inpatient, we  |
| > do not follow the  |     will not pay inpatient hospital benefits. |
| > precertification   |     We will only pay for any covered medical  |
| > rules              |     supplies and services that are otherwise  |
| > (continued)**      |     payable on an outpatient basis.           |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   If we denied the precertification         |
|                      |     request, we will not pay inpatient        |
|                      |     hospital benefits. We will only pay for   |
|                      |     any covered medical supplies and services |
|                      |     that are otherwise payable on an          |
|                      |     outpatient basis.                         |
|                      |                                               |
|                      | -   When we precertified the admission but    |
|                      |     you remained in the hospital beyond the   |
|                      |     number of days we approved and did not    |
|                      |     get the additional days precertified,     |
|                      |     then:                                     |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   for the part of the admission that was    |
|                      |     medically necessary, we will pay          |
|                      |     inpatient benefits, but                   |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   for the part of the admission that was    |
|                      |     not medically necessary, we will pay only |
|                      |     medical services and supplies otherwise   |
|                      |     payable on an outpatient basis and will   |
|                      |     not pay inpatient benefits.               |
+----------------------+-----------------------------------------------+
| **Exceptions**       | You do not need precertification in these     |
|                      | cases:                                        |
|                      |                                               |
|                      | -   You are admitted to a hospital outside    |
|                      |     the United States and Puerto Rico.        |
|                      |                                               |
|                      | -   You have another group health insurance   |
|                      |     policy that is the primary payer for the  |
|                      |     hospital stay.                            |
|                      |                                               |
|                      | -   Your Medicare Part A is the primary payer |
|                      |     for the hospital stay. Note: If you       |
|                      |     exhaust your Medicare hospital benefits   |
|                      |     and do not want to use your Medicare      |
|                      |     lifetime reserve days, then we will       |
|                      |     become the primary payer and you do need  |
|                      |     precertification.                         |
+----------------------+-----------------------------------------------+
| -                    | **High Option:** Radiology precertification   |
|  **Radiology/Imaging | is required prior to scheduling specific      |
|     Procedures       | imaging procedures. We evaluate the medical   |
|                      | necessity of your proposed procedure to       |
|   Precertification** | ensure that the appropriate procedure is      |
|                      | being requested for your condition. In most   |
|                      | cases your physician will take care of the    |
|                      | precertification. Because you are responsible |
|                      | for ensuring that precertification is done,   |
|                      | you should ask your doctor to contact us.     |
|                      |                                               |
|                      | The following outpatient radiology services   |
|                      | require precertification:                     |
|                      |                                               |
|                      | CAT/CT -- Computerized Axial Tomography       |
|                      |                                               |
|                      | MRI -- Magnetic Resonance Imaging             |
|                      |                                               |
|                      | MRA -- Magnetic Resonance Angiography         |
|                      |                                               |
|                      | NC -- Nuclear Cardiology                      |
|                      |                                               |
|                      | PET -- Positron Emission Tomography           |
+----------------------+-----------------------------------------------+
| **How to precertify  | For these outpatient studies; you, your       |
| a radiology/imaging  | representative or doctor must call            |
| procedure**          | MedSolutions before scheduling the procedure. |
|                      | The toll free number is 888/693-3298.         |
|                      |                                               |
|                      | -   Provide the following information:        |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Patient\'s name, Plan identification      |
|                      |     number, and birth date                    |
|                      |                                               |
|                      | -   Requested procedure and clinical support  |
|                      |     for request                               |
|                      |                                               |
|                      | -   Name and phone number of ordering         |
|                      |     provider                                  |
|                      |                                               |
|                      | -   Name of requested imaging facility        |
+----------------------+-----------------------------------------------+
| **Exceptions**       | You do not need precertification in these     |
|                      | cases:                                        |
|                      |                                               |
|                      | -   You have another health insurance policy  |
|                      |     that is primary including Medicare Parts  |
|                      |     A&B or Part B Only                        |
|                      |                                               |
|                      | -   The procedure is performed outside the    |
|                      |     United States or Puerto Rico              |
|                      |                                               |
|                      | -   You are inpatient hospital                |
|                      |                                               |
|                      | -   The procedure is performed as an          |
|                      |     emergenc**y**                             |
+----------------------+-----------------------------------------------+
| **Warning**          | We will reduce our benefits for these         |
|                      | procedures by \$100 if no one contacts us for |
|                      | precertification. If the procedure is not     |
|                      | medically necessary, we will not pay any      |
|                      | benefits.                                     |
+----------------------+-----------------------------------------------+
| -   **Other          | Some services require prior approval **(High  |
|     services**       | Option)** and some require pre-notification   |
|                      | **(Consumer-driven Option)**:                 |
|                      |                                               |
|                      | **High Option:** Call Spectera/CARE at        |
|                      | 800/580-8771 if you need any of the services  |
|                      | listed below:                                 |
|                      |                                               |
|                      | **Consumer-driven Option:** Call Definity     |
|                      | Health at 866/333-4648 if you need any of the |
|                      | services listed below:                        |
|                      |                                               |
|                      | -   Prior approval/pre-notification is        |
|                      |     required for organ transplantation. Call  |
|                      |     before your first evaluation as a         |
|                      |     potential candidate.                      |
|                      |                                               |
|                      | -   Prior approval/pre-notification is        |
|                      |     required for surgical procedures which    |
|                      |     may be cosmetic in nature such as eyelid  |
|                      |     surgery (blepharoplasty) or varicose vein |
|                      |     surgery (sclerotherapy).                  |
|                      |                                               |
|                      | -   Prior approval/pre-notification is        |
|                      |     required for recognized surgery for       |
|                      |     morbid obesity or for organic impotence.  |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Prior approval/pre-notification is        |
|                      |     required for home health care such as     |
|                      |     nursing visits, infusion therapy, growth  |
|                      |     hormone therapy (GHT), rehabilitative     |
|                      |     therapy (physical, occupational or speech |
|                      |     therapy) and pulmonary rehabilitation     |
|                      |     programs.                                 |
|                      |                                               |
|                      |     -   Prior approval/pre-notification is    |
|                      |         required for durable medical          |
|                      |         equipment such as wheelchairs, oxygen |
|                      |         equipment and supplies, artificial    |
|                      |         limbs and braces and for Retin A,     |
|                      |         Botox or drugs for organic impotence. |
|                      |                                               |
|                      | Prior approval is also required for mental    |
|                      | health and substance abuse benefits,          |
|                      | inpatient or outpatient, in-network or        |
|                      | out-of-network. Under the High Option and the |
|                      | Consumer-driven Option, call ValueOptions at  |
|                      | 888/700-7965.                                 |
+----------------------+-----------------------------------------------+

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

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

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

+----------------------+------------+------------+---+------------+---+
| -   **Copayments**   | **High     |            |   |            |   |
|                      | Option:**  |            |   |            |   |
|                      | A          |            |   |            |   |
|                      | copayment  |            |   |            |   |
|                      | is a fixed |            |   |            |   |
|                      | amount of  |            |   |            |   |
|                      | money you  |            |   |            |   |
|                      | pay to the |            |   |            |   |
|                      | provider,  |            |   |            |   |
|                      | facility,  |            |   |            |   |
|                      | pharmacy,  |            |   |            |   |
|                      | etc., when |            |   |            |   |
|                      | you        |            |   |            |   |
|                      | receive    |            |   |            |   |
|                      | services.  |            |   |            |   |
|                      |            |            |   |            |   |
|                      | Example:   |            |   |            |   |
|                      | Under the  |            |   |            |   |
|                      | High       |            |   |            |   |
|                      | Option,    |            |   |            |   |
|                      | when you   |            |   |            |   |
|                      | see your   |            |   |            |   |
|                      | PPO        |            |   |            |   |
|                      | physician  |            |   |            |   |
|                      | you pay a  |            |   |            |   |
|                      | copayment  |            |   |            |   |
|                      | of \$18    |            |   |            |   |
|                      | per visit. |            |   |            |   |
|                      |            |            |   |            |   |
|                      | **Consu    |            |   |            |   |
|                      | mer-driven |            |   |            |   |
|                      | Option:**  |            |   |            |   |
|                      | There are  |            |   |            |   |
|                      | no         |            |   |            |   |
|                      | copayments |            |   |            |   |
|                      | under the  |            |   |            |   |
|                      | Consu      |            |   |            |   |
|                      | mer-driven |            |   |            |   |
|                      | Option.    |            |   |            |   |
+----------------------+------------+------------+---+------------+---+
| -   **Deductible**   | A          |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      | is a fixed |            |   |            |   |
|                      | amount of  |            |   |            |   |
|                      | covered    |            |   |            |   |
|                      | expenses   |            |   |            |   |
|                      | you must   |            |   |            |   |
|                      | incur for  |            |   |            |   |
|                      | certain    |            |   |            |   |
|                      | covered    |            |   |            |   |
|                      | services   |            |   |            |   |
|                      | and        |            |   |            |   |
|                      | supplies   |            |   |            |   |
|                      | before we  |            |   |            |   |
|                      | start      |            |   |            |   |
|                      | paying     |            |   |            |   |
|                      | benefits   |            |   |            |   |
|                      | for them.  |            |   |            |   |
|                      | Copayments |            |   |            |   |
|                      | do not     |            |   |            |   |
|                      | count      |            |   |            |   |
|                      | toward any |            |   |            |   |
|                      | d          |            |   |            |   |
|                      | eductible. |            |   |            |   |
|                      |            |            |   |            |   |
|                      | **High     |            |   |            |   |
|                      | Option**   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | -   If you |            |   |            |   |
|                      |     use    |            |   |            |   |
|                      |     PPO    |            |   |            |   |
|                      |            |            |   |            |   |
|                      | providers, |            |   |            |   |
|                      |     the    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   calendar |            |   |            |   |
|                      |     year   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |     is     |            |   |            |   |
|                      |     \$275  |            |   |            |   |
|                      |     per    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    person. |            |   |            |   |
|                      |     Under  |            |   |            |   |
|                      |     a      |            |   |            |   |
|                      |     family |            |   |            |   |
|                      |     e      |            |   |            |   |
|                      | nrollment, |            |   |            |   |
|                      |     the    |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |     is     |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  satisfied |            |   |            |   |
|                      |     for    |            |   |            |   |
|                      |     all    |            |   |            |   |
|                      |     family |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    members |            |   |            |   |
|                      |     when   |            |   |            |   |
|                      |     the    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   combined |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    covered |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   expenses |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    applied |            |   |            |   |
|                      |     to the |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   calendar |            |   |            |   |
|                      |     year   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |     for    |            |   |            |   |
|                      |     family |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    members |            |   |            |   |
|                      |     reach  |            |   |            |   |
|                      |     \$550. |            |   |            |   |
|                      |     If you |            |   |            |   |
|                      |     use    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    non-PPO |            |   |            |   |
|                      |            |            |   |            |   |
|                      | providers, |            |   |            |   |
|                      |     your   |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   calendar |            |   |            |   |
|                      |     year   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  increases |            |   |            |   |
|                      |     to a   |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    maximum |            |   |            |   |
|                      |     of     |            |   |            |   |
|                      |     \$500  |            |   |            |   |
|                      |     per    |            |   |            |   |
|                      |     person |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   (\$1,000 |            |   |            |   |
|                      |     per    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   family). |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    Whether |            |   |            |   |
|                      |     or not |            |   |            |   |
|                      |     you    |            |   |            |   |
|                      |     use    |            |   |            |   |
|                      |     PPO    |            |   |            |   |
|                      |            |            |   |            |   |
|                      | providers, |            |   |            |   |
|                      |     your   |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   calendar |            |   |            |   |
|                      |     year   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |     will   |            |   |            |   |
|                      |     not    |            |   |            |   |
|                      |     exceed |            |   |            |   |
|                      |     \$500  |            |   |            |   |
|                      |     per    |            |   |            |   |
|                      |     person |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   (\$1,000 |            |   |            |   |
|                      |     per    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   family). |            |   |            |   |
|                      |            |            |   |            |   |
|                      | -   We     |            |   |            |   |
|                      |     also   |            |   |            |   |
|                      |     have a |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   separate |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |     for    |            |   |            |   |
|                      |     mental |            |   |            |   |
|                      |     health |            |   |            |   |
|                      |     and    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  substance |            |   |            |   |
|                      |     abuse  |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  benefits. |            |   |            |   |
|                      |     The    |            |   |            |   |
|                      |            |            |   |            |   |
|                      | in-network |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |     is     |            |   |            |   |
|                      |     \$275  |            |   |            |   |
|                      |     per    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    person. |            |   |            |   |
|                      |     Under  |            |   |            |   |
|                      |     a      |            |   |            |   |
|                      |     family |            |   |            |   |
|                      |     e      |            |   |            |   |
|                      | nrollment, |            |   |            |   |
|                      |     this   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |     is     |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  satisfied |            |   |            |   |
|                      |     for    |            |   |            |   |
|                      |     all    |            |   |            |   |
|                      |     family |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    members |            |   |            |   |
|                      |     when   |            |   |            |   |
|                      |     the    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   combined |            |   |            |   |
|                      |            |            |   |            |   |
|                      | in-network |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    covered |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   expenses |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    applied |            |   |            |   |
|                      |     to     |            |   |            |   |
|                      |     this   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |     for    |            |   |            |   |
|                      |     all    |            |   |            |   |
|                      |     family |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    members |            |   |            |   |
|                      |     reach  |            |   |            |   |
|                      |     \$550. |            |   |            |   |
|                      |     The    |            |   |            |   |
|                      |     out-   |            |   |            |   |
|                      | of-network |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |     is     |            |   |            |   |
|                      |     \$750  |            |   |            |   |
|                      |     per    |            |   |            |   |
|                      |     person |            |   |            |   |
|                      |     each   |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   calendar |            |   |            |   |
|                      |     year   |            |   |            |   |
|                      |     with   |            |   |            |   |
|                      |     no     |            |   |            |   |
|                      |     family |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   maximum. |            |   |            |   |
|                      |            |            |   |            |   |
|                      | Note: If   |            |   |            |   |
|                      | you change |            |   |            |   |
|                      | plans      |            |   |            |   |
|                      | during     |            |   |            |   |
|                      | Open       |            |   |            |   |
|                      | Season,    |            |   |            |   |
|                      | you do not |            |   |            |   |
|                      | have to    |            |   |            |   |
|                      | start a    |            |   |            |   |
|                      | new        |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      | under your |            |   |            |   |
|                      | old plan   |            |   |            |   |
|                      | between    |            |   |            |   |
|                      | January 1  |            |   |            |   |
|                      | and the    |            |   |            |   |
|                      | effective  |            |   |            |   |
|                      | date of    |            |   |            |   |
|                      | your new   |            |   |            |   |
|                      | plan. If   |            |   |            |   |
|                      | you change |            |   |            |   |
|                      | plans at   |            |   |            |   |
|                      | another    |            |   |            |   |
|                      | time       |            |   |            |   |
|                      | during the |            |   |            |   |
|                      | year, you  |            |   |            |   |
|                      | must begin |            |   |            |   |
|                      | a new      |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      | under your |            |   |            |   |
|                      | new plan.  |            |   |            |   |
|                      |            |            |   |            |   |
|                      | And, if    |            |   |            |   |
|                      | you change |            |   |            |   |
|                      | from Self  |            |   |            |   |
|                      | and Family |            |   |            |   |
|                      | to Self    |            |   |            |   |
|                      | Only, or   |            |   |            |   |
|                      | from Self  |            |   |            |   |
|                      | Only to    |            |   |            |   |
|                      | Self and   |            |   |            |   |
|                      | Family     |            |   |            |   |
|                      | during the |            |   |            |   |
|                      | year, we   |            |   |            |   |
|                      | will       |            |   |            |   |
|                      | credit the |            |   |            |   |
|                      | amount of  |            |   |            |   |
|                      | covered    |            |   |            |   |
|                      | expenses   |            |   |            |   |
|                      | already    |            |   |            |   |
|                      | applied    |            |   |            |   |
|                      | toward the |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      | of your    |            |   |            |   |
|                      | old        |            |   |            |   |
|                      | enrollment |            |   |            |   |
|                      | to the     |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      | of your    |            |   |            |   |
|                      | new        |            |   |            |   |
|                      | e          |            |   |            |   |
|                      | nrollment. |            |   |            |   |
|                      | However,   |            |   |            |   |
|                      | if you     |            |   |            |   |
|                      | change     |            |   |            |   |
|                      | from High  |            |   |            |   |
|                      | Option to  |            |   |            |   |
|                      | Consu      |            |   |            |   |
|                      | mer-driven |            |   |            |   |
|                      | Option, or |            |   |            |   |
|                      | from       |            |   |            |   |
|                      | Consu      |            |   |            |   |
|                      | mer-driven |            |   |            |   |
|                      | Option to  |            |   |            |   |
|                      | High       |            |   |            |   |
|                      | Option,    |            |   |            |   |
|                      | during the |            |   |            |   |
|                      | year,      |            |   |            |   |
|                      | expenses   |            |   |            |   |
|                      | incurred   |            |   |            |   |
|                      | as of the  |            |   |            |   |
|                      | effective  |            |   |            |   |
|                      | date of    |            |   |            |   |
|                      | the option |            |   |            |   |
|                      | change are |            |   |            |   |
|                      | subject to |            |   |            |   |
|                      | the        |            |   |            |   |
|                      | benefit    |            |   |            |   |
|                      | provisions |            |   |            |   |
|                      | of your    |            |   |            |   |
|                      | new        |            |   |            |   |
|                      | option.    |            |   |            |   |
|                      |            |            |   |            |   |
|                      | **Consu    |            |   |            |   |
|                      | mer-driven |            |   |            |   |
|                      | Option:**  |            |   |            |   |
|                      | There is   |            |   |            |   |
|                      | no         |            |   |            |   |
|                      | calendar   |            |   |            |   |
|                      | year       |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      | under the  |            |   |            |   |
|                      | Consu      |            |   |            |   |
|                      | mer-driven |            |   |            |   |
|                      | Option.    |            |   |            |   |
|                      | Also,      |            |   |            |   |
|                      | there is   |            |   |            |   |
|                      | no         |            |   |            |   |
|                      | separate   |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      | for mental |            |   |            |   |
|                      | health and |            |   |            |   |
|                      | substance  |            |   |            |   |
|                      | abuse      |            |   |            |   |
|                      | benefits   |            |   |            |   |
|                      | under the  |            |   |            |   |
|                      | Consu      |            |   |            |   |
|                      | mer-driven |            |   |            |   |
|                      | Option.    |            |   |            |   |
+----------------------+------------+------------+---+------------+---+
| -   **Coinsurance**  | **High     |            |   |            |   |
|                      | Option:**  |            |   |            |   |
|                      | C          |            |   |            |   |
|                      | oinsurance |            |   |            |   |
|                      | is the     |            |   |            |   |
|                      | percentage |            |   |            |   |
|                      | of our     |            |   |            |   |
|                      | allowance  |            |   |            |   |
|                      | that you   |            |   |            |   |
|                      | must pay   |            |   |            |   |
|                      | for your   |            |   |            |   |
|                      | care.      |            |   |            |   |
|                      | C          |            |   |            |   |
|                      | oinsurance |            |   |            |   |
|                      | doesn't    |            |   |            |   |
|                      | begin      |            |   |            |   |
|                      | until you  |            |   |            |   |
|                      | meet your  |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      | **(High    |            |   |            |   |
|                      | Option)**  |            |   |            |   |
|                      | or your    |            |   |            |   |
|                      | Member     |            |   |            |   |
|                      | Resp       |            |   |            |   |
|                      | onsibility |            |   |            |   |
|                      | **(Consu   |            |   |            |   |
|                      | mer-driven |            |   |            |   |
|                      | Option).** |            |   |            |   |
|                      |            |            |   |            |   |
|                      | Example:   |            |   |            |   |
|                      | You pay    |            |   |            |   |
|                      | 30% of our |            |   |            |   |
|                      | allowance  |            |   |            |   |
|                      | for office |            |   |            |   |
|                      | visits to  |            |   |            |   |
|                      | a non-PPO  |            |   |            |   |
|                      | physician. |            |   |            |   |
|                      |            |            |   |            |   |
|                      | Note: If   |            |   |            |   |
|                      | your       |            |   |            |   |
|                      | provider   |            |   |            |   |
|                      | routinely  |            |   |            |   |
|                      | waives     |            |   |            |   |
|                      | (does not  |            |   |            |   |
|                      | require    |            |   |            |   |
|                      | you to     |            |   |            |   |
|                      | pay) your  |            |   |            |   |
|                      | c          |            |   |            |   |
|                      | opayments, |            |   |            |   |
|                      | de         |            |   |            |   |
|                      | ductibles, |            |   |            |   |
|                      | or         |            |   |            |   |
|                      | co         |            |   |            |   |
|                      | insurance, |            |   |            |   |
|                      | the        |            |   |            |   |
|                      | provider   |            |   |            |   |
|                      | is         |            |   |            |   |
|                      | misstating |            |   |            |   |
|                      | the fee    |            |   |            |   |
|                      | and may be |            |   |            |   |
|                      | violating  |            |   |            |   |
|                      | the law.   |            |   |            |   |
|                      | In this    |            |   |            |   |
|                      | case, when |            |   |            |   |
|                      | we         |            |   |            |   |
|                      | calculate  |            |   |            |   |
|                      | our share, |            |   |            |   |
|                      | we will    |            |   |            |   |
|                      | reduce the |            |   |            |   |
|                      | provider's |            |   |            |   |
|                      | fee by the |            |   |            |   |
|                      | amount     |            |   |            |   |
|                      | waived.    |            |   |            |   |
+----------------------+------------+------------+---+------------+---+
|                      | For        |            |   |            |   |
|                      | example,   |            |   |            |   |
|                      | if your    |            |   |            |   |
|                      | physician  |            |   |            |   |
|                      | ordinarily |            |   |            |   |
|                      | charges    |            |   |            |   |
|                      | \$100 for  |            |   |            |   |
|                      | a service  |            |   |            |   |
|                      | but        |            |   |            |   |
|                      | routinely  |            |   |            |   |
|                      | waives     |            |   |            |   |
|                      | your 30%   |            |   |            |   |
|                      | co         |            |   |            |   |
|                      | insurance, |            |   |            |   |
|                      | the actual |            |   |            |   |
|                      | charge is  |            |   |            |   |
|                      | \$70. We   |            |   |            |   |
|                      | will pay   |            |   |            |   |
|                      | \$49 (70%  |            |   |            |   |
|                      | of the     |            |   |            |   |
|                      | actual     |            |   |            |   |
|                      | charge of  |            |   |            |   |
|                      | \$70).     |            |   |            |   |
|                      |            |            |   |            |   |
|                      | **Consu    |            |   |            |   |
|                      | mer-driven |            |   |            |   |
|                      | Option:**  |            |   |            |   |
|                      | C          |            |   |            |   |
|                      | oinsurance |            |   |            |   |
|                      | is the     |            |   |            |   |
|                      | percentage |            |   |            |   |
|                      | of our     |            |   |            |   |
|                      | allowance  |            |   |            |   |
|                      | that you   |            |   |            |   |
|                      | must pay   |            |   |            |   |
|                      | for your   |            |   |            |   |
|                      | care after |            |   |            |   |
|                      | you have   |            |   |            |   |
|                      | used up    |            |   |            |   |
|                      | your       |            |   |            |   |
|                      | Personal   |            |   |            |   |
|                      | Care       |            |   |            |   |
|                      | Account    |            |   |            |   |
|                      | (PCA) and  |            |   |            |   |
|                      | paid your  |            |   |            |   |
|                      | Member     |            |   |            |   |
|                      | Respo      |            |   |            |   |
|                      | nsibility. |            |   |            |   |
+----------------------+------------+------------+---+------------+---+
| -   **Member         | **High     |            |   |            |   |
|     Responsibility** | Option:    |            |   |            |   |
|                      | Does not   |            |   |            |   |
|                      | apply.**   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | **Consu    |            |   |            |   |
|                      | mer-driven |            |   |            |   |
|                      | Option:**  |            |   |            |   |
|                      | Your       |            |   |            |   |
|                      | Member     |            |   |            |   |
|                      | Resp       |            |   |            |   |
|                      | onsibility |            |   |            |   |
|                      | is your    |            |   |            |   |
|                      | bridge     |            |   |            |   |
|                      | between    |            |   |            |   |
|                      | your       |            |   |            |   |
|                      | Personal   |            |   |            |   |
|                      | Care       |            |   |            |   |
|                      | Account    |            |   |            |   |
|                      | (PCA) and  |            |   |            |   |
|                      | your       |            |   |            |   |
|                      | T          |            |   |            |   |
|                      | raditional |            |   |            |   |
|                      | Health     |            |   |            |   |
|                      | Coverage.  |            |   |            |   |
|                      | After you  |            |   |            |   |
|                      | have       |            |   |            |   |
|                      | exhausted  |            |   |            |   |
|                      | your PCA,  |            |   |            |   |
|                      | you must   |            |   |            |   |
|                      | pay your   |            |   |            |   |
|                      | Member     |            |   |            |   |
|                      | Resp       |            |   |            |   |
|                      | onsibility |            |   |            |   |
|                      | before     |            |   |            |   |
|                      | your       |            |   |            |   |
|                      | T          |            |   |            |   |
|                      | raditional |            |   |            |   |
|                      | Health     |            |   |            |   |
|                      | Coverage   |            |   |            |   |
|                      | begins.    |            |   |            |   |
|                      | Your       |            |   |            |   |
|                      | Member     |            |   |            |   |
|                      | Resp       |            |   |            |   |
|                      | onsibility |            |   |            |   |
|                      | is         |            |   |            |   |
|                      | generally  |            |   |            |   |
|                      | \$600 for  |            |   |            |   |
|                      | a Self     |            |   |            |   |
|                      | Only       |            |   |            |   |
|                      | enrollment |            |   |            |   |
|                      | or \$1,200 |            |   |            |   |
|                      | for a Self |            |   |            |   |
|                      | and Family |            |   |            |   |
|                      | e          |            |   |            |   |
|                      | nrollment. |            |   |            |   |
|                      | Your       |            |   |            |   |
|                      | Member     |            |   |            |   |
|                      | Resp       |            |   |            |   |
|                      | onsibility |            |   |            |   |
|                      | in         |            |   |            |   |
|                      | subsequent |            |   |            |   |
|                      | years may  |            |   |            |   |
|                      | be reduced |            |   |            |   |
|                      | by rolling |            |   |            |   |
|                      | over any   |            |   |            |   |
|                      | unused     |            |   |            |   |
|                      | portion of |            |   |            |   |
|                      | your       |            |   |            |   |
|                      | Personal   |            |   |            |   |
|                      | Care       |            |   |            |   |
|                      | Account    |            |   |            |   |
|                      | remaining  |            |   |            |   |
|                      | at the end |            |   |            |   |
|                      | of the     |            |   |            |   |
|                      | calendar   |            |   |            |   |
|                      | year(s).   |            |   |            |   |
+----------------------+------------+------------+---+------------+---+
| -   **Differences    | **High     |            |   |            |   |
|     between our      | Option:**  |            |   |            |   |
|     allowance and    | Our "Plan  |            |   |            |   |
|     the bill**       | allowance" |            |   |            |   |
|                      | is the     |            |   |            |   |
|                      | amount we  |            |   |            |   |
|                      | use to     |            |   |            |   |
|                      | calculate  |            |   |            |   |
|                      | our        |            |   |            |   |
|                      | payment    |            |   |            |   |
|                      | for        |            |   |            |   |
|                      | covered    |            |   |            |   |
|                      | services.  |            |   |            |   |
|                      | Fee-f      |            |   |            |   |
|                      | or-service |            |   |            |   |
|                      | plans      |            |   |            |   |
|                      | arrive at  |            |   |            |   |
|                      | their      |            |   |            |   |
|                      | allowances |            |   |            |   |
|                      | in         |            |   |            |   |
|                      | different  |            |   |            |   |
|                      | ways, so   |            |   |            |   |
|                      | their      |            |   |            |   |
|                      | allowances |            |   |            |   |
|                      | vary. For  |            |   |            |   |
|                      | more       |            |   |            |   |
|                      | i          |            |   |            |   |
|                      | nformation |            |   |            |   |
|                      | about how  |            |   |            |   |
|                      | we         |            |   |            |   |
|                      | determine  |            |   |            |   |
|                      | our Plan   |            |   |            |   |
|                      | allowance, |            |   |            |   |
|                      | see the    |            |   |            |   |
|                      | definition |            |   |            |   |
|                      | of Plan    |            |   |            |   |
|                      | allowance  |            |   |            |   |
|                      | in Section |            |   |            |   |
|                      | 11.        |            |   |            |   |
|                      |            |            |   |            |   |
|                      | Often, the |            |   |            |   |
|                      | provider's |            |   |            |   |
|                      | bill is    |            |   |            |   |
|                      | more than  |            |   |            |   |
|                      | a          |            |   |            |   |
|                      | fee-f      |            |   |            |   |
|                      | or-service |            |   |            |   |
|                      | plan's     |            |   |            |   |
|                      | allowance. |            |   |            |   |
|                      | Whether or |            |   |            |   |
|                      | not you    |            |   |            |   |
|                      | have to    |            |   |            |   |
|                      | pay the    |            |   |            |   |
|                      | difference |            |   |            |   |
|                      | between    |            |   |            |   |
|                      | our        |            |   |            |   |
|                      | allowance  |            |   |            |   |
|                      | and the    |            |   |            |   |
|                      | bill will  |            |   |            |   |
|                      | depend on  |            |   |            |   |
|                      | the        |            |   |            |   |
|                      | provider   |            |   |            |   |
|                      | you use.   |            |   |            |   |
+----------------------+------------+------------+---+------------+---+
|                      | -   **PPO  |            |   |            |   |
|                      |     p      |            |   |            |   |
|                      | roviders** |            |   |            |   |
|                      |     agree  |            |   |            |   |
|                      |     to     |            |   |            |   |
|                      |     limit  |            |   |            |   |
|                      |     what   |            |   |            |   |
|                      |     they   |            |   |            |   |
|                      |     will   |            |   |            |   |
|                      |     bill   |            |   |            |   |
|                      |     you.   |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    Because |            |   |            |   |
|                      |     of     |            |   |            |   |
|                      |     that,  |            |   |            |   |
|                      |     when   |            |   |            |   |
|                      |     you    |            |   |            |   |
|                      |     use a  |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  preferred |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  provider, |            |   |            |   |
|                      |     your   |            |   |            |   |
|                      |     share  |            |   |            |   |
|                      |     of     |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    covered |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    charges |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   consists |            |   |            |   |
|                      |     only   |            |   |            |   |
|                      |     of     |            |   |            |   |
|                      |     your   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |     and    |            |   |            |   |
|                      |     c      |            |   |            |   |
|                      | oinsurance |            |   |            |   |
|                      |     or     |            |   |            |   |
|                      |            |            |   |            |   |
|                      | copayment. |            |   |            |   |
|                      |     Here   |            |   |            |   |
|                      |     is an  |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    example |            |   |            |   |
|                      |     about  |            |   |            |   |
|                      |     co     |            |   |            |   |
|                      | insurance: |            |   |            |   |
|                      |     You    |            |   |            |   |
|                      |     see a  |            |   |            |   |
|                      |     PPO    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  physician |            |   |            |   |
|                      |     who    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    charges |            |   |            |   |
|                      |     \$150, |            |   |            |   |
|                      |     but    |            |   |            |   |
|                      |     our    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  allowance |            |   |            |   |
|                      |     is     |            |   |            |   |
|                      |     \$100. |            |   |            |   |
|                      |     If you |            |   |            |   |
|                      |     have   |            |   |            |   |
|                      |     met    |            |   |            |   |
|                      |     your   |            |   |            |   |
|                      |     d      |            |   |            |   |
|                      | eductible, |            |   |            |   |
|                      |     you    |            |   |            |   |
|                      |     are    |            |   |            |   |
|                      |     only   |            |   |            |   |
|                      |     r      |            |   |            |   |
|                      | esponsible |            |   |            |   |
|                      |     for    |            |   |            |   |
|                      |     your   |            |   |            |   |
|                      |     co     |            |   |            |   |
|                      | insurance. |            |   |            |   |
|                      |     That   |            |   |            |   |
|                      |     is,    |            |   |            |   |
|                      |     you    |            |   |            |   |
|                      |     pay    |            |   |            |   |
|                      |     just   |            |   |            |   |
|                      |     \--    |            |   |            |   |
|                      |     10% of |            |   |            |   |
|                      |     our    |            |   |            |   |
|                      |     \$100  |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  allowance |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    (\$10). |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    Because |            |   |            |   |
|                      |     of the |            |   |            |   |
|                      |            |            |   |            |   |
|                      | agreement, |            |   |            |   |
|                      |     your   |            |   |            |   |
|                      |     PPO    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  physician |            |   |            |   |
|                      |     will   |            |   |            |   |
|                      |     not    |            |   |            |   |
|                      |     bill   |            |   |            |   |
|                      |     you    |            |   |            |   |
|                      |     for    |            |   |            |   |
|                      |     the    |            |   |            |   |
|                      |     \$50   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | difference |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    between |            |   |            |   |
|                      |     our    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  allowance |            |   |            |   |
|                      |     and    |            |   |            |   |
|                      |     his    |            |   |            |   |
|                      |     bill.  |            |   |            |   |
|                      |            |            |   |            |   |
|                      | -          |            |   |            |   |
|                      |  **Non-PPO |            |   |            |   |
|                      |     pr     |            |   |            |   |
|                      | oviders**, |            |   |            |   |
|                      |     on the |            |   |            |   |
|                      |     other  |            |   |            |   |
|                      |     hand,  |            |   |            |   |
|                      |     have   |            |   |            |   |
|                      |     no     |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  agreement |            |   |            |   |
|                      |     to     |            |   |            |   |
|                      |     limit  |            |   |            |   |
|                      |     what   |            |   |            |   |
|                      |     they   |            |   |            |   |
|                      |     will   |            |   |            |   |
|                      |     bill   |            |   |            |   |
|                      |     you.   |            |   |            |   |
|                      |     When   |            |   |            |   |
|                      |     you    |            |   |            |   |
|                      |     use a  |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    non-PPO |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  provider, |            |   |            |   |
|                      |     you    |            |   |            |   |
|                      |     will   |            |   |            |   |
|                      |     pay    |            |   |            |   |
|                      |     your   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | deductible |            |   |            |   |
|                      |     and    |            |   |            |   |
|                      |     c      |            |   |            |   |
|                      | oinsurance |            |   |            |   |
|                      |     \--    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   **plus** |            |   |            |   |
|                      |     any    |            |   |            |   |
|                      |            |            |   |            |   |
|                      | difference |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    between |            |   |            |   |
|                      |     our    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  allowance |            |   |            |   |
|                      |     and    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    charges |            |   |            |   |
|                      |     on the |            |   |            |   |
|                      |     bill.  |            |   |            |   |
|                      |     Here   |            |   |            |   |
|                      |     is an  |            |   |            |   |
|                      |            |            |   |            |   |
|                      |   example: |            |   |            |   |
|                      |     You    |            |   |            |   |
|                      |     see a  |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    non-PPO |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  physician |            |   |            |   |
|                      |     who    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    charges |            |   |            |   |
|                      |     \$150  |            |   |            |   |
|                      |     and    |            |   |            |   |
|                      |     our    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  allowance |            |   |            |   |
|                      |     is     |            |   |            |   |
|                      |     again  |            |   |            |   |
|                      |     \$100. |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    Because |            |   |            |   |
|                      |     you've |            |   |            |   |
|                      |     met    |            |   |            |   |
|                      |     your   |            |   |            |   |
|                      |     d      |            |   |            |   |
|                      | eductible, |            |   |            |   |
|                      |     you    |            |   |            |   |
|                      |     are    |            |   |            |   |
|                      |     r      |            |   |            |   |
|                      | esponsible |            |   |            |   |
|                      |     for    |            |   |            |   |
|                      |     your   |            |   |            |   |
|                      |     co     |            |   |            |   |
|                      | insurance, |            |   |            |   |
|                      |     so you |            |   |            |   |
|                      |     pay    |            |   |            |   |
|                      |     30% of |            |   |            |   |
|                      |     our    |            |   |            |   |
|                      |     \$100  |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  allowance |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    (\$30). |            |   |            |   |
|                      |     Plus,  |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    because |            |   |            |   |
|                      |     there  |            |   |            |   |
|                      |     is no  |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  agreement |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    between |            |   |            |   |
|                      |     the    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    non-PPO |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  physician |            |   |            |   |
|                      |     and    |            |   |            |   |
|                      |     us, he |            |   |            |   |
|                      |     can    |            |   |            |   |
|                      |     bill   |            |   |            |   |
|                      |     you    |            |   |            |   |
|                      |     for    |            |   |            |   |
|                      |     the    |            |   |            |   |
|                      |     \$50   |            |   |            |   |
|                      |            |            |   |            |   |
|                      | difference |            |   |            |   |
|                      |            |            |   |            |   |
|                      |    between |            |   |            |   |
|                      |     our    |            |   |            |   |
|                      |            |            |   |            |   |
|                      |  allowance |            |   |            |   |
|                      |     and    |            |   |            |   |
|                      |     his    |            |   |            |   |
|                      |     bill.  |            |   |            |   |
|                      |            |            |   |            |   |
|                      | The        |            |   |            |   |
|                      | following  |            |   |            |   |
|                      | table      |            |   |            |   |
|                      | i          |            |   |            |   |
|                      | llustrates |            |   |            |   |
|                      | the        |            |   |            |   |
|                      | examples   |            |   |            |   |
|                      | of how     |            |   |            |   |
|                      | much you   |            |   |            |   |
|                      | have to    |            |   |            |   |
|                      | pay        |            |   |            |   |
|                      | out        |            |   |            |   |
|                      | -of-pocket |            |   |            |   |
|                      | for        |            |   |            |   |
|                      | services   |            |   |            |   |
|                      | from a PPO |            |   |            |   |
|                      | physician  |            |   |            |   |
|                      | vs. a      |            |   |            |   |
|                      | non-PPO    |            |   |            |   |
|                      | physician. |            |   |            |   |
|                      | The table  |            |   |            |   |
|                      | uses our   |            |   |            |   |
|                      | example of |            |   |            |   |
|                      | a service  |            |   |            |   |
|                      | for which  |            |   |            |   |
|                      | the        |            |   |            |   |
|                      | physician  |            |   |            |   |
|                      | charges    |            |   |            |   |
|                      | \$150 and  |            |   |            |   |
|                      | our        |            |   |            |   |
|                      | allowance  |            |   |            |   |
|                      | is \$100.  |            |   |            |   |
|                      | The table  |            |   |            |   |
|                      | shows the  |            |   |            |   |
|                      | amount you |            |   |            |   |
|                      | pay if you |            |   |            |   |
|                      | have met   |            |   |            |   |
|                      | your       |            |   |            |   |
|                      | calendar   |            |   |            |   |
|                      | year       |            |   |            |   |
|                      | deductible |            |   |            |   |
+----------------------+------------+------------+---+------------+---+
|                      | *          | **PPO      |   | **Non-PPO  |   |
|                      | *EXAMPLE** | p          |   | p          |   |
|                      |            | hysician** |   | hysician** |   |
+----------------------+------------+------------+---+------------+---+
|                      | P          |            | \ |            | \ |
|                      | hysician's |            | $ |            | $ |
|                      | charge     |            | 1 |            | 1 |
|                      |            |            | 5 |            | 5 |
|                      |            |            | 0 |            | 0 |
+----------------------+------------+------------+---+------------+---+
|                      | Our        | We set it  | 1 | We set it  | 1 |
|                      | allowance  | at:        | 0 | at:        | 0 |
|                      |            |            | 0 |            | 0 |
+----------------------+------------+------------+---+------------+---+
|                      | We pay     | 90% of our | 9 | 70% of our | 7 |
|                      |            | allowance: | 0 | allowance: | 0 |
+----------------------+------------+------------+---+------------+---+
|                      | You owe:   | 10% of our | 1 | 30% of our | 3 |
|                      | C          | allowance: | 0 | allowance: | 0 |
|                      | oinsurance |            |   |            |   |
+----------------------+------------+------------+---+------------+---+
|                      | +          | No:        | 0 | Yes:       | 5 |
|                      | Difference |            |   |            | 0 |
|                      | up to      |            |   |            |   |
|                      | charge?    |            |   |            |   |
+----------------------+------------+------------+---+------------+---+
|                      | **TOTAL    |            | \ |            | \ |
|                      | YOU PAY**  |            | $ |            | $ |
|                      |            |            | 1 |            | 8 |
|                      |            |            | 0 |            | 0 |
+----------------------+------------+------------+---+------------+---+

+----------------------+-----------------------------------------------+
|                      | **Consumer-driven Option:**                   |
|                      |                                               |
|                      | -   **PPO providers** agree to accept our     |
|                      |     plan allowance so if you use a PPO        |
|                      |     Provider, you never have to worry about   |
|                      |     paying the difference between the plan    |
|                      |     allowance and the billed amount for       |
|                      |     covered services. If your covered         |
|                      |     expenses are being paid out of your       |
|                      |     Personal Care Account or if you are       |
|                      |     receiving in-network covered preventive   |
|                      |     services, the plan will pay 100%. If you  |
|                      |     have exhausted your Personal Care         |
|                      |     Account, you will be responsible for      |
|                      |     paying your Member Responsibility and     |
|                      |     also coinsurance under the Traditional    |
|                      |     Health Coverage.                          |
|                      |                                               |
|                      | -   **Non PPO Providers:** If you use a       |
|                      |     non-PPO provider, you will have to pay    |
|                      |     the difference between the plan allowance |
|                      |     and the billed amount only if you use up  |
|                      |     your Personal Care Account for the year.  |
|                      |     Note that it usually makes sense to use   |
|                      |     PPO providers because it will make your   |
|                      |     Personal Care Account go much further     |
|                      |     since money left in your Personal Care    |
|                      |     Account can be rolled over to be used in  |
|                      |     the next year.                            |
+----------------------+-----------------------------------------------+
| **Your catastrophic  | There is a limit to the amount you must pay   |
| protection           | out-of-pocket for coinsurance for the year    |
| out-of-pocket        | for certain charges. When you have reached    |
| maximum for          | this limit, you pay no coinsurance for        |
| deductibles,         | covered services for the remainder of the     |
| coinsurance,         | calendar year.                                |
| copayments, and      |                                               |
| Member               | **High Option:**                              |
| Responsibility**     |                                               |
|                      | **PPO benefit**: Your out-of-pocket maximum   |
|                      | is \$4,000 for either a Self Only or a Self   |
|                      | and Family enrollment if you are using PPO    |
|                      | providers. Only eligible expenses for PPO     |
|                      | providers count toward this limit.            |
|                      |                                               |
|                      | **Non-PPO benefit**: Your out-of-pocket       |
|                      | maximum is \$10,000 for either a Self Only or |
|                      | a Self and Family enrollment if you are using |
|                      | non-PPO providers. Eligible expenses for      |
|                      | network providers also count toward this      |
|                      | limit. Your eligible out-of-pocket expenses   |
|                      | will not exceed this amount whether or not    |
|                      | you use network providers.                    |
|                      |                                               |
|                      | Out-of-pocket expenses for the purposes of    |
|                      | this benefit are:                             |
|                      |                                               |
|                      | -   The 10% you pay for PPO Inpatient         |
|                      |     hospital charges, Surgical, Maternity and |
|                      |     Diagnostic and treatment services         |
|                      |                                               |
|                      | -   The 30% you pay for non-PPO Inpatient     |
|                      |     hospital charges, Surgical, Maternity and |
|                      |     Diagnostic and treatment services; and    |
|                      |                                               |
|                      | -   The copayment of \$18 for outpatient      |
|                      |     visits to PPO physicians                  |
|                      |                                               |
|                      | The following cannot be included in the       |
|                      | accumulation of out-of-pocket expenses:       |
|                      |                                               |
|                      | -   Expenses in excess of our allowance or    |
|                      |     maximum benefit limitations               |
|                      |                                               |
|                      | -   Expenses for out-of-network mental health |
|                      |     or substance abuse                        |
|                      |                                               |
|                      | -   Any amounts you pay because benefits have |
|                      |     been reduced for non-compliance with this |
|                      |     Plan\'s cost containment requirements     |
|                      |     (see pages 13, 14, 15 and 16)             |
|                      |                                               |
|                      | -   Covered expenses applied to the \$275 or  |
|                      |     \$500 calendar year deductibles           |
|                      |                                               |
|                      | -   Covered expenses applied to the \$275     |
|                      |     deductible for in-network mental health   |
|                      |     or substance abuse care                   |
|                      |                                               |
|                      | -   The \$300 per admission deductible for    |
|                      |     non-PPO Inpatient hospital charges        |
|                      |                                               |
|                      | -   Expenses for prescription drugs           |
|                      |                                               |
|                      | -   Expenses in excess of visit maximums for  |
|                      |     physical, occupational and speech therapy |
|                      |     (see page 27)                             |
|                      |                                               |
|                      | -   Expenses incurred in excess of the \$90   |
|                      |     per day provided under home nursing care  |
|                      |     (see page 30); and                        |
|                      |                                               |
|                      | -   Expenses in excess of hospice care and    |
|                      |     preventive care maximums                  |
+----------------------+-----------------------------------------------+
| **Your catastrophic  | **Consumer-driven Option:**                   |
| protection           |                                               |
| out-of-pocket        | If you have exceeded your Personal Care       |
| maximum for          | Account and met your Member Responsibility    |
| deductibles,         | the following would apply:                    |
| coinsurance,         |                                               |
| copayments, and      | In-network benefit: Your out-of-pocket        |
| Member               | maximum is \$4,500 for either a Self Only or  |
| Responsibility**     | a Self and Family enrollment if you are using |
| *(continued)*        | network providers. Only eligible expenses for |
|                      | network providers count toward this limit.    |
|                      |                                               |
|                      | Out-of-network benefit: Your out-of-pocket    |
|                      | maximum is \$9,000 for either a Self Only or  |
|                      | a Self and Family enrollment if you are using |
|                      | out-of-network providers. Eligible expenses   |
|                      | for network providers also count toward this  |
|                      | limit. Your eligible out-of-pocket expenses   |
|                      | will not exceed this amount whether or not    |
|                      | you use network providers.                    |
|                      |                                               |
|                      | Out-of-pocket expenses for the purposes of    |
|                      | this benefit are:                             |
|                      |                                               |
|                      | -   The 15% you pay for in-network Inpatient  |
|                      |     and outpatient hospital charges,          |
|                      |     Surgical, Medical, Maternity and          |
|                      |     Emergency services under the Traditional  |
|                      |     Health Coverage                           |
|                      |                                               |
|                      | -   The 40% you pay for out-of-network        |
|                      |     Inpatient and outpatient hospital         |
|                      |     charges, Surgical, Medical, Maternity and |
|                      |     Emergency services under the Traditional  |
|                      |     Health Coverage                           |
|                      |                                               |
|                      | The following cannot be included in the       |
|                      | accumulation of out-of-pocket expenses:       |
|                      |                                               |
|                      | -   Any expenses paid by the Plan under your  |
|                      |     Personal Care Account                     |
|                      |                                               |
|                      | -   Any expenses paid by the Plan under your  |
|                      |     In-network Preventive Care benefit        |
|                      |                                               |
|                      | -   Any expenses you must pay under your      |
|                      |     Member Responsibility                     |
|                      |                                               |
|                      | -   Expenses in excess of our allowance or    |
|                      |     maximum benefit limitations or expenses   |
|                      |     not covered under the Traditional Health  |
|                      |     Coverage                                  |
|                      |                                               |
|                      | -   Expenses for out-of-network mental health |
|                      |     or substance abuse care                   |
|                      |                                               |
|                      | -   The 25% you pay for prescription drugs    |
|                      |     under your Traditional Health Coverage    |
|                      |                                               |
|                      | -   Dental care or vision care expenses above |
|                      |     the limitations provided under your       |
|                      |     Personal Care Account                     |
|                      |                                               |
|                      | -   Any amounts you pay because benefits have |
|                      |     been reduced for non-compliance with this |
|                      |     Plan's cost containment requirements (see |
|                      |     pages 13, 14, 15, 16 and 17)              |
|                      |                                               |
|                      | -   Expenses in excess of hospice care        |
|                      |     maximums                                  |
+----------------------+-----------------------------------------------+
| **Carryover**        | If you enrolled in our Plan during Open       |
|                      | Season and your effective date is after       |
|                      | January 1, your previous plan will be         |
|                      | responsible for any medical care you received |
|                      | before your coverage in our Plan began. The   |
|                      | old plan will pay your covered costs under    |
|                      | this year's benefits since benefit changes    |
|                      | start on January 1. If you did not meet your  |
|                      | out-of-pocket maximum under your old plan     |
|                      | last year, your covered out-of-pocket         |
|                      | expenses will be applied to that maximum. If  |
|                      | you did meet that maximum, your old plan's    |
|                      | catastrophic protection benefit will continue |
|                      | to apply until your effective date in our     |
|                      | Plan.                                         |
+----------------------+-----------------------------------------------+
| **When Government    | Facilities of the Department of Veterans      |
| facilities\          | Affairs, the Department of Defense, and the   |
| bill us**            | Indian Health Service are entitled to seek    |
|                      | reimbursement from us for certain services    |
|                      | and supplies they provide to you or a family  |
|                      | member. They may not seek more than their     |
|                      | governing laws allow.                         |
+----------------------+-----------------------------------------------+
| **If we overpay      | We will make diligent efforts to recover      |
| you**                | benefit payments we made in error but in good |
|                      | faith. We may reduce subsequent benefit       |
|                      | payments to offset overpayments. We will      |
|                      | generally first seek recovery from the        |
|                      | provider if we paid the provider directly, or |
|                      | from the person (covered family member,       |
|                      | guardian, custodial parent, etc.) to whom we  |
|                      | sent our payment.                             |
+----------------------+-----------------------------------------------+

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

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

+-----+---------------------+------------------------------+---------+
| *   |                     |                              |         |
| *If |                     |                              |         |
| yo  |                     |                              |         |
| u.. |                     |                              |         |
| .** |                     |                              |         |
|     |                     |                              |         |
| -   |                     |                              |         |
|     |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| age |                     |                              |         |
|     |                     |                              |         |
|  65 |                     |                              |         |
|     |                     |                              |         |
|  or |                     |                              |         |
|     |                     |                              |         |
|  ov |                     |                              |         |
| er, |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| and |                     |                              |         |
|     |                     |                              |         |
| -   |                     |                              |         |
|  do |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| not |                     |                              |         |
|     |                     |                              |         |
|   h |                     |                              |         |
| ave |                     |                              |         |
|     |                     |                              |         |
|  Me |                     |                              |         |
| dic |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|   P |                     |                              |         |
| art |                     |                              |         |
|     |                     |                              |         |
|  A, |                     |                              |         |
|     |                     |                              |         |
|   P |                     |                              |         |
| art |                     |                              |         |
|     |                     |                              |         |
|  B, |                     |                              |         |
|     |                     |                              |         |
|  or |                     |                              |         |
|     |                     |                              |         |
|  bo |                     |                              |         |
| th; |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| and |                     |                              |         |
|     |                     |                              |         |
| -   |                     |                              |         |
|   h |                     |                              |         |
| ave |                     |                              |         |
|     |                     |                              |         |
|   t |                     |                              |         |
| his |                     |                              |         |
|     |                     |                              |         |
|   P |                     |                              |         |
| lan |                     |                              |         |
|     |                     |                              |         |
|  as |                     |                              |         |
|     |                     |                              |         |
|  an |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| ann |                     |                              |         |
| uit |                     |                              |         |
| ant |                     |                              |         |
|     |                     |                              |         |
|  or |                     |                              |         |
|     |                     |                              |         |
|  as |                     |                              |         |
|     |                     |                              |         |
|   a |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| for |                     |                              |         |
| mer |                     |                              |         |
|     |                     |                              |         |
|   s |                     |                              |         |
| pou |                     |                              |         |
| se, |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| **o |                     |                              |         |
| r** |                     |                              |         |
|     |                     |                              |         |
|  as |                     |                              |         |
|     |                     |                              |         |
|   a |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| fam |                     |                              |         |
| ily |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| mem |                     |                              |         |
| ber |                     |                              |         |
|     |                     |                              |         |
|  of |                     |                              |         |
|     |                     |                              |         |
|  an |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| ann |                     |                              |         |
| uit |                     |                              |         |
| ant |                     |                              |         |
|     |                     |                              |         |
|  or |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| for |                     |                              |         |
| mer |                     |                              |         |
|     |                     |                              |         |
|   s |                     |                              |         |
| pou |                     |                              |         |
| se; |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| and |                     |                              |         |
|     |                     |                              |         |
| -   |                     |                              |         |
|     |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| not |                     |                              |         |
|     |                     |                              |         |
|  em |                     |                              |         |
| plo |                     |                              |         |
| yed |                     |                              |         |
|     |                     |                              |         |
|  in |                     |                              |         |
|     |                     |                              |         |
|   a |                     |                              |         |
|     |                     |                              |         |
|  po |                     |                              |         |
| sit |                     |                              |         |
| ion |                     |                              |         |
|     |                     |                              |         |
|   t |                     |                              |         |
| hat |                     |                              |         |
|     |                     |                              |         |
|  gi |                     |                              |         |
| ves |                     |                              |         |
|     |                     |                              |         |
|   F |                     |                              |         |
| EHB |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| cov |                     |                              |         |
| era |                     |                              |         |
| ge. |                     |                              |         |
|     |                     |                              |         |
|  (Y |                     |                              |         |
| our |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| emp |                     |                              |         |
| loy |                     |                              |         |
| ing |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| off |                     |                              |         |
| ice |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| can |                     |                              |         |
|     |                     |                              |         |
|   t |                     |                              |         |
| ell |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| you |                     |                              |         |
|     |                     |                              |         |
|  if |                     |                              |         |
|     |                     |                              |         |
|   t |                     |                              |         |
| his |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| app |                     |                              |         |
| lie |                     |                              |         |
| s.) |                     |                              |         |
+-----+---------------------+------------------------------+---------+
| *   |                     |                              |         |
| *Th |                     |                              |         |
| en, |                     |                              |         |
| for |                     |                              |         |
| y   |                     |                              |         |
| our |                     |                              |         |
| inp |                     |                              |         |
| ati |                     |                              |         |
| ent |                     |                              |         |
| ho  |                     |                              |         |
| spi |                     |                              |         |
| tal |                     |                              |         |
| c   |                     |                              |         |
| are |                     |                              |         |
| ,** |                     |                              |         |
|     |                     |                              |         |
| -   |                     |                              |         |
|     |                     |                              |         |
| the |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| law |                     |                              |         |
|     |                     |                              |         |
|  re |                     |                              |         |
| qui |                     |                              |         |
| res |                     |                              |         |
|     |                     |                              |         |
|  us |                     |                              |         |
|     |                     |                              |         |
|  to |                     |                              |         |
|     |                     |                              |         |
|   b |                     |                              |         |
| ase |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| our |                     |                              |         |
|     |                     |                              |         |
|   p |                     |                              |         |
| aym |                     |                              |         |
| ent |                     |                              |         |
|     |                     |                              |         |
|  on |                     |                              |         |
|     |                     |                              |         |
|  an |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| amo |                     |                              |         |
| unt |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| \-- |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| the |                     |                              |         |
|     |                     |                              |         |
|  "e |                     |                              |         |
| qui |                     |                              |         |
| val |                     |                              |         |
| ent |                     |                              |         |
|     |                     |                              |         |
|  Me |                     |                              |         |
| dic |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|   a |                     |                              |         |
| mou |                     |                              |         |
| nt" |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| \-- |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| set |                     |                              |         |
|     |                     |                              |         |
|  by |                     |                              |         |
|     |                     |                              |         |
|   M |                     |                              |         |
| edi |                     |                              |         |
| car |                     |                              |         |
| e's |                     |                              |         |
|     |                     |                              |         |
|  ru |                     |                              |         |
| les |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| for |                     |                              |         |
|     |                     |                              |         |
|   w |                     |                              |         |
| hat |                     |                              |         |
|     |                     |                              |         |
|  Me |                     |                              |         |
| dic |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|  wo |                     |                              |         |
| uld |                     |                              |         |
|     |                     |                              |         |
|   p |                     |                              |         |
| ay, |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| not |                     |                              |         |
|     |                     |                              |         |
|  on |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| the |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| act |                     |                              |         |
| ual |                     |                              |         |
|     |                     |                              |         |
|   c |                     |                              |         |
| har |                     |                              |         |
| ge; |                     |                              |         |
|     |                     |                              |         |
| -   |                     |                              |         |
|     |                     |                              |         |
| you |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|  re |                     |                              |         |
| spo |                     |                              |         |
| nsi |                     |                              |         |
| ble |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| for |                     |                              |         |
|     |                     |                              |         |
|   y |                     |                              |         |
| our |                     |                              |         |
|     |                     |                              |         |
|   a |                     |                              |         |
| ppl |                     |                              |         |
| ica |                     |                              |         |
| ble |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| ded |                     |                              |         |
| uct |                     |                              |         |
| ibl |                     |                              |         |
| es, |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| coi |                     |                              |         |
| nsu |                     |                              |         |
| ran |                     |                              |         |
| ce, |                     |                              |         |
|     |                     |                              |         |
|  or |                     |                              |         |
|     |                     |                              |         |
|   c |                     |                              |         |
| opa |                     |                              |         |
| yme |                     |                              |         |
| nts |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| you |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| owe |                     |                              |         |
|     |                     |                              |         |
|  un |                     |                              |         |
| der |                     |                              |         |
|     |                     |                              |         |
|   t |                     |                              |         |
| his |                     |                              |         |
|     |                     |                              |         |
|  Pl |                     |                              |         |
| an; |                     |                              |         |
|     |                     |                              |         |
| -   |                     |                              |         |
|     |                     |                              |         |
| you |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| not |                     |                              |         |
|     |                     |                              |         |
|  re |                     |                              |         |
| spo |                     |                              |         |
| nsi |                     |                              |         |
| ble |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| for |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| any |                     |                              |         |
|     |                     |                              |         |
|   c |                     |                              |         |
| har |                     |                              |         |
| ges |                     |                              |         |
|     |                     |                              |         |
|   g |                     |                              |         |
| rea |                     |                              |         |
| ter |                     |                              |         |
|     |                     |                              |         |
|   t |                     |                              |         |
| han |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| the |                     |                              |         |
|     |                     |                              |         |
|   e |                     |                              |         |
| qui |                     |                              |         |
| val |                     |                              |         |
| ent |                     |                              |         |
|     |                     |                              |         |
|  Me |                     |                              |         |
| dic |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|   a |                     |                              |         |
| mou |                     |                              |         |
| nt; |                     |                              |         |
|     |                     |                              |         |
|  we |                     |                              |         |
|     |                     |                              |         |
|   w |                     |                              |         |
| ill |                     |                              |         |
|     |                     |                              |         |
|   s |                     |                              |         |
| how |                     |                              |         |
|     |                     |                              |         |
|   t |                     |                              |         |
| hat |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| amo |                     |                              |         |
| unt |                     |                              |         |
|     |                     |                              |         |
|  on |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| the |                     |                              |         |
|     |                     |                              |         |
|  ex |                     |                              |         |
| pla |                     |                              |         |
| nat |                     |                              |         |
| ion |                     |                              |         |
|     |                     |                              |         |
|  of |                     |                              |         |
|     |                     |                              |         |
|  be |                     |                              |         |
| nef |                     |                              |         |
| its |                     |                              |         |
|     |                     |                              |         |
|  (E |                     |                              |         |
| OB) |                     |                              |         |
|     |                     |                              |         |
|   f |                     |                              |         |
| orm |                     |                              |         |
|     |                     |                              |         |
|   t |                     |                              |         |
| hat |                     |                              |         |
|     |                     |                              |         |
|  we |                     |                              |         |
|     |                     |                              |         |
|   s |                     |                              |         |
| end |                     |                              |         |
|     |                     |                              |         |
|   y |                     |                              |         |
| ou; |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| and |                     |                              |         |
|     |                     |                              |         |
| -   |                     |                              |         |
|     |                     |                              |         |
| the |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| law |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| pro |                     |                              |         |
| hib |                     |                              |         |
| its |                     |                              |         |
|     |                     |                              |         |
|   a |                     |                              |         |
|     |                     |                              |         |
|  ho |                     |                              |         |
| spi |                     |                              |         |
| tal |                     |                              |         |
|     |                     |                              |         |
|   f |                     |                              |         |
| rom |                     |                              |         |
|     |                     |                              |         |
|   c |                     |                              |         |
| oll |                     |                              |         |
| ect |                     |                              |         |
| ing |                     |                              |         |
|     |                     |                              |         |
|   m |                     |                              |         |
| ore |                     |                              |         |
|     |                     |                              |         |
|   t |                     |                              |         |
| han |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| the |                     |                              |         |
|     |                     |                              |         |
|  Me |                     |                              |         |
| dic |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|   e |                     |                              |         |
| qui |                     |                              |         |
| val |                     |                              |         |
| ent |                     |                              |         |
|     |                     |                              |         |
|   a |                     |                              |         |
| mou |                     |                              |         |
| nt. |                     |                              |         |
+-----+---------------------+------------------------------+---------+
| **A |                     |                              |         |
| nd, |                     |                              |         |
| for |                     |                              |         |
| y   |                     |                              |         |
| our |                     |                              |         |
| phy |                     |                              |         |
| sic |                     |                              |         |
| ian |                     |                              |         |
| c   |                     |                              |         |
| are |                     |                              |         |
| ,** |                     |                              |         |
| the |                     |                              |         |
| law |                     |                              |         |
| re  |                     |                              |         |
| qui |                     |                              |         |
| res |                     |                              |         |
| us  |                     |                              |         |
| to  |                     |                              |         |
| b   |                     |                              |         |
| ase |                     |                              |         |
| our |                     |                              |         |
| p   |                     |                              |         |
| aym |                     |                              |         |
| ent |                     |                              |         |
| and |                     |                              |         |
| y   |                     |                              |         |
| our |                     |                              |         |
| co  |                     |                              |         |
| ins |                     |                              |         |
| ura |                     |                              |         |
| nce |                     |                              |         |
| on  |                     |                              |         |
| ... |                     |                              |         |
|     |                     |                              |         |
| -   |                     |                              |         |
|  an |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| amo |                     |                              |         |
| unt |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| set |                     |                              |         |
|     |                     |                              |         |
|  by |                     |                              |         |
|     |                     |                              |         |
|  Me |                     |                              |         |
| dic |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| and |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| cal |                     |                              |         |
| led |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| the |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| "Me |                     |                              |         |
| dic |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|  ap |                     |                              |         |
| pro |                     |                              |         |
| ved |                     |                              |         |
|     |                     |                              |         |
|  am |                     |                              |         |
| oun |                     |                              |         |
| t," |                     |                              |         |
|     |                     |                              |         |
|  or |                     |                              |         |
|     |                     |                              |         |
| -   |                     |                              |         |
|     |                     |                              |         |
| the |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| act |                     |                              |         |
| ual |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| cha |                     |                              |         |
| rge |                     |                              |         |
|     |                     |                              |         |
|  if |                     |                              |         |
|     |                     |                              |         |
|  it |                     |                              |         |
|     |                     |                              |         |
|  is |                     |                              |         |
|     |                     |                              |         |
|  lo |                     |                              |         |
| wer |                     |                              |         |
|     |                     |                              |         |
|   t |                     |                              |         |
| han |                     |                              |         |
|     |                     |                              |         |
|     |                     |                              |         |
| the |                     |                              |         |
|     |                     |                              |         |
|  Me |                     |                              |         |
| dic |                     |                              |         |
| are |                     |                              |         |
|     |                     |                              |         |
|  ap |                     |                              |         |
| pro |                     |                              |         |
| ved |                     |                              |         |
|     |                     |                              |         |
|   a |                     |                              |         |
| mou |                     |                              |         |
| nt. |                     |                              |         |
+-----+---------------------+------------------------------+---------+
|     | **If your           | **Then you are responsible   |         |
|     | physician**...      | for...**                     |         |
+-----+---------------------+------------------------------+---------+
|     | Participates with   | your deductibles,            |         |
|     | Medicare or accepts | coinsurance, and copayments; |         |
|     | Medicare assignment |                              |         |
|     | for the claim and   |                              |         |
|     | is a member of our  |                              |         |
|     | PPO network,        |                              |         |
+-----+---------------------+------------------------------+---------+
|     | Participates with   | your deductibles,            |         |
|     | Medicare and is     | coinsurance, copayments, and |         |
|     | **not** in our PPO  | any balance up to the        |         |
|     | network,            | Medicare approved amount;    |         |
+-----+---------------------+------------------------------+---------+
|     | Does not            | your deductibles,            |         |
|     | participate with    | coinsurance, copayments, and |         |
|     | Medicare,           | any balance up to 115% of    |         |
|     |                     | the Medicare approved amount |         |
+-----+---------------------+------------------------------+---------+
| It  |                     |                              |         |
| is  |                     |                              |         |
| gen |                     |                              |         |
| era |                     |                              |         |
| lly |                     |                              |         |
| to  |                     |                              |         |
| y   |                     |                              |         |
| our |                     |                              |         |
| fin |                     |                              |         |
| anc |                     |                              |         |
| ial |                     |                              |         |
| adv |                     |                              |         |
| ant |                     |                              |         |
| age |                     |                              |         |
| to  |                     |                              |         |
| use |                     |                              |         |
| a   |                     |                              |         |
| phy |                     |                              |         |
| sic |                     |                              |         |
| ian |                     |                              |         |
| who |                     |                              |         |
| par |                     |                              |         |
| tic |                     |                              |         |
| ipa |                     |                              |         |
| tes |                     |                              |         |
| w   |                     |                              |         |
| ith |                     |                              |         |
| Med |                     |                              |         |
| ica |                     |                              |         |
| re. |                     |                              |         |
| S   |                     |                              |         |
| uch |                     |                              |         |
| p   |                     |                              |         |
| hys |                     |                              |         |
| ici |                     |                              |         |
| ans |                     |                              |         |
| are |                     |                              |         |
| per |                     |                              |         |
| mit |                     |                              |         |
| ted |                     |                              |         |
| to  |                     |                              |         |
| c   |                     |                              |         |
| oll |                     |                              |         |
| ect |                     |                              |         |
| o   |                     |                              |         |
| nly |                     |                              |         |
| up  |                     |                              |         |
| to  |                     |                              |         |
| the |                     |                              |         |
| Me  |                     |                              |         |
| dic |                     |                              |         |
| are |                     |                              |         |
| ap  |                     |                              |         |
| pro |                     |                              |         |
| ved |                     |                              |         |
| a   |                     |                              |         |
| mou |                     |                              |         |
| nt. |                     |                              |         |
|     |                     |                              |         |
| Our |                     |                              |         |
| ex  |                     |                              |         |
| pla |                     |                              |         |
| nat |                     |                              |         |
| ion |                     |                              |         |
| of  |                     |                              |         |
| be  |                     |                              |         |
| nef |                     |                              |         |
| its |                     |                              |         |
| (E  |                     |                              |         |
| OB) |                     |                              |         |
| f   |                     |                              |         |
| orm |                     |                              |         |
| w   |                     |                              |         |
| ill |                     |                              |         |
| t   |                     |                              |         |
| ell |                     |                              |         |
| you |                     |                              |         |
| how |                     |                              |         |
| m   |                     |                              |         |
| uch |                     |                              |         |
| the |                     |                              |         |
| phy |                     |                              |         |
| sic |                     |                              |         |
| ian |                     |                              |         |
| or  |                     |                              |         |
| ho  |                     |                              |         |
| spi |                     |                              |         |
| tal |                     |                              |         |
| can |                     |                              |         |
| c   |                     |                              |         |
| oll |                     |                              |         |
| ect |                     |                              |         |
| f   |                     |                              |         |
| rom |                     |                              |         |
| y   |                     |                              |         |
| ou. |                     |                              |         |
| If  |                     |                              |         |
| y   |                     |                              |         |
| our |                     |                              |         |
| phy |                     |                              |         |
| sic |                     |                              |         |
| ian |                     |                              |         |
| or  |                     |                              |         |
| ho  |                     |                              |         |
| spi |                     |                              |         |
| tal |                     |                              |         |
| tr  |                     |                              |         |
| ies |                     |                              |         |
| to  |                     |                              |         |
| c   |                     |                              |         |
| oll |                     |                              |         |
| ect |                     |                              |         |
| m   |                     |                              |         |
| ore |                     |                              |         |
| t   |                     |                              |         |
| han |                     |                              |         |
| a   |                     |                              |         |
| llo |                     |                              |         |
| wed |                     |                              |         |
| by  |                     |                              |         |
| l   |                     |                              |         |
| aw, |                     |                              |         |
| ask |                     |                              |         |
| the |                     |                              |         |
| phy |                     |                              |         |
| sic |                     |                              |         |
| ian |                     |                              |         |
| or  |                     |                              |         |
| ho  |                     |                              |         |
| spi |                     |                              |         |
| tal |                     |                              |         |
| to  |                     |                              |         |
| red |                     |                              |         |
| uce |                     |                              |         |
| the |                     |                              |         |
| ch  |                     |                              |         |
| arg |                     |                              |         |
| es. |                     |                              |         |
| If  |                     |                              |         |
| you |                     |                              |         |
| h   |                     |                              |         |
| ave |                     |                              |         |
| p   |                     |                              |         |
| aid |                     |                              |         |
| m   |                     |                              |         |
| ore |                     |                              |         |
| t   |                     |                              |         |
| han |                     |                              |         |
| al  |                     |                              |         |
| low |                     |                              |         |
| ed, |                     |                              |         |
| ask |                     |                              |         |
| for |                     |                              |         |
| a   |                     |                              |         |
| r   |                     |                              |         |
| efu |                     |                              |         |
| nd. |                     |                              |         |
| If  |                     |                              |         |
| you |                     |                              |         |
| n   |                     |                              |         |
| eed |                     |                              |         |
| f   |                     |                              |         |
| urt |                     |                              |         |
| her |                     |                              |         |
| as  |                     |                              |         |
| sis |                     |                              |         |
| tan |                     |                              |         |
| ce, |                     |                              |         |
| c   |                     |                              |         |
| all |                     |                              |         |
| us. |                     |                              |         |
+-----+---------------------+------------------------------+---------+

+----------------------+-----------------------------------------------+
| **When you have the  | We limit our payment to an amount that        |
| Original Medicare    | supplements the benefits that Medicare would  |
| Plan\                | pay under Medicare Part A (Hospital           |
| (Part A, Part B, or  | insurance) and Medicare Part B (Medical       |
| both)**              | insurance), regardless of whether Medicare    |
|                      | pays. Note: We pay our regular benefits for   |
| **Should I enroll    | emergency services to an institutional        |
| in\                  | provider, such as a hospital, that does not   |
| Medicare?**          | participate with Medicare and is not          |
|                      | reimbursed by Medicare.                       |
|                      |                                               |
|                      | If you are covered by Medicare Part B and it  |
|                      | is primary, your out-of-pocket costs for      |
|                      | services that both Medicare Part B and we     |
|                      | cover depend on whether your physician        |
|                      | accepts Medicare assignment for the claim.    |
|                      |                                               |
|                      | -   **High Option:** If your physician        |
|                      |     **accepts** Medicare assignment, then you |
|                      |     pay nothing for covered charges.          |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Consumer-driven Option: If your physician |
|                      |     accepts Medicare assignment, then you pay |
|                      |     nothing if you have unused benefits       |
|                      |     available under your Personal Care        |
|                      |     Account to pay the difference between the |
|                      |     Medicare approved amount and Medicare's   |
|                      |     payment. If your PCA is exhausted, you    |
|                      |     must pay either this full difference      |
|                      |     under your Member Responsibility or the   |
|                      |     lesser of your coinsurance or the full    |
|                      |     difference if your Member Responsibility  |
|                      |     has been met.                             |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   If your physician **does not accept**     |
|                      |     Medicare assignment, then you pay the     |
|                      |     difference between the \"limiting         |
|                      |     charge\" or the physician\'s charge       |
|                      |     (whichever is less) and our payment       |
|                      |     combined with Medicare's payment.         |
|                      |                                               |
|                      | It\'s important to know that a physician who  |
|                      | does not accept Medicare assignment may not   |
|                      | bill you for more than 115% of the amount     |
|                      | Medicare bases its payment on, called the     |
|                      | "limiting charge." The Medicare Summary       |
|                      | Notice (MSN) that Medicare will send you will |
|                      | have more information about the limiting      |
|                      | charge. If your physician tries to collect    |
|                      | more than allowed by law, ask the physician   |
|                      | to reduce the charges. If the physician does  |
|                      | not, report the physician to your Medicare    |
|                      | carrier who sent you the MSN form. Call us if |
|                      | you need further assistance.                  |
|                      |                                               |
|                      | 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 800/772-1213  |
|                      | to set up an appointment to apply. If you do  |
|                      | not apply for one or both Parts of Medicare,  |
|                      | you can still be covered under the FEHB       |
|                      | Program.                                      |
|                      |                                               |
|                      | If you can get premium-free Part A coverage,  |
|                      | we advise you to enroll in it. Most Federal   |
|                      | employees and annuitants are entitled to      |
|                      | Medicare Part A at age 65 **without cost**.   |
|                      | Medicare Part A covers hospital stays,        |
|                      | skilled nursing facility care and other       |
|                      | expenses. When you don't have to pay premiums |
|                      | for Medicare Part A, it makes good sense to   |
|                      | obtain the coverage. It can reduce your       |
|                      | out-of-pocket expenses as well as costs to    |
|                      | the FEHB, which can help keep FEHB premiums   |
|                      | down.                                         |
|                      |                                               |
|                      | Medicare Part B covers doctors' services and  |
|                      | outpatient hospital care. Everyone is charged |
|                      | a premium for Medicare Part B coverage. The   |
|                      | Social Security Administration can provide    |
|                      | you with premium and benefit information.     |
|                      | Review the information and decide if it makes |
|                      | sense for you to buy the Medicare Part B      |
|                      | coverage.                                     |
|                      |                                               |
|                      | **Please see Section 10, Coordinating         |
|                      | benefits with other coverage, for more        |
|                      | information about how we coordinate benefits  |
|                      | with Medicare.**                              |
+----------------------+-----------------------------------------------+

+-----------------------------------------------------------------------+
| **Section 5. High Option Benefits \-- OVERVIEW**                      |
|                                                                       |
| ***(See page10 for how our benefits changed this year and page 99 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 7; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
800/222-APWU or at our Web site at [www.apwuhp.com]{.underline}.

(a) Medical services and supplies provided by physicians and other
    health care professionals 23-30

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

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

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

(c) Services provided by a hospital or other facility, and ambulance
    services 36-38

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

(d) Emergency services/Accidents 39-40

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

(e) Mental health and substance abuse benefits 41-42

(f) Prescription drug benefits 43-45

(g) Special features 46

+----------------------------------+-----------------------------------+
| -   Flexible benefits option     | -   Disease management program    |
+----------------------------------+-----------------------------------+
| -   24-hour nurse line           | -   Review and reward program     |
+----------------------------------+-----------------------------------+
| -   Wellness benefit             |                                   |
+----------------------------------+-----------------------------------+

(h) Dental benefits 47

\(i\) Non-FEHB benefits available to Plan members 48

*SUMMARY OF BENEFITS - HIGH OPTION* 99

+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| S |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| 5 |   |                                   |                    |   |   |
| ( |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| ) |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
| M |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| \ |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
|   | * | **Here are some important things  |                    | * |   |
|   | * | you should keep in mind about     |                    | * |   |
|   | I | these benefits:**                 |                    | I |   |
|   | * |                                   |                    | * |   |
|   | * | -   Please remember that all      |                    | * |   |
|   |   |     benefits are subject to the   |                    |   |   |
|   | * |     definitions, limitations, and |                    | * |   |
|   | * |     exclusions in this brochure   |                    | * |   |
|   | M |     and are payable only when we  |                    | M |   |
|   | * |     determine they are medically  |                    | * |   |
|   | * |     necessary.                    |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   The calendar year deductible  |                    | * |   |
|   | * |     is: PPO - \$275 per person    |                    | * |   |
|   | P |     (\$550 per family); Non-PPO - |                    | P |   |
|   | * |     \$500 per person (\$1,000 per |                    | * |   |
|   | * |     family). The calendar year    |                    | * |   |
|   |   |     deductible applies to almost  |                    |   |   |
|   | * |     all benefits in this Section. |                    | * |   |
|   | * |     We added "(No deductible)" to |                    | * |   |
|   | O |     show when the calendar year   |                    | O |   |
|   | * |     deductible does not apply.    |                    | * |   |
|   | * |                                   |                    | * |   |
|   |   | -   The non-PPO benefits are the  |                    |   |   |
|   | * |     standard benefits of this     |                    | * |   |
|   | * |     Plan. PPO benefits apply only |                    | * |   |
|   | R |     when you use a PPO provider.  |                    | R |   |
|   | * |     When no PPO provider is       |                    | * |   |
|   | * |     available, non-PPO benefits   |                    | * |   |
|   |   |     apply.                        |                    |   |   |
|   | * |                                   |                    | * |   |
|   | * | -   When you use a PPO hospital,  |                    | * |   |
|   | T |     keep in mind that the         |                    | T |   |
|   | * |     professionals who provide     |                    | * |   |
|   | * |     services to you in the        |                    | * |   |
|   |   |     hospital, such as             |                    |   |   |
|   | * |     radiologists, emergency room  |                    | * |   |
|   | * |     physicians,                   |                    | * |   |
|   | A |     anesthesiologists, and        |                    | A |   |
|   | * |     pathologists, may not all be  |                    | * |   |
|   | * |     preferred providers. If they  |                    | * |   |
|   |   |     are not, they will be paid by |                    |   |   |
|   | * |     this Plan as non-PPO          |                    | * |   |
|   | * |     providers.                    |                    | * |   |
|   | N |                                   |                    | N |   |
|   | * | ```{=html}                        |                    | * |   |
|   | * | <!-- -->                          |                    | * |   |
|   |   | ```                               |                    |   |   |
|   | * | -   Be sure to read Section 4,    |                    | * |   |
|   | * |     *Your costs for covered       |                    | * |   |
|   | T |     services,* for valuable       |                    | T |   |
|   | * |     information about how cost    |                    | * |   |
|   | * |     sharing works, with special   |                    | * |   |
|   |   |     sections for members who are  |                    |   |   |
|   |   |     age 65 or over. Also read     |                    |   |   |
|   |   |     Section 10 about coordinating |                    |   |   |
|   |   |     benefits with other coverage, |                    |   |   |
|   |   |     including with Medicare.      |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   **YOU MUST GET                |                    |   |   |
|   |   |     PRECERTIFICATION OF CERTAIN   |                    |   |   |
|   |   |     OUTPATIENT IMAGING            |                    |   |   |
|   |   |     PROCEDURES. FAILURE TO DO SO  |                    |   |   |
|   |   |     WILL RESULT IN A MINIMUM OF   |                    |   |   |
|   |   |     \$100 PENALTY. Please refer   |                    |   |   |
|   |   |     to precertification           |                    |   |   |
|   |   |     information in Section 3 to   |                    |   |   |
|   |   |     be sure which procedures      |                    |   |   |
|   |   |     require precertification.**   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | **You Pay**        |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   | **After the        |   |   |
| # |   |                                   | calendar year      |   |   |
| # |   |                                   | deductible...**    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| B |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
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| f |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
| D |   |                                   |                    |   |   |
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| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   |                    |   |   |
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| # |   |                                   |                    |   |   |
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| . |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | ###                |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| D |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| g |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| m |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| P |   |                                   | > PPO: \$18        |   |   |
| r |   |                                   | > copayment (No    |   |   |
| o |   |                                   | > deductible)      |   |   |
| f |   |                                   | >                  |   |   |
| e |   |                                   | > Non-PPO: 30% of  |   |   |
| s |   |                                   | > the Plan         |   |   |
| s |   |                                   | > allowance and    |   |   |
| i |   |                                   | > any difference   |   |   |
| o |   |                                   | > between our      |   |   |
| n |   |                                   | > allowance and    |   |   |
| a |   |                                   | > the billed       |   |   |
| l |   |                                   | > amount           |   |   |
| s |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| - |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| I |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| ' |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| P |   |                                   | > PPO: 10% of the  |   |   |
| r |   |                                   | > Plan allowance   |   |   |
| o |   |                                   | >                  |   |   |
| f |   |                                   | > Non-PPO: 30% of  |   |   |
| e |   |                                   | > the Plan         |   |   |
| s |   |                                   | > allowance and    |   |   |
| s |   |                                   | > any difference   |   |   |
| i |   |                                   | > between our      |   |   |
| o |   |                                   | > allowance and    |   |   |
| n |   |                                   | > the billed       |   |   |
| a |   |                                   | > amount           |   |   |
| l |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
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| f |   |                                   |                    |   |   |
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| s |   |                                   |                    |   |   |
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| a |   |                                   |                    |   |   |
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+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   | > *All charges*    |   |   |
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| p |   |                                   |                    |   |   |
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| s |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+

+------------------------------------------+---------------------------+
| # Lab, X-ray and other diagnostic tests  | ### You pay               |
+------------------------------------------+---------------------------+
| Tests, such as:                          | > PPO: 10% of the Plan    |
|                                          | > allowance               |
| -   Blood tests                          | >                         |
|                                          | > Non-PPO: 30% of the     |
| -   Urinalysis                           | > Plan allowance and any  |
|                                          | > difference between our  |
| -   Non-routine pap tests                | > allowance and the       |
|                                          | > billed amount           |
| -   Pathology                            | >                         |
|                                          | > Note: If your PPO       |
| -   X-rays                               | > provider uses a non-PPO |
|                                          | > lab or radiologist, we  |
| -   Non-routine Mammograms               | > will pay non-PPO        |
|                                          | > benefits for any lab    |
| -   CAT and CT Scans/MRI/MRA/NC/PET      | > and X-ray charges.      |
|     (Outpatient requires                 |                           |
|     precertification -- See Section 3)   |                           |
|                                          |                           |
| -   Ultrasound                           |                           |
|                                          |                           |
| -   Electrocardiogram and EEG            |                           |
+------------------------------------------+---------------------------+
| *Not covered: Professional fees for      | > *All charges*           |
| automated lab tests*                     |                           |
+------------------------------------------+---------------------------+
| # Preventive care, adult                 | #                         |
+------------------------------------------+---------------------------+
| Routine screenings, limited to:          | > PPO: 10% of the Plan    |
|                                          | > allowance               |
| -   Total Blood Cholesterol -- once      | >                         |
|     annually                             | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
| -   Fasting lipoprotein profile, once    | > difference between our  |
|     every 5 years for adults age 20 or   | > allowance and the       |
|     over                                 | > billed amount           |
|                                          |                           |
| -   Osteoporosis screening, once every   |                           |
|     two years, for women age 65 and      |                           |
|     older                                |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Chlamydial infection                 |                           |
|                                          |                           |
| -   Colorectal Cancer Screening,         |                           |
|     including                            |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Fecal occult blood test, once        |                           |
|     annually, ages 40 and older          |                           |
|                                          |                           |
| -   Sigmoidoscopy, screening -- every    |                           |
|     five years starting at age 50        |                           |
|                                          |                           |
| -   Colonoscopy, once every 10 years     |                           |
|     starting at age 50                   |                           |
|                                          |                           |
| -   Double Contrast Barium Enema (DCBE), |                           |
|     once every 5 years starting at age   |                           |
|     50                                   |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Routine Prostate Specific Antigen    |                           |
|     (PSA) test -- one annually for men   |                           |
|     age 40 and older                     |                           |
|                                          |                           |
| -   Routine pap test, one annually,      |                           |
|     women age 18 and older               |                           |
+------------------------------------------+---------------------------+
| Routine mammograms-- covered for women   | > PPO: 10% of the Plan    |
| age 35 and older, as follows:            | > allowance               |
|                                          | >                         |
| -   From age 35 through 39, one during   | > Non-PPO: 30% of the     |
|     this five year period                | > Plan allowance and any  |
|                                          | > difference between our  |
| -   From age 40 through 64, one every    | > allowance and the       |
|     calendar year                        | > billed amount           |
|                                          |                           |
| -   At age 65 and older, one every two   |                           |
|     consecutive calendar years           |                           |
+------------------------------------------+---------------------------+
| Routine immunizations, limited to:       | > PPO: 10% of the Plan    |
|                                          | > allowance               |
| -   Tetanus-diphtheria (Td) booster --   | >                         |
|     once every 10 years, ages 19 and     | > Non-PPO: 30% of the     |
|     over (except as provided for under   | > Plan allowance and any  |
|     Childhood immunizations)             | > difference between our  |
|                                          | > allowance and the       |
| -   Influenza vaccine, annually          | > billed amount           |
|                                          |                           |
| -   Pneumococcal vaccine, age 65 and     |                           |
|     older                                |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Adult immunizations other than      |                           |
|     those listed above*                  |                           |
|                                          |                           |
| -   *Office visit associated with        |                           |
|     preventive care*                     |                           |
+------------------------------------------+---------------------------+
| # Preventive care, children              | # You pay                 |
+------------------------------------------+---------------------------+
| -   Childhood immunizations recommended  | > PPO: Nothing (No        |
|     by the American Academy of           | > deductible)             |
|     Pediatrics up to age 22              | >                         |
|                                          | > Non-PPO: Any difference |
| -   Examinations, limited to:            | > between the Plan        |
|                                          | > allowance and the       |
| ```{=html}                               | > billed charge (No       |
| <!-- -->                                 | > deductible)             |
| ```                                      | >                         |
| -   Well-child care charges for physical | > PPO: Nothing (No        |
|     examinations and laboratory tests    | > deductible)             |
|     through age 12                       | >                         |
|                                          | > Non-PPO: Any difference |
| -   Examination for amblyopia and        | > between the Plan        |
|     strabismus-limited to one screening  | > allowance and the       |
|     examination (age 2 through 6)        | > billed charge and any   |
|                                          | > amount above \$250 per  |
|                                          | > child (ages 0 through   |
|                                          | > 3) each year and any    |
|                                          | > amount above \$150 per  |
|                                          | > child (ages 4 through   |
|                                          | > 12) each year (No       |
|                                          | > deductible)             |
+------------------------------------------+---------------------------+
| # Maternity care                         | #                         |
+------------------------------------------+---------------------------+
| Complete maternity (obstetrical) care,   | > PPO: 10% of the Plan    |
| such as:                                 | > allowance               |
|                                          | >                         |
| -   Prenatal care                        | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
| -   Delivery                             | > difference between our  |
|                                          | > allowance and the       |
| -   Postnatal care                       | > billed amount           |
|                                          |                           |
| Note: Here are some things to keep in    |                           |
| mind:                                    |                           |
|                                          |                           |
| -   You do not need to precertify your   |                           |
|     normal delivery; see pages 13 and 14 |                           |
|     for other circumstances, such as     |                           |
|     extended stays for you or your baby. |                           |
|                                          |                           |
| -   You may remain in the hospital up to |                           |
|     48 hours after a regular delivery    |                           |
|     and 96 hours after a cesarean        |                           |
|     delivery. We will cover an extended  |                           |
|     stay if medically necessary, but     |                           |
|     you, your representative, your       |                           |
|     doctor, or your hospital must        |                           |
|     precertify.                          |                           |
|                                          |                           |
| -   We cover routine nursery care of the |                           |
|     newborn child during the covered     |                           |
|     portion of the mother's maternity    |                           |
|     stay. We will cover other care of an |                           |
|     infant who requires non-routine      |                           |
|     treatment if we cover the infant     |                           |
|     under a Self and Family enrollment.  |                           |
|     We cover circumcision of a covered   |                           |
|     newborn under Surgical benefits. See |                           |
|     Surgery benefits (Section 5b).       |                           |
|                                          |                           |
| -   We pay hospitalization and surgeon   |                           |
|     services (delivery) the same as for  |                           |
|     illness and injury. See Hospital     |                           |
|     Benefits (Section 5c) and Surgery    |                           |
|     Benefits (Section 5b)*.*             |                           |
+------------------------------------------+---------------------------+
| > *Not covered: Amniocentesis if for     | > *All charges*           |
| > diagnosing multiple births*            |                           |
+------------------------------------------+---------------------------+
| # Family planning                        | #                         |
+------------------------------------------+---------------------------+
| A range of voluntary family planning     | > PPO: 10% of the Plan    |
| services, limited to:                    | > allowance               |
|                                          | >                         |
| -   Voluntary sterilization (See         | > Non-PPO: 30% of the     |
|     Surgical procedures Section 5(b))    | > Plan allowance and any  |
|                                          | > difference between our  |
| -   Surgically implanted contraceptives  | > allowance and the       |
|                                          | > billed amount           |
| -   Injectable contraceptive drugs (such |                           |
|     as Depo provera)                     |                           |
|                                          |                           |
| -   Intrauterine devices (IUDs)          |                           |
|                                          |                           |
| -   Diaphragms                           |                           |
|                                          |                           |
| Note: We cover oral contraceptives under |                           |
| the prescription drug benefit.           |                           |
+------------------------------------------+---------------------------+
| *Not covered: Reversal of voluntary      | > *All charges*           |
| surgical sterilization and genetic       |                           |
| counseling*                              |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| # Infertility services                   | # You pay                 |
+------------------------------------------+---------------------------+
| Diagnosis and treatment of infertility,  | > PPO: 10% of the Plan    |
| except as shown in *Not covered.*        | > allowance and any       |
|                                          | > amount over \$2,500     |
|                                          | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance, any     |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount and any   |
|                                          | > amount over \$2,500     |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Infertility services after          |                           |
|     voluntary sterilization*             |                           |
|                                          |                           |
| -   *Assisted reproductive technology    |                           |
|     (ART) procedures, such as:*          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *artificial insemination (all        |                           |
|     procedures)*                         |                           |
|                                          |                           |
| -   *in vitro fertilization*             |                           |
|                                          |                           |
| -   *embryo transfer and gamete          |                           |
|     intrafallopian transfer (GIFT)*      |                           |
|                                          |                           |
| -   *intravaginal insemination (IVI)*    |                           |
|                                          |                           |
| -   *intracervical insemination (ICI)*   |                           |
|                                          |                           |
| -   *intrauterine insemination (IUI)*    |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Services and supplies related to    |                           |
|     ART procedures*                      |                           |
|                                          |                           |
| -   *Cost of donor sperm*                |                           |
|                                          |                           |
| -   *Cost of donor egg*                  |                           |
+------------------------------------------+---------------------------+
| # Allergy care                           | #                         |
+------------------------------------------+---------------------------+
| Testing and treatment, including         | > PPO: 10% of the Plan    |
| materials (such as allergy serum)        | > allowance               |
|                                          | >                         |
| Allergy injections                       | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| *Not covered: Provocative food testing   | > *All charges*           |
| and sublingual allergy desensitization*  |                           |
+------------------------------------------+---------------------------+
| # Treatment therapies                    | #                         |
+------------------------------------------+---------------------------+
| -   Chemotherapy and radiation therapy   | > PPO: 10% of the Plan    |
|                                          | > allowance               |
| Note: High dose chemotherapy in          | >                         |
| association with autologous bone marrow  | > Non-PPO: 30% of the     |
| transplants is limited to those          | > Plan allowance and any  |
| transplants listed on page 34.           | > difference between our  |
|                                          | > allowance and the       |
| -   Dialysis -- hemodialysis and         | > billed amount           |
|     peritoneal dialysis                  |                           |
|                                          |                           |
| -   Intravenous (IV)/Infusion Therapy -- |                           |
|     Home IV and antibiotic therapy       |                           |
|                                          |                           |
| -   Growth hormone therapy (GHT)         |                           |
|                                          |                           |
| Note: Growth hormone is covered under    |                           |
| the prescription drug benefit.           |                           |
|                                          |                           |
| Note: We only cover IV/Infusion therapy  |                           |
| and GHT when we preauthorize the         |                           |
| treatment. Call Spectera/CARE at         |                           |
| 800/580-8771 for preauthorization.       |                           |
| Spectera/CARE will ask you to submit     |                           |
| information that establishes that GHT is |                           |
| medically necessary. You should ask for  |                           |
| preauthorization before you begin        |                           |
| treatment. If you do not ask or if we    |                           |
| determine GHT is not medically           |                           |
| necessary, we will not cover GHT or      |                           |
| related services and supplies. See       |                           |
| *Other* services under *How to get       |                           |
| approval for*\... in Section 3.          |                           |
|                                          |                           |
| -   Respiratory and inhalation therapies |                           |
+------------------------------------------+---------------------------+
| # Physical and occupational therapies    | # You pay                 |
+------------------------------------------+---------------------------+
| Physical therapy and occupational        | > PPO: 10% of the Plan    |
| therapy provided by a licensed           | > allowance               |
| registered therapist up to a combined 60 | >                         |
| visits per calendar year.                | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
| Note: Preauthorization of rehabilitative | > difference between our  |
| therapies is required. Call              | > allowance and the       |
| Spectera/CARE at 800/580-8771 for        | > billed amount           |
| preauthorization.                        |                           |
|                                          |                           |
| Note: We only cover physical and         |                           |
| occupational therapy to restore bodily   |                           |
| function when there has been a total or  |                           |
| partial loss of bodily function due to   |                           |
| illness or injury and when a physician:  |                           |
|                                          |                           |
| 1)  Orders the care                      |                           |
|                                          |                           |
| 2)  Identifies the specific professional |                           |
|     skills the patient requires and the  |                           |
|     medical necessity for skilled        |                           |
|     services; and                        |                           |
|                                          |                           |
| 3)  Indicates the length of time the     |                           |
|     services are needed                  |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Maintenance therapies*              |                           |
|                                          |                           |
| -   *Exercise programs*                  |                           |
|                                          |                           |
| -   *Physical and occupational therapies |                           |
|     without preauthorization*            |                           |
+------------------------------------------+---------------------------+
| # Speech therapy                         | #                         |
+------------------------------------------+---------------------------+
| Speech therapy where medically necessary | > PPO: 10% of the Plan    |
| and provided by a licensed therapist     | > allowance               |
|                                          | >                         |
| Note: Preauthorization of speech therapy | > Non-PPO: 30% of the     |
| is required. Call Spectera/CARE at       | > Plan allowance and any  |
| 800/580-8771 for preauthorization.       | > difference between our  |
|                                          | > allowance and the       |
| Note: Speech therapy is combined with 60 | > billed amount           |
| visits per year for the services of      |                           |
| physical therapy and/or occupational     |                           |
| therapy (see above).                     |                           |
+------------------------------------------+---------------------------+
| # Hearing ser                            | #                         |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| Audiologist to diagnose a hearing        | > PPO: 10% of the Plan    |
| problem                                  | > allowance               |
|                                          | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Hearing aids, testing and           |                           |
|     examinations for them*               |                           |
+------------------------------------------+---------------------------+
| # Vision ser                             | #                         |
| vices (testing, treatment, and supplies) |                           |
+------------------------------------------+---------------------------+
| -   Internal (implant) ocular lenses     | > PPO: 10% of the Plan    |
|     and/or the first contact lenses      | > allowance               |
|     required to correct an impairment    | >                         |
|     caused by accident or illness. The   | > Non-PPO: 30% of the     |
|     services of an optometrist are       | > Plan allowance and any  |
|     limited to the testing, evaluation   | > difference between our  |
|     and fitting of the first contact     | > allowance and the       |
|     lenses required to correct an        | > billed amount           |
|     impairment caused by accident or     |                           |
|     illness.                             |                           |
|                                          |                           |
| Note: See Preventive care, children for  |                           |
| eye exams for children                   |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Eyeglasses or contact lenses and    |                           |
|     examinations for them*               |                           |
|                                          |                           |
| -   *Eye exercises and visual training*  |                           |
|                                          |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
+------------------------------------------+---------------------------+
| # Foot care                              | # You pay                 |
+------------------------------------------+---------------------------+
| Routine foot care when you are under     | > PPO: \$18 copayment for |
| active treatment for a metabolic or      | > the office visit (No    |
| peripheral vascular disease, such as     | > deductible) plus 10% of |
| diabetes                                 | > the Plan allowance for  |
|                                          | > other services          |
| See Orthopedic and prosthetic devices    | > performed during the    |
| for information on podiatric shoe        | > visit                   |
| inserts                                  | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Cutting, trimming or removal of     |                           |
|     corns, calluses, or the free edge of |                           |
|     toenails, and similar routine        |                           |
|     treatment of conditions of the foot, |                           |
|     except as stated above*              |                           |
|                                          |                           |
| -   *Treatment of weak, strained or flat |                           |
|     feet or bunions or spurs; and of any |                           |
|     instability, imbalance or            |                           |
|     subluxation of the foot (unless the  |                           |
|     treatment is by open cutting         |                           |
|     surgery)*                            |                           |
+------------------------------------------+---------------------------+
| # Orthopedic and prosthetic devices      | #                         |
+------------------------------------------+---------------------------+
| -   Artificial limbs and eyes; stump     | > PPO: 10% of the Plan    |
|     hose                                 | > allowance               |
|                                          | >                         |
| -   Externally worn breast prostheses    | > Non-PPO: 30% of the     |
|     and surgical bras, including         | > Plan allowance and any  |
|     necessary replacements following a   | > difference between our  |
|     mastectomy                           | > allowance and the       |
|                                          | > billed amount           |
| -   Leg, arm, neck and back braces       |                           |
|                                          |                           |
| -   Internal prosthetic devices, such as |                           |
|     artificial joints, pacemakers,       |                           |
|     cochlear implants, and surgically    |                           |
|     implanted breast implant following   |                           |
|     mastectomy. Note: See Section 5(b)   |                           |
|     for coverage of the surgery to       |                           |
|     insert the device.                   |                           |
|                                          |                           |
| Note: We recommend preauthorization of   |                           |
| orthopedic and prosthetic devices. Call  |                           |
| Spectera/CARE at 800/580-8771 for        |                           |
| preauthorization.                        |                           |
|                                          |                           |
| Note: We will pay only for the cost of   |                           |
| the standard item. Coverage for          |                           |
| specialty items, such as bionics, is     |                           |
| limited to the cost of the standard      |                           |
| item.                                    |                           |
+------------------------------------------+---------------------------+
| *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*                  |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| # Durable medical equipment (DME)        | # You pay                 |
+------------------------------------------+---------------------------+
| > Durable medical equipment (DME) is     | > PPO: 10% of the Plan    |
| > equipment and supplies that:           | > allowance               |
|                                          | >                         |
| 1)  Are prescribed by your attending     | > Non-PPO: 30% of the     |
|     physician (i.e., the physician who   | > Plan allowance and any  |
|     is treating your illness or injury)  | > difference between our  |
|                                          | > allowance and the       |
| 2)  Are medically necessary              | > billed amount           |
|                                          |                           |
| 3)  Are primarily and customarily used   |                           |
|     only for a medical purpose           |                           |
|                                          |                           |
| 4)  Are generally useful only to a       |                           |
|     person with an illness or injury     |                           |
|                                          |                           |
| 5)  Are designed for prolonged use; and  |                           |
|                                          |                           |
| 6)  Serve a specific therapeutic purpose |                           |
|     in the treatment of an illness or    |                           |
|     injury                               |                           |
|                                          |                           |
| > We cover rental or purchase, at our    |                           |
| > option, including repair and           |                           |
| > adjustment, of durable medical         |                           |
| > equipment, such as oxygen and dialysis |                           |
| > equipment.                             |                           |
+------------------------------------------+---------------------------+
| > Under this benefit, we also cover      | > (see above)             |
| > equipment such as:                     |                           |
|                                          |                           |
| -   Hospital beds                        |                           |
|                                          |                           |
| -   Wheelchairs                          |                           |
|                                          |                           |
| -   Ostomy supplies (including supplies  |                           |
|     purchased at a pharmacy)             |                           |
|                                          |                           |
| -   Crutches; and                        |                           |
|                                          |                           |
| -   Walkers                              |                           |
|                                          |                           |
| > Note: Call Spectera/CARE at            |                           |
| > 800/580-8771 as soon as your physician |                           |
| > prescribes this equipment because      |                           |
| > prior approval is required. We arrange |                           |
| > with a health care provider to rent or |                           |
| > sell you durable medical equipment at  |                           |
| > discounted rates and will tell you     |                           |
| > more about this service when you call. |                           |
| >                                        |                           |
| > Note: We will pay only for the cost of |                           |
| > the standard item. Coverage for        |                           |
| > specialty equipment, such as           |                           |
| > all-terrain wheelchairs, is limited to |                           |
| > the cost of the standard equipment.    |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Whirlpool equipment*                |                           |
|                                          |                           |
| -   *Sun and heat lamps*                 |                           |
|                                          |                           |
| -   *Light boxes*                        |                           |
|                                          |                           |
| -   *Heating pads*                       |                           |
|                                          |                           |
| -   *Exercise devices*                   |                           |
|                                          |                           |
| -   *Stair glides*                       |                           |
|                                          |                           |
| -   *Elevators*                          |                           |
|                                          |                           |
| -   *Air Purifiers*                      |                           |
|                                          |                           |
| -   *Computer "story boards", "light     |                           |
|     talkers", or other communication     |                           |
|     aids for communication-impaired      |                           |
|     individuals*                         |                           |
+------------------------------------------+---------------------------+
| # Home health services                   | #                         |
+------------------------------------------+---------------------------+
| > Services for skilled nursing care up   | > PPO: 10%; all charges   |
| > to 25 visits per calendar year, not to | > after we pay \$90 per   |
| > exceed a maximum plan payment of \$90  | > day                     |
| > per day, when preauthorized and:       | >                         |
|                                          | > Non-PPO: 30%; all       |
| -   A registered nurse (R.N.), licensed  | > charges after we pay    |
|     practical nurse (L.P.N.) or licensed | > \$90 per day            |
|     vocational nurse (L.V.N.) provides   |                           |
|     the services                         |                           |
|                                          |                           |
| -   The attending physician orders the   |                           |
|     care                                 |                           |
|                                          |                           |
| -   The physician identifies the         |                           |
|     specific professional skills         |                           |
|     required by the patient and the      |                           |
|     medical necessity for skilled        |                           |
|     services; and                        |                           |
|                                          |                           |
| -   The physician indicates the length   |                           |
|     of time the services are needed      |                           |
|                                          |                           |
| Note: Skilled nursing care must be       |                           |
| preauthorized. Call Spectera/CARE at     |                           |
| 800/580-8771 for preauthorization.       |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Nursing care requested by, or for   |                           |
|     the convenience of, the patient or   |                           |
|     the patient's family*                |                           |
|                                          |                           |
| -   *Home care primarily for personal    |                           |
|     assistance that does not include a   |                           |
|     medical component and is not         |                           |
|     diagnostic, therapeutic, or          |                           |
|     rehabilitative*                      |                           |
|                                          |                           |
| -   *Nursing services without            |                           |
|     preauthorization*                    |                           |
|                                          |                           |
| -   *Services of nurses aides or home    |                           |
|     health aides*                        |                           |
+------------------------------------------+---------------------------+
| # Chiropractic                           | # You pay                 |
+------------------------------------------+---------------------------+
| > Chiropractic treatment limited to 12   | > PPO: \$18 copayment (No |
| > visits and/or manipulations per year   | > deductible)             |
|                                          | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| # Alternative treatments                 | #                         |
+------------------------------------------+---------------------------+
| > Acupuncture -- by a doctor of medicine | > PPO: \$18 copayment (No |
| > or osteopathy                          | > deductible)             |
|                                          | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| ## Not covered:                          | > *All charges*           |
|                                          |                           |
| -   *Services of any provider not listed |                           |
|     as covered; see Covered providers on |                           |
|     page 11*                             |                           |
|                                          |                           |
| ##                                       |                           |
|                                          |                           |
| > *Note: Benefits of certain alternative |                           |
| > treatment providers may be covered in  |                           |
| > medically underserved areas; see page  |                           |
| > 11.*                                   |                           |
+------------------------------------------+---------------------------+
| # Educational classes and programs       | #                         |
+------------------------------------------+---------------------------+
| > Coverage is limited to:                | > PPO: Nothing            |
|                                          | >                         |
| -   Smoking Cessation -- Up to \$100 for | > Non-PPO: Nothing        |
|     one smoking cessation program per    |                           |
|     member per lifetime                  |                           |
+------------------------------------------+---------------------------+

+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   |                    |   |   |
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| \ |   |                                   |                    |   |   |
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| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
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| s |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
|   | * | **Here are some important things  |                    | * |   |
|   | * | you should keep in mind about     |                    | * |   |
|   | I | these benefits:**                 |                    | I |   |
|   | * |                                   |                    | * |   |
|   | * | -   Please remember that all      |                    | * |   |
|   |   |     benefits are subject to the   |                    |   |   |
|   | * |     definitions, limitations, and |                    | * |   |
|   | * |     exclusions in this brochure   |                    | * |   |
|   | M |     and are payable only when we  |                    | M |   |
|   | * |     determine they are medically  |                    | * |   |
|   | * |     necessary.                    |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   The calendar year deductible  |                    | * |   |
|   | * |     is: PPO - \$275 per person    |                    | * |   |
|   | P |     (\$550 per family); Non-PPO - |                    | P |   |
|   | * |     \$500 per person (\$1,000per  |                    | * |   |
|   | * |     family). The calendar year    |                    | * |   |
|   |   |     deductible applies to almost  |                    |   |   |
|   | * |     all benefits in this Section. |                    | * |   |
|   | * |     We added "(No deductible)" to |                    | * |   |
|   | O |     show when the calendar year   |                    | O |   |
|   | * |     deductible does not apply.    |                    | * |   |
|   | * |                                   |                    | * |   |
|   |   | -   The non-PPO benefits are the  |                    |   |   |
|   | * |     standard benefits of this     |                    | * |   |
|   | * |     Plan. PPO benefits apply only |                    | * |   |
|   | R |     when you use a PPO provider.  |                    | R |   |
|   | * |     When no PPO provider is       |                    | * |   |
|   | * |     available, non-PPO benefits   |                    | * |   |
|   |   |     apply.                        |                    |   |   |
|   | * |                                   |                    | * |   |
|   | * | -   When you use a PPO hospital,  |                    | * |   |
|   | T |     keep in mind that the         |                    | T |   |
|   | * |     professionals who provide     |                    | * |   |
|   | * |     services to you in the        |                    | * |   |
|   |   |     hospital, such as             |                    |   |   |
|   | * |     radiologists, emergency room  |                    | * |   |
|   | * |     physicians,                   |                    | * |   |
|   | A |     anesthesiologists, and        |                    | A |   |
|   | * |     pathologists, may not all be  |                    | * |   |
|   | * |     preferred providers. If they  |                    | * |   |
|   |   |     are not, they will be paid by |                    |   |   |
|   | * |     this Plan as non-PPO          |                    | * |   |
|   | * |     providers.                    |                    | * |   |
|   | N |                                   |                    | N |   |
|   | * | -   Be sure to read Section 4,    |                    | * |   |
|   | * |     *Your costs for covered       |                    | * |   |
|   |   |     services,* for valuable       |                    |   |   |
|   | * |     information about how cost    |                    | * |   |
|   | * |     sharing works, with special   |                    | * |   |
|   | T |     sections for members who are  |                    | T |   |
|   | * |     age 65 or over. Also read     |                    | * |   |
|   | * |     Section 10 about coordinating |                    | * |   |
|   |   |     benefits with other coverage, |                    |   |   |
|   |   |     including with Medicare.      |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   The amounts listed below are  |                    |   |   |
|   |   |     for the charges billed by a   |                    |   |   |
|   |   |     physician or other health     |                    |   |   |
|   |   |     care professional for your    |                    |   |   |
|   |   |     surgical care. Look in        |                    |   |   |
|   |   |     Section 5(c) for charges      |                    |   |   |
|   |   |     associated with the facility  |                    |   |   |
|   |   |     (i.e. hospital, surgical      |                    |   |   |
|   |   |     center, etc.).                |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   **YOU MUST GET                |                    |   |   |
|   |   |     PRECERTIFICATION OF SOME      |                    |   |   |
|   |   |     SURGICAL PROCEDURES. Please   |                    |   |   |
|   |   |     refer to the precertification |                    |   |   |
|   |   |     information shown in Section  |                    |   |   |
|   |   |     3 to be sure which services   |                    |   |   |
|   |   |     require precertification.**   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | >                                 |                    |   |   |
|   |   | Precertification/preauthorization |                    |   |   |
|   |   | > is required for:                |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   Organ transplantations        |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   Procedures which might be     |                    |   |   |
|   |   |     cosmetic in nature, such as   |                    |   |   |
|   |   |     eyelid surgery or varicose    |                    |   |   |
|   |   |     vein surgery                  |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   Surgery for morbid obesity,   |                    |   |   |
|   |   |     or                            |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   Surgery for organic impotence |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   | **You Pay**        |   |   |
| * |   |                                   |                    |   |   |
| B |   |                                   | **After the        |   |   |
| e |   |                                   | calendar year      |   |   |
| n |   |                                   | deductible...**    |   |   |
| e |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| D |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
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| . |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | #                  |   |   |
|   |   |                                   |                    |   |   |
| S |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
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| s |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| A |   |                                   | PPO: 10% of the    |   |   |
| c |   |                                   | Plan allowance     |   |   |
| o |   |                                   |                    |   |   |
| m |   |                                   | Non-PPO: 30% of    |   |   |
| p |   |                                   | the Plan allowance |   |   |
| r |   |                                   | and any difference |   |   |
| e |   |                                   | between our        |   |   |
| h |   |                                   | allowance and the  |   |   |
| e |   |                                   | billed amount      |   |   |
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+---+---+-----------------------------------+--------------------+---+---+

Surgical procedures benefits -- continued on next page

+------------------------------------------+---------------------------+
| # Surgical procedures *(continued*)      | # You Pay                 |
+------------------------------------------+---------------------------+
| -   Insertion of internal prosthetic     | (see above)               |
|     devices. See Section 5(a) for        |                           |
|     Orthopedic and prosthetic devices    |                           |
|     for device coverage information      |                           |
|                                          |                           |
| -   Voluntary sterilization (e.g., Tubal |                           |
|     ligation, Vasectomy)                 |                           |
|                                          |                           |
| -   Surgically implanted contraceptives  |                           |
|                                          |                           |
| -   Intrauterine devices (IUDs)          |                           |
|                                          |                           |
| -   Treatment of burns                   |                           |
|                                          |                           |
| -   Assistant surgeons - We cover up to  |                           |
|     20% of our allowance for the         |                           |
|     surgeon's charge                     |                           |
+------------------------------------------+---------------------------+
| > When multiple or bilateral surgical    | > PPO: 10% of the Plan    |
| > procedures performed during the same   | > allowance for the       |
| > operative session add time or          | > primary procedure and   |
| > complexity to patient care, our        | > 10% of one-half of the  |
| > benefits are:                          | > Plan allowance for the  |
|                                          | > secondary procedure(s)  |
| -   For the primary procedure:           | >                         |
|                                          | > Non-PPO: 30% of the     |
| ```{=html}                               | > Plan allowance for the  |
| <!-- -->                                 | > primary procedure and   |
| ```                                      | > 30% of one-half of the  |
| -   PPO: 90% of the Plan allowance or    | > Plan allowance for the  |
|                                          | > secondary procedure(s); |
| -   Non-PPO: 70% of the Plan allowance   | > and any difference      |
|                                          | > between our payment and |
| ```{=html}                               | > the billed amount       |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   For the secondary procedure(s):      |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   PPO: 90% of one-half of the Plan     |                           |
|     allowance or                         |                           |
|                                          |                           |
| -   Non-PPO: 70% of one-half of the Plan |                           |
|     > allowance                          |                           |
|                                          |                           |
| > Note: Multiple or bilateral surgical   |                           |
| > procedures performed through the same  |                           |
| > incision are "incidental" to the       |                           |
| > primary surgery. That is, the          |                           |
| > procedure would not add time or        |                           |
| > complexity to patient care. We do not  |                           |
| > pay extra for incidental procedures.   |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Cosmetic surgery and other related  |                           |
|     expenses if not preauthorized*       |                           |
|                                          |                           |
| -   *Reversal of voluntary               |                           |
|     sterilization*                       |                           |
|                                          |                           |
| -   *Services of a standby surgeon,      |                           |
|     except during angioplasty or other   |                           |
|     high risk procedures when we         |                           |
|     determine standbys are medically     |                           |
|     necessary*                           |                           |
|                                          |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
+------------------------------------------+---------------------------+
| # Reconstructive surgery                 | #                         |
+------------------------------------------+---------------------------+
| -   Surgery to correct a functional      | > PPO: 10% of the Plan    |
|     defect                               | > allowance               |
|                                          | >                         |
| -   Surgery to correct a condition       | > Non-PPO: 30% of the     |
|     caused by injury or illness if:      | > Plan allowance and any  |
|                                          | > difference between our  |
| ```{=html}                               | > allowance and the       |
| <!-- -->                                 | > billed amount           |
| ```                                      |                           |
| -   The condition produced a major       |                           |
|     effect on the member's appearance    |                           |
|     and                                  |                           |
|                                          |                           |
| -   The condition can reasonably be      |                           |
|     expected to be corrected by such     |                           |
|     surgery                              |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Surgery to correct a condition that  |                           |
|     existed at or from birth and is a    |                           |
|     significant deviation from the       |                           |
|     common form or norm. Examples of     |                           |
|     congenital anomalies are: protruding |                           |
|     ear deformities; cleft lip; cleft    |                           |
|     palate; birth marks (including port  |                           |
|     wine stains); and webbed fingers and |                           |
|     toes.                                |                           |
+------------------------------------------+---------------------------+

*Reconstructive surgery benefits -- continued on next page*

+------------------------------------------+---------------------------+
| # Reconstructive surgery *(continued*)   | # You Pay                 |
+------------------------------------------+---------------------------+
| -   All stages of breast reconstruction  | (see above)               |
|     surgery following a mastectomy, such |                           |
|     as:                                  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Surgery to produce a symmetrical     |                           |
|     appearance of breasts                |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Treatment of any physical            |                           |
|     complications, such as lymphedemas   |                           |
|                                          |                           |
| -   Breast prostheses; and surgical bras |                           |
|     and replacements (see Prosthetic     |                           |
|     devices for coverage)                |                           |
|                                          |                           |
| > Note: We pay for internal breast       |                           |
| > prostheses as hospital benefits.       |                           |
| >                                        |                           |
| > Note: If you need a mastectomy, you    |                           |
| > may choose to have the procedure       |                           |
| > performed on an inpatient basis and    |                           |
| > remain in the hospital up to 48 hours  |                           |
| > after the procedure.                   |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Cosmetic surgery -- any surgical    |                           |
|     procedure (or any portion of a       |                           |
|     procedure) performed primarily to    |                           |
|     improve physical appearance through  |                           |
|     change in bodily form, except repair |                           |
|     of accidental injury if repair is    |                           |
|     initiated within two years of the    |                           |
|     accident*                            |                           |
|                                          |                           |
| -   *Surgeries related to sex            |                           |
|     transformation, sexual dysfunction   |                           |
|     or sexual inadequacy except if       |                           |
|     preauthorized for organic impotence* |                           |
+------------------------------------------+---------------------------+
| # Oral and maxillofacial surgery         | #                         |
+------------------------------------------+---------------------------+
| Oral surgical procedures, limited to:    | PPO: 10% of the Plan      |
|                                          | allowance                 |
| -   Reduction of fractures of the jaws   |                           |
|     or facial bones                      | Non-PPO: 30% of the Plan  |
|                                          | allowance and any         |
| -   Surgical correction of cleft lip,    | difference between our    |
|     cleft plate or severe functional     | allowance and the billed  |
|     malocclusion                         | amount                    |
|                                          |                           |
| -   Removal of stones from salivary      |                           |
|     ducts                                |                           |
|                                          |                           |
| -   Excision of leukoplakia or           |                           |
|     malignancies                         |                           |
|                                          |                           |
| -   Excision of cysts and incision of    |                           |
|     abscesses when done as independent   |                           |
|     procedures                           |                           |
|                                          |                           |
| -   Other surgical procedures that do    |                           |
|     not involve the teeth or their       |                           |
|     supporting structures                |                           |
|                                          |                           |
| -   Extraction of impacted (unerupted)   |                           |
|     teeth                                |                           |
|                                          |                           |
| -   Alveoplasty, partial ostectomy and   |                           |
|     radical resection of mandible with   |                           |
|     bone graft unrelated to tooth        |                           |
|     structure                            |                           |
|                                          |                           |
| -   Excision of bony cysts of the jaw    |                           |
|     unrelated to tooth structure         |                           |
|                                          |                           |
| -   Excision of tori, tumors, and        |                           |
|     premalignant lesions, and biopsy of  |                           |
|     hard and soft oral tissues           |                           |
|                                          |                           |
| -   Reduction of dislocations and        |                           |
|     excision, manipulation,              |                           |
|     arthrocentesis, aspiration or        |                           |
|     injection of temporomandibular       |                           |
|     joints                               |                           |
|                                          |                           |
| -   Removal of foreign body, skin,       |                           |
|     subcutaneous alveolar tissue,        |                           |
|     reaction-producing foreign bodies in |                           |
|     the musculoskeletal system and       |                           |
|     salivary stones                      |                           |
+------------------------------------------+---------------------------+
| # Or                                     | #                         |
| al and maxillofacial surgery (continued) |                           |
+------------------------------------------+---------------------------+
| -   Incision/excision of salivary glands | (See above)               |
|     and ducts                            |                           |
|                                          | *All charges*             |
| -   Repair of traumatic wounds           |                           |
|                                          |                           |
| -   Sinusotomy, including repair of      |                           |
|     oroantral and oromaxillary fistula   |                           |
|     and/or root recovery                 |                           |
|                                          |                           |
| -   Surgical treatment of trigeminal     |                           |
|     neuralgia                            |                           |
|                                          |                           |
| -   Frenectomy or frenotomy, skin graft  |                           |
|     or vestibuloplasty-stomatoplasty     |                           |
|     unrelated to periodontal disease     |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Incision and drainage of cellulitis  |                           |
|     unrelated to tooth structure         |                           |
|                                          |                           |
| > Note: We suggest you call us at        |                           |
| > 800/222-APWU to determine whether a    |                           |
| > procedure is covered.                  |                           |
| >                                        |                           |
| > *Not covered:*                         |                           |
|                                          |                           |
| -   *Oral implants and transplants*      |                           |
|                                          |                           |
| -   *Procedures that involve the teeth   |                           |
|     or their supporting structures (such |                           |
|     as the periodontal membrane, gingiva |                           |
|     and alveolar bone)*                  |                           |
|                                          |                           |
| -   *Dental bridges, replacement of      |                           |
|     natural teeth,                       |                           |
|     dental/orthodontic/temporomandibular |                           |
|     joint dysfunction appliances and any |                           |
|     related expenses*                    |                           |
|                                          |                           |
| -   *Treatment of periodontal disease    |                           |
|     and gingival tissues, and abscesses* |                           |
|                                          |                           |
| -   *Charges related to orthodontic      |                           |
|     treatment*                           |                           |
+------------------------------------------+---------------------------+
| # Organ/tissue transplants               | #                         |
+------------------------------------------+---------------------------+
| > Limited to:                            | > PPO: 10% of the Plan    |
|                                          | > allowance               |
| -   Cornea                               | >                         |
|                                          | > Non-PPO: 30% of the     |
| -   Heart                                | > Plan allowance and any  |
|                                          | > difference between our  |
| -   Heart/lung                           | > allowance and the       |
|                                          | > billed amount and any   |
| -   Kidney                               | > amount over \$50,000    |
|                                          | > for kidney transplants  |
| -   Kidney/Pancreas                      | > or \$100,000 for other  |
|                                          | > listed transplants      |
| -   Liver                                |                           |
|                                          |                           |
| -   Lung: Single -- only for the         |                           |
|     following end-stage pulmonary        |                           |
|     diseases: pulmonary fibrosis,        |                           |
|     primary pulmonary hypertension, or   |                           |
|     emphysema; Double -- only for        |                           |
|     patients with cystic fibrosis        |                           |
|                                          |                           |
| -   Pancreas                             |                           |
|                                          |                           |
| -   Allogeneic bone marrow transplants   |                           |
|     are limited to patients with         |                           |
|     leukemia, advanced Hodgkin's         |                           |
|     lymphoma, advanced non-Hodgkin's     |                           |
|     lymphoma, aplastic anemia, severe    |                           |
|     combined immuno-deficiency disease   |                           |
|     or Wiskott-Aldrich syndrome          |                           |
|                                          |                           |
| -   Autologous bone marrow transplants   |                           |
|     and autologous peripheral stem cell  |                           |
|     support are limited to patients with |                           |
|     acute leukemia in remission,         |                           |
|     relapsed non-Hodgkin's lymphomas     |                           |
|     responding to treatment, resistant   |                           |
|     or recurrent neuroblastoma, relapsed |                           |
|     Hodgkin's disease responding to      |                           |
|     treatment, testicular cancer,        |                           |
|     mediastinal cancer, retroperitoneal  |                           |
|     cancer, ovarian germ cell tumors,    |                           |
|     epithelial ovarian cancer, breast    |                           |
|     cancer and multiple myeloma          |                           |
|                                          |                           |
| > Intestinal transplants (small          |                           |
| > intestine) and the small intestine     |                           |
| > with the liver or small intestine with |                           |
| > multiple organs such as the liver,     |                           |
| > stomach, and pancreas only for those   |                           |
| > patients with irreversible intestinal  |                           |
| > failure who have failed TPN (total     |                           |
| > parenteral nutrition)                  |                           |
+------------------------------------------+---------------------------+

*Organ/tissue transplant benefits -- continued on next page*

+------------------------------------------+---------------------------+
| # Organ/tissue transplants *(continued*  | # You pay                 |
+------------------------------------------+---------------------------+
| > The Plan uses specific Plan-designated | > PPO: 10% of the Plan    |
| > organ/tissue transplant facilities.    | > allowance               |
| > Before your initial evaluation as a    | >                         |
| > potential candidate for a transplant   | > Non-PPO: 30% of the     |
| > procedure, you or your doctor **must** | > Plan allowance and any  |
| > contact Spectera/CARE at 800/580-8771  | > difference between our  |
| > and ask to speak to a Transplant Case  | > allowance and the       |
| > Manager. You will be provided with     | > billed amount and any   |
| > information about transplant preferred | > amount over \$50,000    |
| > providers. If you choose a             | > for kidney transplants  |
| > Plan-designated transplant facility,   | > or \$100,000 for other  |
| > you may receive prior approval for     | > listed transplants      |
| > travel and lodging costs.              |                           |
| >                                        |                           |
| > Limited Benefits -- If you don't use a |                           |
| > Plan-designated transplant facility,   |                           |
| > benefits for pretransplant evaluation, |                           |
| > organ procurement, inpatient hospital, |                           |
| > surgical and medical expenses for      |                           |
| > covered transplants, whether incurred  |                           |
| > by the recipient or donor, are limited |                           |
| > to a maximum of \$50,000 for kidney    |                           |
| > transplants or \$100,000 for each      |                           |
| > other listed transplant, including     |                           |
| > multiple organ transplants.            |                           |
|                                          |                           |
| Note: We cover related medical and       |                           |
| hospital expenses of the donor when we   |                           |
| cover the recipient.                     |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Donor screening tests and donor     |                           |
|     search expenses, except those        |                           |
|     performed for the actual donor*      |                           |
|                                          |                           |
| -   *Services or supplies for, or        |                           |
|     related to, surgical transplant      |                           |
|     procedures for artificial or human   |                           |
|     organ transplants not listed as      |                           |
|     specifically covered. Related        |                           |
|     services include administration of   |                           |
|     high dose chemotherapy when          |                           |
|     supported by autologous bone marrow  |                           |
|     transplant*                          |                           |
|                                          |                           |
| -   *Transplants not listed as covered*  |                           |
+------------------------------------------+---------------------------+
| # Anesthesia                             | #                         |
+------------------------------------------+---------------------------+
| > Professional services for              | PPO: 10% of the Plan      |
| > administration of anesthesia           | allowance                 |
|                                          |                           |
|                                          | Non-PPO: 30% of the Plan  |
|                                          | allowance and any         |
|                                          | difference between our    |
|                                          | allowance and the billed  |
|                                          | amount                    |
|                                          |                           |
|                                          | Note: If your PPO         |
|                                          | provider uses a non-PPO   |
|                                          | anesthesiologist, we will |
|                                          | pay non-PPO benefits for  |
|                                          | any anesthesia charges.   |
+------------------------------------------+---------------------------+

+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| S |   |                                   |                    |   |   |
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| i |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
| 5 |   |                                   |                    |   |   |
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| c |   |                                   |                    |   |   |
| ) |   |                                   |                    |   |   |
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| S |   |                                   |                    |   |   |
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+---+---+-----------------------------------+--------------------+---+---+
|   | * | > **Here are some important       |                    | * |   |
|   | * | > things you should keep in mind  |                    | * |   |
|   | I | > about these benefits:**         |                    | I |   |
|   | * |                                   |                    | * |   |
|   | * | -   Please remember that all      |                    | * |   |
|   |   |     benefits are subject to the   |                    |   |   |
|   | * |     definitions, limitations, and |                    | * |   |
|   | * |     exclusions in this brochure   |                    | * |   |
|   | M |     and are payable only when we  |                    | M |   |
|   | * |     determine they are medically  |                    | * |   |
|   | * |     necessary.                    |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | ```{=html}                        |                    | * |   |
|   | * | <!-- -->                          |                    | * |   |
|   | P | ```                               |                    | P |   |
|   | * | -   In this Section, unlike       |                    | * |   |
|   | * |     Sections 5(a) and 5(b), the   |                    | * |   |
|   |   |     calendar year deductible      |                    |   |   |
|   | * |     applies to only a few         |                    | * |   |
|   | * |     benefits. In that case, we    |                    | * |   |
|   | O |     added "(calendar year         |                    | O |   |
|   | * |     deductible applies)." The     |                    | * |   |
|   | * |     calendar year deductible is;  |                    | * |   |
|   |   |     PPO - \$275 per person (\$550 |                    |   |   |
|   | * |     per family); Non-PPO - \$500  |                    | * |   |
|   | * |     per person (\$1,000 per       |                    | * |   |
|   | R |     family).                      |                    | R |   |
|   | * |                                   |                    | * |   |
|   | * | -   The non-PPO benefits are the  |                    | * |   |
|   |   |     standard benefits of this     |                    |   |   |
|   | * |     Plan. PPO benefits apply only |                    | * |   |
|   | * |     when you use a PPO provider.  |                    | * |   |
|   | T |     When no PPO provider is       |                    | T |   |
|   | * |     available, non-PPO benefits   |                    | * |   |
|   | * |     apply.                        |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   When you use a PPO hospital,  |                    | * |   |
|   | * |     keep in mind that the         |                    | * |   |
|   | A |     professionals who provide     |                    | A |   |
|   | * |     services to you in the        |                    | * |   |
|   | * |     hospital, such as             |                    | * |   |
|   |   |     radiologists, emergency room  |                    |   |   |
|   | * |     physicians,                   |                    | * |   |
|   | * |     anesthesiologists, and        |                    | * |   |
|   | N |     pathologists, may not all be  |                    | N |   |
|   | * |     preferred providers. If they  |                    | * |   |
|   | * |     are not, they will be paid by |                    | * |   |
|   |   |     this Plan as non-PPO          |                    |   |   |
|   | * |     providers.                    |                    | * |   |
|   | * |                                   |                    | * |   |
|   | T | -   Be sure to read Section 4,    |                    | T |   |
|   | * |     *Your costs for covered       |                    | * |   |
|   | * |     services,* for valuable       |                    | * |   |
|   |   |     information about how cost    |                    |   |   |
|   |   |     sharing works, with special   |                    |   |   |
|   |   |     sections for members who are  |                    |   |   |
|   |   |     age 65 or over. Also read     |                    |   |   |
|   |   |     Section 10 about coordinating |                    |   |   |
|   |   |     benefits with other coverage, |                    |   |   |
|   |   |     including with Medicare.      |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | ```{=html}                        |                    |   |   |
|   |   | <!-- -->                          |                    |   |   |
|   |   | ```                               |                    |   |   |
|   |   | -   The amounts listed below are  |                    |   |   |
|   |   |     for the charges billed by the |                    |   |   |
|   |   |     facility (i.e. hospital or    |                    |   |   |
|   |   |     surgical center) or ambulance |                    |   |   |
|   |   |     service for your surgery or   |                    |   |   |
|   |   |     care. Any costs associated    |                    |   |   |
|   |   |     with the professional charge  |                    |   |   |
|   |   |     (i.e. physicians, etc.) are   |                    |   |   |
|   |   |     in Sections 5(a) or (b).      |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | ```{=html}                        |                    |   |   |
|   |   | <!-- -->                          |                    |   |   |
|   |   | ```                               |                    |   |   |
|   |   | -   **YOU MUST GET                |                    |   |   |
|   |   |     PRECERTIFICATION OF HOSPITAL  |                    |   |   |
|   |   |     STAYS; FAILURE TO DO SO WILL  |                    |   |   |
|   |   |     RESULT IN A MINIMUM \$500     |                    |   |   |
|   |   |     PENALTY.** Please refer to    |                    |   |   |
|   |   |     the precertification          |                    |   |   |
|   |   |     information shown in Section  |                    |   |   |
|   |   |     3 to be sure which services   |                    |   |   |
|   |   |     require precertification.     |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   | **You Pay**        |   |   |
| * |   |                                   |                    |   |   |
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+---+---+-----------------------------------+--------------------+---+---+
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+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | #                  |   |   |
|   |   |                                   |                    |   |   |
| I |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
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| l |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| > |   |                                   | > PPO: 10% of the  |   |   |
|   |   |                                   | > covered charges  |   |   |
| R |   |                                   | >                  |   |   |
| o |   |                                   | > Non-PPO: \$300   |   |   |
| o |   |                                   | > per admission    |   |   |
| m |   |                                   | > and 30% of the   |   |   |
| > |   |                                   | > covered charges  |   |   |
|   |   |                                   | >                  |   |   |
| a |   |                                   | > Note: If you use |   |   |
| n |   |                                   | > a PPO provider   |   |   |
| d |   |                                   | > and a PPO        |   |   |
| > |   |                                   | > facility, we may |   |   |
|   |   |                                   | > still pay        |   |   |
| b |   |                                   | > non-PPO benefits |   |   |
| o |   |                                   | > if you receive   |   |   |
| a |   |                                   | > treatment from a |   |   |
| r |   |                                   | > radiologist,     |   |   |
| d |   |                                   | > pathologist, or  |   |   |
| , |   |                                   | > anesthesiologist |   |   |
| > |   |                                   | > who is not a PPO |   |   |
|   |   |                                   | > provider.        |   |   |
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| s |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+

*Inpatient hospital benefits -- continued on next page*

+------------------------------------------+---------------------------+
| # Inpatient hospital *(continued*)       | # You pay                 |
+------------------------------------------+---------------------------+
| > Other hospital services and supplies,  | > (see above)             |
| > such as:                               |                           |
|                                          |                           |
| -   Operating, recovery, maternity, and  |                           |
|     other treatment rooms                |                           |
|                                          |                           |
| -   Prescribed drugs and medicines       |                           |
|                                          |                           |
| -   Diagnostic laboratory tests and      |                           |
|     X-rays                               |                           |
|                                          |                           |
| -   Blood or blood plasma, if not        |                           |
|     donated or replaced                  |                           |
|                                          |                           |
| -   Dressings, splints, casts, and       |                           |
|     sterile tray services                |                           |
|                                          |                           |
| -   Medical supplies and equipment,      |                           |
|     including oxygen                     |                           |
|                                          |                           |
| -   Anesthetics, including nurse         |                           |
|     anesthetist services                 |                           |
|                                          |                           |
| > Note: We cover appliances, medical     |                           |
| > equipment and medical supplies         |                           |
| > provided for take-home use under       |                           |
| > Section 5(a). We cover prescription    |                           |
| > drugs and medicines dispensed for      |                           |
| > take-home use under Section 5(f).      |                           |
| >                                        |                           |
| > Note: We base payment on whether the   |                           |
| > facility or a health care professional |                           |
| > bills for the services or supplies.    |                           |
| > For example, when the hospital bills   |                           |
| > for its nurse anesthetists' services,  |                           |
| > we pay Hospital benefits and when the  |                           |
| > anesthesiologist bills, we pay Surgery |                           |
| > benefits.                              |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Any part of a hospital admission    |                           |
|     that is not medically necessary (see |                           |
|     definition), such as when you do not |                           |
|     need acute hospital inpatient        |                           |
|     (overnight) care, but could receive  |                           |
|     care in some other setting without   |                           |
|     adversely affecting your condition   |                           |
|     or the quality of your medical care. |                           |
|     Note: In this event, we pay benefits |                           |
|     for services and supplies other than |                           |
|     room and board and in-hospital       |                           |
|     physician care at the level they     |                           |
|     would have been covered if provided  |                           |
|     in an alternative setting*           |                           |
|                                          |                           |
| -   *Custodial care; see definition*     |                           |
|                                          |                           |
| -   *Non-covered facilities, such as     |                           |
|     nursing homes, skilled nursing*      |                           |
|     *facilities, residential treatment   |                           |
|     facilities, day and evening care     |                           |
|     centers, and schools*                |                           |
|                                          |                           |
| -   *Personal comfort items such as      |                           |
|     radio, television, air conditioners, |                           |
|     beauty and barber services, guest    |                           |
|     meals and beds*                      |                           |
|                                          |                           |
| -   *Services of a private duty nurse    |                           |
|     that would normally be provided by   |                           |
|     hospital nursing staff*              |                           |
+------------------------------------------+---------------------------+
| # Outpatien                              | # You pay                 |
| t hospital or ambulatory surgical center |                           |
+------------------------------------------+---------------------------+
| -   Operating, recovery, and other       | > PPO: 10% of the Plan    |
|     treatment rooms                      | > allowance (calendar     |
|                                          | > year deductible         |
| -   Prescribed drugs and medicines       | > applies)                |
|                                          | >                         |
| -   Diagnostic laboratory tests, X-rays, | > Non-PPO: 30% of the     |
|     and pathology services               | > Plan allowance and any  |
|                                          | > difference between our  |
| -   Administration of blood, blood       | > allowance and the       |
|     plasma, and other biologicals        | > billed amount (calendar |
|                                          | > year deductible         |
| -   Blood and blood plasma, if not       | > applies)                |
|     donated or replaced                  |                           |
|                                          |                           |
| -   Pre-surgical testing                 |                           |
|                                          |                           |
| -   Dressings, casts, and sterile tray   |                           |
|     services                             |                           |
|                                          |                           |
| -   Medical supplies, including oxygen   |                           |
|                                          |                           |
| -   Anesthetics and anesthesia service   |                           |
|                                          |                           |
| > Note: We cover hospital services and   |                           |
| > supplies related to dental procedures  |                           |
| > when necessitated by a non-dental      |                           |
| > physical impairment. We do not cover   |                           |
| > the dental procedures.                 |                           |
| >                                        |                           |
| > Note: We cover outpatient services and |                           |
| > supplies of a hospital or              |                           |
| > free-standing ambulatory facility the  |                           |
| > day of a surgical procedure (including |                           |
| > change of cast), hemophilia treatment, |                           |
| > hyperalimentation, rabies shots, cast  |                           |
| > or suture removal, oral surgery, foot  |                           |
| > treatment, chemotherapy for treatment  |                           |
| > of cancer, and radiation therapy.      |                           |
+------------------------------------------+---------------------------+
| # Extended care benefit                  | #                         |
| s/Skilled nursing care facility benefits |                           |
+------------------------------------------+---------------------------+
| > No benefit                             | > All charges             |
+------------------------------------------+---------------------------+
| # Hospice care                           | #                         |
+------------------------------------------+---------------------------+
| > Hospice is a coordinated program of    | > Any amount over the     |
| > home and inpatient supportive care for | > annual maximums shown   |
| > the terminally ill patient and the     |                           |
| > patient's family provided by a         |                           |
| > medically supervised specialized team  |                           |
| > under the direction of a duly licensed |                           |
| > or certified Hospice Care Program.     |                           |
|                                          |                           |
| -   We pay \$3,000 annually for          |                           |
|     outpatient services and \$2,000      |                           |
|     annually for inpatient services      |                           |
|                                          |                           |
| -   We pay a \$200 annual bereavement    |                           |
|     benefit per family unit              |                           |
+------------------------------------------+---------------------------+
| # Ambulance                              | #                         |
+------------------------------------------+---------------------------+
| -   Local professional ambulance service | > PPO: 10% of the Plan    |
|     when medically appropriate           | > allowance               |
|     immediately before or after an       | >                         |
|     inpatient admission                  | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Ambulance service used for routine  |                           |
|     transport*                           |                           |
+------------------------------------------+---------------------------+

+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
| 5 |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
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| s |   |                                   |                    |   |   |
| / |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
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| c |   |                                   |                    |   |   |
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| s |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
|   | * | > **Here are some important       |                    | * |   |
|   | * | > things to keep in mind about    |                    | * |   |
|   | I | > these benefits:**               |                    | I |   |
|   | * |                                   |                    | * |   |
|   | * | -   Please remember that all      |                    | * |   |
|   |   |     benefits are subject to the   |                    |   |   |
|   | * |     definitions, limitations, and |                    | * |   |
|   | * |     exclusions in this brochure   |                    | * |   |
|   | M |     and are payable only when we  |                    | M |   |
|   | * |     determine they are medically  |                    | * |   |
|   | * |     necessary.                    |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   The calendar year deductible  |                    | * |   |
|   | * |     is: PPO - \$275 per person    |                    | * |   |
|   | P |     (\$550 per family); Non-PPO - |                    | P |   |
|   | * |     \$500 per person (\$1,000 per |                    | * |   |
|   | * |     family). The calendar year    |                    | * |   |
|   |   |     deductible applies to almost  |                    |   |   |
|   | * |     all benefits in this Section. |                    | * |   |
|   | * |     We added "(No deductible)" to |                    | * |   |
|   | O |     show when the calendar year   |                    | O |   |
|   | * |     deductible does not apply.    |                    | * |   |
|   | * |                                   |                    | * |   |
|   |   | -   The non-PPO benefits are the  |                    |   |   |
|   | * |     standard benefits of this     |                    | * |   |
|   | * |     Plan. PPO benefits apply only |                    | * |   |
|   | R |     when you use a PPO provider.  |                    | R |   |
|   | * |     When no PPO provider is       |                    | * |   |
|   | * |     available, non-PPO benefits   |                    | * |   |
|   |   |     apply.                        |                    |   |   |
|   | * |                                   |                    | * |   |
|   | * | -   When you use a PPO hospital,  |                    | * |   |
|   | T |     keep in mind that the         |                    | T |   |
|   | * |     professionals who provide     |                    | * |   |
|   | * |     services to you in the        |                    | * |   |
|   |   |     hospital, such as             |                    |   |   |
|   | * |     radiologists, emergency room  |                    | * |   |
|   | * |     physicians,                   |                    | * |   |
|   | A |     anesthesiologists, and        |                    | A |   |
|   | * |     pathologists, may not all be  |                    | * |   |
|   | * |     preferred providers. If they  |                    | * |   |
|   |   |     are not, they will be paid by |                    |   |   |
|   | * |     this Plan as non-PPO          |                    | * |   |
|   | * |     providers.                    |                    | * |   |
|   | N |                                   |                    | N |   |
|   | * | -   Be sure to read Section 4,    |                    | * |   |
|   | * |     *Your costs for covered       |                    | * |   |
|   |   |     services,* for valuable       |                    |   |   |
|   | * |     information about how cost    |                    | * |   |
|   | * |     sharing works, with special   |                    | * |   |
|   | T |     sections for members who are  |                    | T |   |
|   | * |     age 65 or over. Also read     |                    | * |   |
|   | * |     Section 10 about coordinating |                    | * |   |
|   |   |     benefits with other coverage, |                    |   |   |
|   |   |     including with Medicare.      |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
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| e |   |                                   |                    |   |   |
| ) |   |                                   |                    |   |   |
| " |   |                                   |                    |   |   |
| w |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | #                  |   |   |
|   |   |                                   |                    |   |   |
| A |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| j |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| I |   |                                   | PPO: Nothing (No   |   |   |
| f |   |                                   | deductible)        |   |   |
| y |   |                                   |                    |   |   |
| o |   |                                   | > Non-PPO: Only    |   |   |
| u |   |                                   | > the difference   |   |   |
| r |   |                                   | > between\         |   |   |
| e |   |                                   | > our allowance    |   |   |
| c |   |                                   | > and the billed   |   |   |
| e |   |                                   | > amount\          |   |   |
| i |   |                                   | > (No deductible)  |   |   |
| v |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
| j |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| w |   |                                   |                    |   |   |
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| t |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
| 2 |   |                                   |                    |   |   |
| 4 |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
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| r |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| , |   |                                   |                    |   |   |
| w |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| : |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| - |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| P |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
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| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
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| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| - |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| R |   |                                   |                    |   |   |
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| l |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
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| a |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
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| d |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
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| u |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
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| s |   |                                   |                    |   |   |
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| N |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
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| W |   |                                   |                    |   |   |
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| p |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
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| H |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| m |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+

+------------------------------------------+---------------------------+
| # Medical emergency                      | # You Pay                 |
+------------------------------------------+---------------------------+
| Outpatient facility charges in an Urgent | > PPO: \$40 copayment (No |
| Care Center                              | > deductible)             |
|                                          | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| Outpatient medical or surgical services  | > PPO: 10% of the Plan    |
| and supplies, other than an Urgent Care  | > allowance               |
| Center                                   | >                         |
|                                          | > Non-PPO: 30% of the     |
|                                          | > Plan allowance and any  |
|                                          | > difference between our  |
|                                          | > allowance and the       |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| # Ambulance                              | #                         |
+------------------------------------------+---------------------------+
| -   Professional ambulance service       | > PPO: 10% of the Plan    |
|     within 24 hours of a medical         | > allowance               |
|     emergency                            | >                         |
|                                          | > Non-PPO: 30% of the     |
| -   Air ambulance if medically necessary | > Plan allowance and any  |
|     for transport to the closest         | > difference between our  |
|     appropriate facility for treatment   | > allowance and the       |
|     within 24 hours of a medical         | > billed amount           |
|     emergency                            |                           |
|                                          |                           |
| Note: See Section 5(c) for non-emergency |                           |
| service.                                 |                           |
+------------------------------------------+---------------------------+

+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| S |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| 5 |   |                                   |                    |   |   |
| ( |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| ) |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
| M |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
|   | * | You may choose to get care        |                    | * |   |
|   | * | **In-network** or Out-of-network. |                    | * |   |
|   | I | When you receive In-network care, |                    | I |   |
|   | * | you must get our approval for     |                    | * |   |
|   | * | services and follow a treatment   |                    | * |   |
|   |   | plan we approve. If you do,       |                    |   |   |
|   | * | cost-sharing and limitations for  |                    | * |   |
|   | * | In-network mental health and      |                    | * |   |
|   | M | substance abuse benefits will be  |                    | M |   |
|   | * | no greater than for similar       |                    | * |   |
|   | * | benefits for other illnesses and  |                    | * |   |
|   |   | conditions.                       |                    |   |   |
|   | * |                                   |                    | * |   |
|   | * | **Here are some important things  |                    | * |   |
|   | P | to keep in mind about these       |                    | P |   |
|   | * | benefits:**                       |                    | * |   |
|   | * |                                   |                    | * |   |
|   |   | -   Please remember that all      |                    |   |   |
|   | * |     benefits are subject to the   |                    | * |   |
|   | * |     definitions, limitations, and |                    | * |   |
|   | O |     exclusions in this brochure   |                    | O |   |
|   | * |     and are payable only when we  |                    | * |   |
|   | * |     determine they are medically  |                    | * |   |
|   |   |     necessary.                    |                    |   |   |
|   | * |                                   |                    | * |   |
|   | * | -   The Mental health and         |                    | * |   |
|   | R |     substance abuse benefits have |                    | R |   |
|   | * |     a separate calendar year      |                    | * |   |
|   | * |     deductible. The\              |                    | * |   |
|   |   |     In-network deductible is      |                    |   |   |
|   | * |     \$275 per person, \$550 per   |                    | * |   |
|   | * |     family.                       |                    | * |   |
|   | T |                                   |                    | T |   |
|   | * | -   Be sure to read Section 4,    |                    | * |   |
|   | * |     *Your costs for covered       |                    | * |   |
|   |   |     services,* for valuable       |                    |   |   |
|   | * |     information about how cost    |                    | * |   |
|   | * |     sharing works. Also read      |                    | * |   |
|   | A |     Section 10 about coordinating |                    | A |   |
|   | * |     benefits with other coverage, |                    | * |   |
|   | * |     including with Medicare.      |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   **YOU MUST GET                |                    | * |   |
|   | * |     PREAUTHORIZATION OF THESE     |                    | * |   |
|   | N |     SERVICES**. See the           |                    | N |   |
|   | * |     instructions after the        |                    | * |   |
|   | * |     benefits descriptions below.  |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   In-network mental health and  |                    | * |   |
|   | * |     substance abuse benefits are  |                    | * |   |
|   | T |     below, then Out-of-network    |                    | T |   |
|   | * |     benefits begin on page 42.    |                    | * |   |
|   | * |                                   |                    | * |   |
+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   | **You Pay**        |   |   |
| * |   |                                   |                    |   |   |
| B |   |                                   | **After the        |   |   |
| e |   |                                   | calendar year      |   |   |
| n |   |                                   | deductible...**    |   |   |
| e |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| D |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| N |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| : |   |                                   |                    |   |   |
| T |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
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| d |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
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| s |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
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| s |   |                                   |                    |   |   |
| S |   |                                   |                    |   |   |
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| t |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
| W |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| " |   |                                   |                    |   |   |
| ( |   |                                   |                    |   |   |
| N |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| ) |   |                                   |                    |   |   |
| " |   |                                   |                    |   |   |
| w |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | #                  |   |   |
|   |   |                                   |                    |   |   |
| I |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| - |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| w |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| k |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | > Your cost        |   |   |
|   |   |                                   | > sharing          |   |   |
| A |   |                                   | > responsibilities |   |   |
| l |   |                                   | > are no greater   |   |   |
| l |   |                                   | > than for other   |   |   |
|   |   |                                   | > illnesses or     |   |   |
| d |   |                                   | > conditions       |   |   |
| i |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| g |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
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+---+---+-----------------------------------+--------------------+---+---+
| - |   |                                   | # \$18 per vis     |   |   |
|   |   |                                   | it (No deductible) |   |   |
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| a |   |                                   |                    |   |   |
| g |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| m |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| - |   |                                   | # 10% of           |   |   |
|   |   |                                   | the Plan allowance |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| D |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| g |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| - |   |                                   | # 10% of           |   |   |
|   |   |                                   |  the covered charg |   |   |
|   |   |                                   | es (No deductible) |   |   |
|   |   |                                   |                    |   |   |
| I |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| - |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| S |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| z |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| g |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| > |   |                                   | # *All charges*    |   |   |
|   |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| N |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| : |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| S |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| w |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| N |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| : |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| O |   |                                   |                    |   |   |
| P |   |                                   |                    |   |   |
| M |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| w |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| w |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| m |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| m |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| ' |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| O |   |                                   |                    |   |   |
| P |   |                                   |                    |   |   |
| M |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| w |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| g |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| m |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+

*In-network benefits -- continued on next page*

+---------------+--------------------------+---------------------------+
| # In-netw     |                          | # You Pay                 |
| ork benefits  |                          |                           |
| *(continued*) |                          |                           |
+---------------+--------------------------+---------------------------+
| > **Preau     | To be eligible to        |                           |
| thorization** | receive these enhanced   |                           |
|               | mental health and        |                           |
|               | substance abuse benefits |                           |
|               | you must obtain a        |                           |
|               | treatment plan and       |                           |
|               | follow all of the        |                           |
|               | following network        |                           |
|               | authorization processes: |                           |
|               |                          |                           |
|               | -   Inpatient careYou    |                           |
|               |     must get             |                           |
|               |     preauthorization of  |                           |
|               |     hospital stays;      |                           |
|               |     failure to do so     |                           |
|               |     will result in a     |                           |
|               |     minimum \$500        |                           |
|               |     penalty. Please      |                           |
|               |     refer to the         |                           |
|               |     precertification     |                           |
|               |     information shown in |                           |
|               |     Section 3. To obtain |                           |
|               |     preauthorization of  |                           |
|               |     an admission for     |                           |
|               |     mental conditions or |                           |
|               |     substance abuse,     |                           |
|               |     call ValueOptions at |                           |
|               |     888/700-7965.        |                           |
|               |                          |                           |
|               | -   Outpatient careYou   |                           |
|               |     must get             |                           |
|               |     preauthorization of  |                           |
|               |     outpatient care for  |                           |
|               |     mental conditions or |                           |
|               |     substance abuse.     |                           |
|               |     Preauthorization     |                           |
|               |     must be obtained by  |                           |
|               |     calling ValueOptions |                           |
|               |     at 888/700-7965.     |                           |
|               |                          |                           |
|               | -   We do not make       |                           |
|               |     available provider   |                           |
|               |     directories for      |                           |
|               |     mental health or     |                           |
|               |     substance abuse      |                           |
|               |     providers.           |                           |
|               |     ValueOptions will    |                           |
|               |     provide you with a   |                           |
|               |     choice of network    |                           |
|               |     providers when you   |                           |
|               |     call to preauthorize |                           |
|               |     your care.           |                           |
+---------------+--------------------------+---------------------------+
| # Out-of-net  |                          | #                         |
| work benefits |                          |                           |
+---------------+--------------------------+---------------------------+
| Professional  |                          | > After a \$750 mental    |
| outpatient    |                          | > conditions/substance    |
| care to treat |                          | > abuse calendar year     |
| mental        |                          | > deductible, 50% of our  |
| conditions    |                          | > allowance for up to 15  |
| and substance |                          | > visits; all charges     |
| abuse         |                          | > after 15 visits         |
+---------------+--------------------------+---------------------------+
| Inpatient     |                          | > After a \$750 mental    |
| care to treat |                          | > conditions/substance    |
| mental        |                          | > abuse calendar year     |
| conditions    |                          | > deductible, 50% of      |
| includes ward |                          | > charges for up to 30    |
| or            |                          | > days per calendar year; |
| semiprivate   |                          | > all charges after 30    |
| a             |                          | > days                    |
| ccommodations |                          |                           |
| and other     |                          |                           |
| hospital      |                          |                           |
| charges       |                          |                           |
+---------------+--------------------------+---------------------------+
| Inpatient     |                          | > After a \$750 mental    |
| care to treat |                          | > conditions/substance    |
| substance     |                          | > abuse calendar year     |
| abuse         |                          | > deductible, 50% of      |
| includes room |                          | > charges for one         |
| and board and |                          | > treatment program up to |
| ancillary     |                          | > \$3,000; all charges    |
| charges for   |                          | > over \$3,000 per        |
| confinements  |                          | > lifetime                |
| in a          |                          |                           |
| treatment     |                          |                           |
| facility for  |                          |                           |
| r             |                          |                           |
| ehabilitative |                          |                           |
| treatment of  |                          |                           |
| alcoholism or |                          |                           |
| substance     |                          |                           |
| abuse         |                          |                           |
+---------------+--------------------------+---------------------------+
| ## N          |                          | > *All charges*           |
| ot covered ou |                          |                           |
| t-of-network: |                          |                           |
|               |                          |                           |
| -             |                          |                           |
|    *Treatment |                          |                           |
|     for       |                          |                           |
|     learning  |                          |                           |
|               |                          |                           |
|  disabilities |                          |                           |
|     and       |                          |                           |
|     mental    |                          |                           |
|               |                          |                           |
|  retardation* |                          |                           |
|               |                          |                           |
| -   *Services |                          |                           |
|     rendered  |                          |                           |
|     or billed |                          |                           |
|     by a      |                          |                           |
|     school or |                          |                           |
|     halfway   |                          |                           |
|     house or  |                          |                           |
|     a member  |                          |                           |
|     of its    |                          |                           |
|     staff*    |                          |                           |
|               |                          |                           |
| -             |                          |                           |
| *Phototherapy |                          |                           |
|     for       |                          |                           |
|     treatment |                          |                           |
|     of        |                          |                           |
|     Seasonal  |                          |                           |
|     Affective |                          |                           |
|     Disorder  |                          |                           |
|     (SAD)*    |                          |                           |
+---------------+--------------------------+---------------------------+
| > **Lifetime  | Out-of-network inpatient |                           |
| > maximum**   | care for the treatment   |                           |
|               | of alcoholism and drug   |                           |
|               | abuse is limited to one  |                           |
|               | treatment program per    |                           |
|               | lifetime not to exceed   |                           |
|               | \$3,000.                 |                           |
+---------------+--------------------------+---------------------------+
| > **Prece     | -   Inpatient care --    |                           |
| rtification** |     You must get         |                           |
|               |     preauthorization of  |                           |
|               |     hospital stays;      |                           |
|               |     failure to do so     |                           |
|               |     will result in a     |                           |
|               |     minimum \$500        |                           |
|               |     penalty. Please      |                           |
|               |     refer to the         |                           |
|               |     precertification     |                           |
|               |     information shown in |                           |
|               |     Section 3. To obtain |                           |
|               |     preauthorization of  |                           |
|               |     an admission for     |                           |
|               |     mental conditions or |                           |
|               |     substance abuse,     |                           |
|               |     call ValueOptions at |                           |
|               |     888/700-7965.        |                           |
|               |                          |                           |
|               | -   Outpatient care --   |                           |
|               |     You must get         |                           |
|               |     preauthorization of  |                           |
|               |     outpatient care for  |                           |
|               |     mental conditions or |                           |
|               |     substance abuse.     |                           |
|               |     Preauthorization     |                           |
|               |     must be obtained by  |                           |
|               |     calling ValueOptions |                           |
|               |     at 888/700-7965.     |                           |
+---------------+--------------------------+---------------------------+
| > See these   |                          |                           |
| > sections of |                          |                           |
| > the         |                          |                           |
| > brochure    |                          |                           |
| > for more    |                          |                           |
| > valuable    |                          |                           |
| > information |                          |                           |
| > about these |                          |                           |
| > benefits:   |                          |                           |
|               |                          |                           |
| -   Section   |                          |                           |
|     4, *Your  |                          |                           |
|     costs for |                          |                           |
|     covered   |                          |                           |
|               |                          |                           |
|    services*, |                          |                           |
|     for       |                          |                           |
|               |                          |                           |
|   information |                          |                           |
|     about     |                          |                           |
|               |                          |                           |
|  catastrophic |                          |                           |
|               |                          |                           |
|    protection |                          |                           |
|     for these |                          |                           |
|     benefits. |                          |                           |
|               |                          |                           |
| -   Section   |                          |                           |
|     8,        |                          |                           |
|     *Filing a |                          |                           |
|     claim for |                          |                           |
|     covered   |                          |                           |
|               |                          |                           |
|    services*, |                          |                           |
|     for       |                          |                           |
|               |                          |                           |
|   information |                          |                           |
|     about     |                          |                           |
|               |                          |                           |
|    submitting |                          |                           |
|     o         |                          |                           |
| ut-of-network |                          |                           |
|     claims    |                          |                           |
+---------------+--------------------------+---------------------------+

+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| S |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| 5 |   |                                   |                    |   |   |
| ( |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| ) |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
| P |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| g |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
|   | * | > **Here are some important       |                    | * |   |
|   | * | > things to keep in mind about    |                    | * |   |
|   | I | > these benefits:**               |                    | I |   |
|   | * |                                   |                    | * |   |
|   | * | -   We cover prescribed drugs and |                    | * |   |
|   |   |     medications, as described in  |                    |   |   |
|   | * |     the chart on the next page.   |                    | * |   |
|   | * |                                   |                    | * |   |
|   | M | -   Please remember that all      |                    | M |   |
|   | * |     benefits are subject to the   |                    | * |   |
|   | * |     definitions, limitations, and |                    | * |   |
|   |   |     exclusions in this brochure   |                    |   |   |
|   | * |     and are payable only when we  |                    | * |   |
|   | * |     determine they are medically  |                    | * |   |
|   | P |     necessary.                    |                    | P |   |
|   | * |                                   |                    | * |   |
|   | * | -   The calendar year deductible  |                    | * |   |
|   |   |     does not apply to             |                    |   |   |
|   | * |     prescription drug benefits.   |                    | * |   |
|   | * |                                   |                    | * |   |
|   | O | -   The non-PPO benefits are the  |                    | O |   |
|   | * |     standard benefits of this     |                    | * |   |
|   | * |     Plan. PPO benefits apply only |                    | * |   |
|   |   |     when you use a PPO provider.  |                    |   |   |
|   | * |     When no PPO provider is       |                    | * |   |
|   | * |     available, non-PPO benefits   |                    | * |   |
|   | R |     apply.                        |                    | R |   |
|   | * |                                   |                    | * |   |
|   | * | -   Be sure to read Section 4,    |                    | * |   |
|   |   |     *Your costs for covered       |                    |   |   |
|   | * |     services,* for valuable       |                    | * |   |
|   | * |     information about how cost    |                    | * |   |
|   | T |     sharing works, with special   |                    | T |   |
|   | * |     sections for members who are  |                    | * |   |
|   | * |     age 65 or over. Also read     |                    | * |   |
|   |   |     Section 10 about coordinating |                    |   |   |
|   | * |     benefits with other coverage, |                    | * |   |
|   | * |     including with Medicare.      |                    | * |   |
|   | A |                                   |                    | A |   |
|   | * |                                   |                    | * |   |
|   | * |                                   |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * |                                   |                    | * |   |
|   | * |                                   |                    | * |   |
|   | N |                                   |                    | N |   |
|   | * |                                   |                    | * |   |
|   | * |                                   |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * |                                   |                    | * |   |
|   | * |                                   |                    | * |   |
|   | T |                                   |                    | T |   |
|   | * |                                   |                    | * |   |
|   | * |                                   |                    | * |   |
+---+---+-----------------------------------+--------------------+---+---+
|   |   | **There are important features    |                    |   |   |
|   |   | you should be aware of.** These   |                    |   |   |
|   |   | include:                          |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   **Who can write your          |                    |   |   |
|   |   |     prescription.** Any covered   |                    |   |   |
|   |   |     provider licensed to          |                    |   |   |
|   |   |     prescribe drugs may write     |                    |   |   |
|   |   |     your prescription.            |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   **Where can you obtain        |                    |   |   |
|   |   |     them.** You can fill the      |                    |   |   |
|   |   |     prescription at a Medco       |                    |   |   |
|   |   |     Health network pharmacy, a    |                    |   |   |
|   |   |     non-network pharmacy, or by   |                    |   |   |
|   |   |     mail. We pay our highest      |                    |   |   |
|   |   |     level of benefits for mail    |                    |   |   |
|   |   |     order and you should use the  |                    |   |   |
|   |   |     mail order program to obtain  |                    |   |   |
|   |   |     your maintenance medications. |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   **We use a formulary.** Our   |                    |   |   |
|   |   |     formulary is open and         |                    |   |   |
|   |   |     voluntary. A formulary is a   |                    |   |   |
|   |   |     list of medications we have   |                    |   |   |
|   |   |     selected based on their       |                    |   |   |
|   |   |     clinical effectiveness and    |                    |   |   |
|   |   |     lower cost. By asking your    |                    |   |   |
|   |   |     doctor to prescribe formulary |                    |   |   |
|   |   |     medications, you can help     |                    |   |   |
|   |   |     reduce your costs while       |                    |   |   |
|   |   |     maintaining high-quality      |                    |   |   |
|   |   |     care. Use of a formulary drug |                    |   |   |
|   |   |     is voluntary; there is no     |                    |   |   |
|   |   |     financial penalty if your     |                    |   |   |
|   |   |     physician does not prescribe  |                    |   |   |
|   |   |     a formulary drug.             |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   **Brand/Generic Drugs**       |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | > **Why use generic drugs?** A    |                    |   |   |
|   |   | > generic drug is a chemical      |                    |   |   |
|   |   | > equivalent of a corresponding   |                    |   |   |
|   |   | > name brand drug. The US Food    |                    |   |   |
|   |   | > and Drug Administration sets    |                    |   |   |
|   |   | > quality standards for generic   |                    |   |   |
|   |   | > drugs to ensure that these      |                    |   |   |
|   |   | > drugs meet the same standards   |                    |   |   |
|   |   | > of quality and strength as      |                    |   |   |
|   |   | > brand name drugs. Generic drugs |                    |   |   |
|   |   | > are less expensive than brand   |                    |   |   |
|   |   | > drugs, therefore, you may       |                    |   |   |
|   |   | > reduce your                     |                    |   |   |
|   |   | > out-of-pocket-expenses by       |                    |   |   |
|   |   | > choosing to use a generic drug. |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | A generic equivalent will be      |                    |   |   |
|   |   | dispensed if it is available,     |                    |   |   |
|   |   | unless your physician             |                    |   |   |
|   |   | specifically requires a name      |                    |   |   |
|   |   | brand. If you receive a name      |                    |   |   |
|   |   | brand drug when a                 |                    |   |   |
|   |   | Federally-approved generic drug   |                    |   |   |
|   |   | is available, and your physician  |                    |   |   |
|   |   | has not received a                |                    |   |   |
|   |   | preauthorization, you have to pay |                    |   |   |
|   |   | the difference in cost between    |                    |   |   |
|   |   | the name brand drug and the       |                    |   |   |
|   |   | generic, in addition to your      |                    |   |   |
|   |   | coinsurance. However, if your     |                    |   |   |
|   |   | doctor obtains preauthorization   |                    |   |   |
|   |   | because it is medically necessary |                    |   |   |
|   |   | that a brand name drug be         |                    |   |   |
|   |   | dispensed, you will not be        |                    |   |   |
|   |   | required to pay this cost         |                    |   |   |
|   |   | difference. Your doctor may seek  |                    |   |   |
|   |   | preauthorization by calling       |                    |   |   |
|   |   | 800/841-5409.                     |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   **These are the dispensing    |                    |   |   |
|   |   |     limitations.**                |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | ```{=html}                        |                    |   |   |
|   |   | <!-- -->                          |                    |   |   |
|   |   | ```                               |                    |   |   |
|   |   | -   The Medco Health Retail       |                    |   |   |
|   |   |     Network --you may obtain up   |                    |   |   |
|   |   |     to a 30-day supply plus one   |                    |   |   |
|   |   |     30-day refill for each        |                    |   |   |
|   |   |     prescription purchased from a |                    |   |   |
|   |   |     Medco Health network          |                    |   |   |
|   |   |     pharmacy. After one 30-day    |                    |   |   |
|   |   |     refill, you must obtain a new |                    |   |   |
|   |   |     prescription and submit it to |                    |   |   |
|   |   |     the mail order program. If    |                    |   |   |
|   |   |     you do not, we will pay the   |                    |   |   |
|   |   |     non-network pharmacy benefit  |                    |   |   |
|   |   |     level. To receive maximum     |                    |   |   |
|   |   |     savings you must present your |                    |   |   |
|   |   |     card at the time of each      |                    |   |   |
|   |   |     purchase, and your enrollment |                    |   |   |
|   |   |     information must be current   |                    |   |   |
|   |   |     and correct. In most cases,   |                    |   |   |
|   |   |     you simply present the card   |                    |   |   |
|   |   |     together with the             |                    |   |   |
|   |   |     prescription to the           |                    |   |   |
|   |   |     pharmacist. Refills cannot be |                    |   |   |
|   |   |     obtained until 75% of the     |                    |   |   |
|   |   |     drug has been used.           |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | > Exceptions for special          |                    |   |   |
|   |   | > circumstances -- The Plan will  |                    |   |   |
|   |   | > authorize up to a 90-day supply |                    |   |   |
|   |   | > at a network pharmacy for       |                    |   |   |
|   |   | > covered persons called to       |                    |   |   |
|   |   | > active military service. Also,  |                    |   |   |
|   |   | > the Plan will authorize an      |                    |   |   |
|   |   | > extra 30-day supply, either at  |                    |   |   |
|   |   | > network retail or Home          |                    |   |   |
|   |   | > Delivery, for civilian          |                    |   |   |
|   |   | > Government employees who are    |                    |   |   |
|   |   | > relocated for assignment in the |                    |   |   |
|   |   | > event of a national emergency.  |                    |   |   |
|   |   | > Authorization may be obtained   |                    |   |   |
|   |   | > from Medco Health at            |                    |   |   |
|   |   | > 800/589-7818 or from the Plan   |                    |   |   |
|   |   | > at 800/222-APWU.                |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   Non-network pharmacy -- if    |                    |   |   |
|   |   |     you do not use your           |                    |   |   |
|   |   |     identification card, if you   |                    |   |   |
|   |   |     elect to use a non-network    |                    |   |   |
|   |   |     pharmacy, or if a Medco       |                    |   |   |
|   |   |     Health network pharmacy is    |                    |   |   |
|   |   |     not available, you will need  |                    |   |   |
|   |   |     to file a claim and we will   |                    |   |   |
|   |   |     pay at the non-network retail |                    |   |   |
|   |   |     pharmacy benefit level.       |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   Mail order -- through this    |                    |   |   |
|   |   |     program, you may receive up   |                    |   |   |
|   |   |     to a 90-day supply of         |                    |   |   |
|   |   |     maintenance medications for   |                    |   |   |
|   |   |     drugs which require a         |                    |   |   |
|   |   |     prescription, diabetic        |                    |   |   |
|   |   |     supplies and insulin,         |                    |   |   |
|   |   |     syringes and needles for      |                    |   |   |
|   |   |     covered injectable            |                    |   |   |
|   |   |     medications, and oral         |                    |   |   |
|   |   |     contraceptives. Some          |                    |   |   |
|   |   |     medications may not be        |                    |   |   |
|   |   |     available in a 90-day supply  |                    |   |   |
|   |   |     from Medco Health Home        |                    |   |   |
|   |   |     Delivery Pharmacy Service     |                    |   |   |
|   |   |     even though the prescription  |                    |   |   |
|   |   |     is for 90 days.               |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   Refills for maintenance       |                    |   |   |
|   |   |     medications are not           |                    |   |   |
|   |   |     considered new prescriptions  |                    |   |   |
|   |   |     except when the doctor        |                    |   |   |
|   |   |     changes the strength or 180   |                    |   |   |
|   |   |     days has elapsed since the    |                    |   |   |
|   |   |     previous purchase. Refill     |                    |   |   |
|   |   |     orders submitted too early    |                    |   |   |
|   |   |     after the last one was filled |                    |   |   |
|   |   |     are held until the right      |                    |   |   |
|   |   |     amount of time has passed. As |                    |   |   |
|   |   |     part of the administration of |                    |   |   |
|   |   |     the prescription drug         |                    |   |   |
|   |   |     program, we reserve the right |                    |   |   |
|   |   |     to maximize your quality of   |                    |   |   |
|   |   |     care as it relates to the     |                    |   |   |
|   |   |     utilization of pharmacies.    |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
|   |   | -   You may fill your             |                    |   |   |
|   |   |     prescription at any pharmacy  |                    |   |   |
|   |   |     participating in the Medco    |                    |   |   |
|   |   |     Health system. For the names  |                    |   |   |
|   |   |     of participating pharmacies,  |                    |   |   |
|   |   |     call 800/841-2734.            |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | > Certain controlled substances   |                    |   |   |
|   |   | > and several other prescribed    |                    |   |   |
|   |   | > medications may be subject to   |                    |   |   |
|   |   | > other dispensing limitations,   |                    |   |   |
|   |   | > such as quantities dispensed,   |                    |   |   |
|   |   | > and to the judgment of the      |                    |   |   |
|   |   | > pharmacist.                     |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
|   |   | -   **When you have to file a     |                    |   |   |
|   |   |     claim.** Use a Prescription   |                    |   |   |
|   |   |     Drug Claim Form to claim      |                    |   |   |
|   |   |     benefits for prescription     |                    |   |   |
|   |   |     drugs and supplies purchased  |                    |   |   |
|   |   |     from a non-network pharmacy.  |                    |   |   |
|   |   |     You may obtain forms by       |                    |   |   |
|   |   |     calling 800/222-APWU or from  |                    |   |   |
|   |   |     our Web site at               |                    |   |   |
|   |   |     [www.apwuhp.com]{.underline}. |                    |   |   |
|   |   |     Your claim must include       |                    |   |   |
|   |   |     receipts that show the        |                    |   |   |
|   |   |     prescription number, the      |                    |   |   |
|   |   |     National Drug Code (NDC)      |                    |   |   |
|   |   |     number, name of the drug,     |                    |   |   |
|   |   |     prescribing physician's name, |                    |   |   |
|   |   |     date of purchase and charge   |                    |   |   |
|   |   |     for the drug. Mail the claim  |                    |   |   |
|   |   |     form and receipt(s) to:       |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | > APWU Health Plan                |                    |   |   |
|   |   | >                                 |                    |   |   |
|   |   | > P.O. Box 967                    |                    |   |   |
|   |   | >                                 |                    |   |   |
|   |   | > Silver Spring, MD 20910         |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   | > **You Pay**      |   |   |
| * |   |                                   |                    |   |   |
| B |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
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+---+---+-----------------------------------+--------------------+---+---+
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+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | ###                |   |   |
| # |   |                                   |                    |   |   |
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+---+---+-----------------------------------+--------------------+---+---+
| > |   |                                   | -   Network        |   |   |
|   |   |                                   |     Retail: \$8    |   |   |
| > |   |                                   |     generic/25%    |   |   |
|   |   |                                   |     brand name     |   |   |
| E |   |                                   |     with an \$8    |   |   |
| a |   |                                   |     minimum        |   |   |
| c |   |                                   |     coinsurance    |   |   |
| h |   |                                   |     for brand name |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   | -   Network Retail |   |   |
| > |   |                                   |     Medicare: \$8  |   |   |
|   |   |                                   |     generic/25%    |   |   |
| n |   |                                   |     brand name     |   |   |
| e |   |                                   |     with an \$8    |   |   |
| w |   |                                   |     minimum        |   |   |
| > |   |                                   |     coinsurance    |   |   |
|   |   |                                   |     for brand name |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   | -   Non-network    |   |   |
| e |   |                                   |     Retail: 50% of |   |   |
| n |   |                                   |     cost with an   |   |   |
| r |   |                                   |     \$8 minimum    |   |   |
| o |   |                                   |     coinsurance    |   |   |
| l |   |                                   |                    |   |   |
| l |   |                                   | -   Non-network    |   |   |
| e |   |                                   |     Retail         |   |   |
| e |   |                                   |     Medicare: 50%  |   |   |
| > |   |                                   |     of cost with   |   |   |
|   |   |                                   |     an \$8 minimum |   |   |
| > |   |                                   |     coinsurance    |   |   |
|   |   |                                   |                    |   |   |
| w |   |                                   | -   Network Mail   |   |   |
| i |   |                                   |     Order: \$12    |   |   |
| l |   |                                   |     generic/25%    |   |   |
| l |   |                                   |     brand name     |   |   |
| > |   |                                   |     with a \$12    |   |   |
|   |   |                                   |     minimum        |   |   |
| > |   |                                   |     coinsurance    |   |   |
|   |   |                                   |     for brand name |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   | -   Network Mail   |   |   |
| c |   |                                   |     Order          |   |   |
| e |   |                                   |     Medicare: \$12 |   |   |
| i |   |                                   |     generic/25%    |   |   |
| v |   |                                   |     brand name     |   |   |
| e |   |                                   |     with a \$12    |   |   |
| > |   |                                   |     minimum        |   |   |
|   |   |                                   |     coinsurance    |   |   |
| > |   |                                   |     for brand name |   |   |
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| c |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
| m |   |                                   |                    |   |   |
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| d |   |                                   |                    |   |   |
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| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+

+----------------------+-----------------------------------------------+
| Section 5 (g).       |                                               |
| Special features     |                                               |
+======================+===============================================+
| > **Special          | > **Description**                             |
| > features**         |                                               |
+----------------------+-----------------------------------------------+
| **Flexible benefits  | Under the flexible benefits option, we        |
| option**             | determine the most effective way to provide   |
|                      | services.                                     |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit                |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review                            |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future                                    |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits                 |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process                                   |
+----------------------+-----------------------------------------------+
| **24 hour nurse      | We offer a 24-hour nurse advisory service for |
| line**               | your use. This program is strictly voluntary  |
|                      | and confidential. You may call toll-free at   |
|                      | 888/993-0333 and reach registered nurses to   |
|                      | discuss an existing medical concern or to     |
|                      | receive information about numerous health     |
|                      | care issues.                                  |
+----------------------+-----------------------------------------------+
| **Services for deaf  | We offer a toll-free TDD line for customer    |
| and hearing          | service. The number is 800/622-2511. TDD      |
| impaired**           | equipment is required.                        |
+----------------------+-----------------------------------------------+
| **Wellness benefit** | We reimburse you up to \$250 per Self Only    |
|                      | enrollment and \$350 per Self and Family      |
|                      | enrollment per calendar year for non-covered  |
|                      | expenses such as vision, eyeglasses, hearing  |
|                      | aids, if received in 2004 and no other        |
|                      | benefits for 2004 have been paid. If we paid  |
|                      | claims of less than \$350 for a Self and      |
|                      | Family enrollment, the difference up to \$350 |
|                      | will be paid.                                 |
|                      |                                               |
|                      | We will notify you in November if you are     |
|                      | eligible for the Wellness benefit. Submit     |
|                      | Wellness claims after January 1, 2005.        |
|                      | Wellness claims are paid after March 1, 2005. |
|                      | If, after Wellness benefits have been paid,   |
|                      | subsequent claims are received for hospital,  |
|                      | medical or dental expenses, payments made     |
|                      | under the Wellness benefit will be deducted   |
|                      | from allowable charges.                       |
+----------------------+-----------------------------------------------+
| **Disease Management | A voluntary program that provides a variety   |
| Program**            | of services to help you manage a chronic      |
|                      | condition with outpatient treatment and avoid |
|                      | unnecessary emergency care or impatient       |
|                      | admissions. Some examples of conditions that  |
|                      | can be managed through this program are:      |
|                      | diabetes, coronary artery disease and heart   |
|                      | failure. We use medical and/or pharmacy       |
|                      | claims data as well as interactions with you  |
|                      | and your physician(s). If you have a chronic  |
|                      | condition and would like additional           |
|                      | information, call CorSolutions at             |
|                      | 866/676-0740.                                 |
+----------------------+-----------------------------------------------+
| **Review and reward  | If you send us a corrected hospital billing,  |
| program**            | we will credit 20% of any hospital charge     |
|                      | over \$20 for covered services and supplies   |
|                      | that were not actually provided to a covered  |
|                      | person. The maximum amount payable under this |
|                      | program is \$100 per person per calendar      |
|                      | year.                                         |
+----------------------+-----------------------------------------------+

+---+---+---------------+-------------------+----+--------------+---+---+
| S |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
| c |   |               |                   |    |              |   |   |
| t |   |               |                   |    |              |   |   |
| i |   |               |                   |    |              |   |   |
| o |   |               |                   |    |              |   |   |
| n |   |               |                   |    |              |   |   |
| 5 |   |               |                   |    |              |   |   |
| ( |   |               |                   |    |              |   |   |
| h |   |               |                   |    |              |   |   |
| ) |   |               |                   |    |              |   |   |
| . |   |               |                   |    |              |   |   |
| D |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
| n |   |               |                   |    |              |   |   |
| t |   |               |                   |    |              |   |   |
| a |   |               |                   |    |              |   |   |
| l |   |               |                   |    |              |   |   |
| b |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
| n |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
| f |   |               |                   |    |              |   |   |
| i |   |               |                   |    |              |   |   |
| t |   |               |                   |    |              |   |   |
| s |   |               |                   |    |              |   |   |
+===+===+===============+===================+====+==============+===+===+
|   | * | **Here are    |                   |    |              | * |   |
|   | * | some          |                   |    |              | * |   |
|   | I | important     |                   |    |              | I |   |
|   | * | things to     |                   |    |              | * |   |
|   | * | keep in mind  |                   |    |              | * |   |
|   |   | about these   |                   |    |              |   |   |
|   | * | benefits:**   |                   |    |              | * |   |
|   | * |               |                   |    |              | * |   |
|   | M | -   Please    |                   |    |              | M |   |
|   | * |     remember  |                   |    |              | * |   |
|   | * |     that all  |                   |    |              | * |   |
|   |   |     benefits  |                   |    |              |   |   |
|   | * |     are       |                   |    |              | * |   |
|   | * |     subject   |                   |    |              | * |   |
|   | P |     to the    |                   |    |              | P |   |
|   | * |               |                   |    |              | * |   |
|   | * |  definitions, |                   |    |              | * |   |
|   |   |               |                   |    |              |   |   |
|   | * |  limitations, |                   |    |              | * |   |
|   | * |     and       |                   |    |              | * |   |
|   | O |               |                   |    |              | O |   |
|   | * |    exclusions |                   |    |              | * |   |
|   | * |     in this   |                   |    |              | * |   |
|   |   |     only when |                   |    |              |   |   |
|   | * |     we        |                   |    |              | * |   |
|   | * |     determine |                   |    |              | * |   |
|   | R |     they are  |                   |    |              | R |   |
|   | * |     medically |                   |    |              | * |   |
|   | * |               |                   |    |              | * |   |
|   |   |    necessary. |                   |    |              |   |   |
|   | * |               |                   |    |              | * |   |
|   | * | -   The       |                   |    |              | * |   |
|   | T |     calendar  |                   |    |              | T |   |
|   | * |     year      |                   |    |              | * |   |
|   | * |               |                   |    |              | * |   |
|   |   |    deductible |                   |    |              |   |   |
|   | * |     is: PPO - |                   |    |              | * |   |
|   | * |     \$275 per |                   |    |              | * |   |
|   | A |     person    |                   |    |              | A |   |
|   | * |     (\$550    |                   |    |              | * |   |
|   | * |     per       |                   |    |              | * |   |
|   |   |     family);  |                   |    |              |   |   |
|   | * |     Non-PPO - |                   |    |              | * |   |
|   | * |     \$500 per |                   |    |              | * |   |
|   | N |     person    |                   |    |              | N |   |
|   | * |     (\$1,000  |                   |    |              | * |   |
|   | * |     per       |                   |    |              | * |   |
|   |   |     family).  |                   |    |              |   |   |
|   | * |     The       |                   |    |              | * |   |
|   | * |     calendar  |                   |    |              | * |   |
|   | T |     year      |                   |    |              | T |   |
|   | * |               |                   |    |              | * |   |
|   | * |    deductible |                   |    |              | * |   |
|   |   |     applies   |                   |    |              |   |   |
|   |   |     to almost |                   |    |              |   |   |
|   |   |     all       |                   |    |              |   |   |
|   |   |     benefits  |                   |    |              |   |   |
|   |   |     in this   |                   |    |              |   |   |
|   |   |     Section.  |                   |    |              |   |   |
|   |   |     We added  |                   |    |              |   |   |
|   |   |     "(No      |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
|   |   |  deductible)" |                   |    |              |   |   |
|   |   |     to show   |                   |    |              |   |   |
|   |   |     when the  |                   |    |              |   |   |
|   |   |     calendar  |                   |    |              |   |   |
|   |   |     year      |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
|   |   |    deductible |                   |    |              |   |   |
|   |   |     does not  |                   |    |              |   |   |
|   |   |     apply.    |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
|   |   | -   Be sure   |                   |    |              |   |   |
|   |   |     to read   |                   |    |              |   |   |
|   |   |     Section   |                   |    |              |   |   |
|   |   |     4, *Your  |                   |    |              |   |   |
|   |   |     costs for |                   |    |              |   |   |
|   |   |     covered   |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
|   |   |    services,* |                   |    |              |   |   |
|   |   |     for       |                   |    |              |   |   |
|   |   |     valuable  |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
|   |   |   information |                   |    |              |   |   |
|   |   |     about how |                   |    |              |   |   |
|   |   |     cost      |                   |    |              |   |   |
|   |   |     sharing   |                   |    |              |   |   |
|   |   |     works,    |                   |    |              |   |   |
|   |   |     with      |                   |    |              |   |   |
|   |   |     special   |                   |    |              |   |   |
|   |   |     sections  |                   |    |              |   |   |
|   |   |     for       |                   |    |              |   |   |
|   |   |     members   |                   |    |              |   |   |
|   |   |     who are   |                   |    |              |   |   |
|   |   |     age 65 or |                   |    |              |   |   |
|   |   |     over.     |                   |    |              |   |   |
|   |   |     Also read |                   |    |              |   |   |
|   |   |     Section   |                   |    |              |   |   |
|   |   |     10 about  |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
|   |   |  coordinating |                   |    |              |   |   |
|   |   |     benefits  |                   |    |              |   |   |
|   |   |     with      |                   |    |              |   |   |
|   |   |     other     |                   |    |              |   |   |
|   |   |     coverage, |                   |    |              |   |   |
|   |   |     including |                   |    |              |   |   |
|   |   |     with      |                   |    |              |   |   |
|   |   |     Medicare. |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
|   |   | > Note: We    |                   |    |              |   |   |
|   |   | > cover       |                   |    |              |   |   |
|   |   | > ho          |                   |    |              |   |   |
|   |   | spitalization |                   |    |              |   |   |
|   |   | > for dental  |                   |    |              |   |   |
|   |   | > procedures  |                   |    |              |   |   |
|   |   | > only when a |                   |    |              |   |   |
|   |   | > non-dental  |                   |    |              |   |   |
|   |   | > physical    |                   |    |              |   |   |
|   |   | > impairment  |                   |    |              |   |   |
|   |   | > exists      |                   |    |              |   |   |
|   |   | > which makes |                   |    |              |   |   |
|   |   | > ho          |                   |    |              |   |   |
|   |   | spitalization |                   |    |              |   |   |
|   |   | > necessary   |                   |    |              |   |   |
|   |   | > to          |                   |    |              |   |   |
|   |   | > safeguard   |                   |    |              |   |   |
|   |   | > the health  |                   |    |              |   |   |
|   |   | > of the      |                   |    |              |   |   |
|   |   | > patient. We |                   |    |              |   |   |
|   |   | > do not      |                   |    |              |   |   |
|   |   | > cover the   |                   |    |              |   |   |
|   |   | > dental      |                   |    |              |   |   |
|   |   | > procedure.  |                   |    |              |   |   |
|   |   | > See Section |                   |    |              |   |   |
|   |   | > 5(c) for    |                   |    |              |   |   |
|   |   | > inpatient   |                   |    |              |   |   |
|   |   | > hospital    |                   |    |              |   |   |
|   |   | > benefits.   |                   |    |              |   |   |
+---+---+---------------+-------------------+----+--------------+---+---+
| # |   |               |                   | >  |              |   |   |
| # |   |               |                   |  * |              |   |   |
| # |   |               |                   | *Y |              |   |   |
|   |   |               |                   | ou |              |   |   |
| A |   |               |                   | >  |              |   |   |
| c |   |               |                   |  p |              |   |   |
| c |   |               |                   | ay |              |   |   |
| i |   |               |                   | ** |              |   |   |
| d |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
| n |   |               |                   |    |              |   |   |
| t |   |               |                   |    |              |   |   |
| a |   |               |                   |    |              |   |   |
| l |   |               |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
| i |   |               |                   |    |              |   |   |
| n |   |               |                   |    |              |   |   |
| j |   |               |                   |    |              |   |   |
| u |   |               |                   |    |              |   |   |
| r |   |               |                   |    |              |   |   |
| y |   |               |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
| b |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
| n |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
| f |   |               |                   |    |              |   |   |
| i |   |               |                   |    |              |   |   |
| t |   |               |                   |    |              |   |   |
+---+---+---------------+-------------------+----+--------------+---+---+
| > |   |               |                   | Wi |              |   |   |
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+---+---+---------------+-------------------+----+--------------+---+---+
| * |   |               |                   |    |              |   |   |
| * |   |               |                   |    |              |   |   |
| D |   |               |                   |    |              |   |   |
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+---+---+---------------+-------------------+----+--------------+---+---+
| # |   |               | ### We pay (sch   |    | **You pay**  |   |   |
| # |   |               | eduled allowance) |    |              |   |   |
| # |   |               |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
| S |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
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| c |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
+---+---+---------------+-------------------+----+--------------+---+---+
| > |   |               | > \$25 per visit  |    | All charges  |   |   |
|   |   |               | > (limit 2 visits |    | in excess of |   |   |
| O |   |               | > per year)       |    | the          |   |   |
| f |   |               | >                 |    | scheduled    |   |   |
| f |   |               | > \$13 per tooth  |    | amounts      |   |   |
| i |   |               | > (single         |    | listed to    |   |   |
| c |   |               | > surface)\       |    | the left (No |   |   |
| e |   |               | > \$18 per tooth  |    | deductible)  |   |   |
| > |   |               | > (two or more    |    |              |   |   |
|   |   |               | > surfaces)       |    |              |   |   |
| v |   |               | >                 |    |              |   |   |
| i |   |               | > \$13 per tooth  |    |              |   |   |
| s |   |               |                   |    |              |   |   |
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| t |   |               |                   |    |              |   |   |
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| n |   |               |                   |    |              |   |   |
| d |   |               |                   |    |              |   |   |
| > |   |               |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
| f |   |               |                   |    |              |   |   |
| l |   |               |                   |    |              |   |   |
| u |   |               |                   |    |              |   |   |
| o |   |               |                   |    |              |   |   |
| r |   |               |                   |    |              |   |   |
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| d |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
| > |   |               |                   |    |              |   |   |
|   |   |               |                   |    |              |   |   |
| t |   |               |                   |    |              |   |   |
| r |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
| a |   |               |                   |    |              |   |   |
| t |   |               |                   |    |              |   |   |
| m |   |               |                   |    |              |   |   |
| e |   |               |                   |    |              |   |   |
| n |   |               |                   |    |              |   |   |
| t |   |               |                   |    |              |   |   |
+---+---+---------------+-------------------+----+--------------+---+---+

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

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

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

+---------+---+--------------------------+-----------------------------+
| **Vo    | T |                          |                             |
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+---------+---+--------------------------+-----------------------------+
| **      |   | After the Annual         |                             |
| Benefit |   | Deductible, this plan    |                             |
| Sch     |   | will pay:                |                             |
| edule** |   |                          |                             |
+---------+---+--------------------------+-----------------------------+
|         |   | High Option Plan         | Low Option Plan             |
+---------+---+--------------------------+-----------------------------+
| **Type  |   | 100%\                    | 100%\                       |
| I       |   | of the Reasonable and    | of the Reasonable and       |
| Ben     |   | Customary charges        | Customary charges           |
| efits** |   |                          |                             |
|         |   |                          |                             |
| Pre     |   |                          |                             |
| ventive |   |                          |                             |
| S       |   |                          |                             |
| ervices |   |                          |                             |
|         |   |                          |                             |
| -       |   |                          |                             |
|   Exams |   |                          |                             |
|         |   |                          |                             |
| -       |   |                          |                             |
|  X-rays |   |                          |                             |
|         |   |                          |                             |
| -   Cl  |   |                          |                             |
| eanings |   |                          |                             |
+---------+---+--------------------------+-----------------------------+
| **Type  |   | 80%\                     | 50%\                        |
| II      |   | of the Reasonable and    | of the Reasonable and       |
| Ben     |   | Customary charges\       | Customary charges\          |
| efits** |   | (6 month waiting period) | (6 month waiting period)    |
|         |   |                          |                             |
| Basic   |   |                          |                             |
| S       |   |                          |                             |
| ervices |   |                          |                             |
|         |   |                          |                             |
| -   F   |   |                          |                             |
| illings |   |                          |                             |
|         |   |                          |                             |
| -       |   |                          |                             |
|    Oral |   |                          |                             |
|         |   |                          |                             |
| Surgery |   |                          |                             |
|         |   |                          |                             |
| -       |   |                          |                             |
|    Extr |   |                          |                             |
| actions |   |                          |                             |
+---------+---+--------------------------+-----------------------------+
| **Type  |   | 50%\                     | 50%\                        |
| III     |   | of the Reasonable and    | of the Reasonable and       |
| Ben     |   | Customary charges\       | Customary charges\          |
| efits** |   | (12 month waiting        | (18 month waiting period)   |
|         |   | period)                  |                             |
| Major   |   |                          |                             |
| S       |   |                          |                             |
| ervices |   |                          |                             |
|         |   |                          |                             |
| -       |   |                          |                             |
|  Crowns |   |                          |                             |
|         |   |                          |                             |
| -       |   |                          |                             |
| Bridges |   |                          |                             |
|         |   |                          |                             |
| -   D   |   |                          |                             |
| entures |   |                          |                             |
|         |   |                          |                             |
| -       |   |                          |                             |
|   Perio |   |                          |                             |
| dontics |   |                          |                             |
+---------+---+--------------------------+-----------------------------+
| **Type  |   | 50%\                     | 50%\                        |
| IV      |   | of the Reasonable and    | of the Reasonable and       |
| Ben     |   | Customary charges\       | Customary charges\          |
| efits** |   | (24 month waiting        | (24 month waiting period)   |
|         |   | period)                  |                             |
| (O      |   |                          |                             |
| ptional |   |                          |                             |
| Co      |   |                          |                             |
| verage) |   |                          |                             |
|         |   |                          |                             |
| -       |   |                          |                             |
|    Orth |   |                          |                             |
| odontic |   |                          |                             |
+---------+---+--------------------------+-----------------------------+

> This is a partial summary of the terms, conditions and limitations of
> the Dental Plan policy #G-224,540. For more information\
> regarding the coverage, rates or to receive an enrollment form, please
> contact the Voluntary Benefits Plan office by calling\
> or writing:

+----------------------------------+-----------------------------------+
| **Voluntary Benefits Plan**      | **800/422-4492**                  |
|                                  |                                   |
| P.O. Box 1471                    | 800/237-5536 (In CT)              |
|                                  |                                   |
| Waterbury, CT 06721              | 203/754-4410 (TDD)                |
+----------------------------------+-----------------------------------+

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

+-----------------------------------------------------------------------+
| **Section 6. Consumer-driven Option Benefits \-- OVERVIEW**           |
|                                                                       |
| ***(See page 10 for how our benefits changed this year and page 100   |
| 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 7; 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
1-866/UDEFINE (1-866/833-3463) or at our Web site at
[www.definityhealth.com](http://www.definityhealth.com/). User ID:
**APWUHP**, Password: **HPINFO**

**The new Consumer-driven Option focuses on you, the health care
consumer, and gives you greater control in how you use your health care
benefits. With this plan, in-network preventive care is covered in full
and you can use a Personal Care Account (PCA) for non-preventive care.
If you use up your PCA, the Traditional Health Coverage works like a
regular preferred provider organization (PPO) plan. If you don't use up
your PCA for the year, you can roll it over to the next year.**

**The Consumer-driven Option includes four key components:**

**(a) In-network Preventive Care 50-51**

> This component covers 100% for preventive care for adults and children
> if you use a network provider. The covered services include office
> visits/exams, immunizations and screenings and are fully described in
> Section 6(a). They are based on recommendations by the American
> Medical Association.

**(b) Personal Care Account (PCA) 52-53**

> The plan also provides a Personal Care Account (PCA) for each
> enrollment. Each year, the plan provides \$1,000 for a Self Only
> enrollment or \$2,000 for a Self and Family enrollment. The PCA covers
> 100% for your covered medical expenses, which include dental and
> vision care.
>
> If you have an unused PCA balance at the end of the year, you can
> rollover that balance so you can use them in the future. The Personal
> Care Account is described in Section 6(b).
>
> Note that the In-network Preventive Care benefits paid under Section
> 6(a) do NOT count against your Personal Care Account (PCA).

**(c) Traditional Health Coverage 54-73**

> After you have used up your Personal Care Account (PCA) and paid your
> Member Responsibility, the plan starts paying benefits under the
> Traditional Health Coverage described in Section 6(c). The plan
> generally pays 85% of the cost for in-network care and 60% of the plan
> allowance for out-of-network care.
>
> Covered services include:

-   Medical services and supplies

-   Surgical and anesthesia services

-   Hospital services, other facilities and ambulance

-   Emergency services/Accidents

-   Mental health and substance abuse benefits

-   Prescription drug benefits

**(d) Health tools and resources 74**

> Section 6(d) describes the health tools and resources available to you
> under the Consumer-driven Option to help you improve the quality of
> your health care and manage your expenses. There is also care support
> and a 24-hour nurse advisory service.

**Non-FEHB benefits available to Plan members 48**

***SUMMARY OF BENEFITS -- CONSUMER-DRIVEN OPTION*** 100

+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| S |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| 6 |   |                                   |                    |   |   |
| ( |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| ) |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
| I |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| - |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| w |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| k |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
|   | * | **Here are some important things  |                    | * |   |
|   | * | you should keep in mind about     |                    | * |   |
|   | I | these in-network preventive care  |                    | I |   |
|   | * | benefits:**                       |                    | * |   |
|   | * |                                   |                    | * |   |
|   |   | -   Under the Consumer-driven     |                    |   |   |
|   | * |     Option, the plan pays 100%    |                    | * |   |
|   | * |     for the preventive care       |                    | * |   |
|   | M |     services listed in this       |                    | M |   |
|   | * |     Section as long as you use a  |                    | * |   |
|   | * |     network (PPO) provider.       |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   For preventive care not       |                    | * |   |
|   | * |     listed in this Section or for |                    | * |   |
|   | P |     preventive care from a        |                    | P |   |
|   | * |     non-network provider, please  |                    | * |   |
|   | * |     see Section 6(b) -- Personal  |                    | * |   |
|   |   |     Care Account (PCA).           |                    |   |   |
|   | * |                                   |                    | * |   |
|   | * | -   For all other covered         |                    | * |   |
|   | O |     expenses, please see Section  |                    | O |   |
|   | * |     6(b) -- Personal Care Account |                    | * |   |
|   | * |     and\                          |                    | * |   |
|   |   |     Section 6(c) -- Traditional   |                    |   |   |
|   | * |     Health Coverage.              |                    | * |   |
|   | * |                                   |                    | * |   |
|   | R | -   Note that the in-network      |                    | R |   |
|   | * |     preventive care paid under    |                    | * |   |
|   | * |     this Section does NOT count   |                    | * |   |
|   |   |     against or use up your        |                    |   |   |
|   | * |     Personal Care Account (PCA).  |                    | * |   |
|   | * |                                   |                    | * |   |
|   | T | -   Under the Consumer-driven     |                    | T |   |
|   | * |     Option, there is no calendar  |                    | * |   |
|   | * |     year deductible.              |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   Please remember that all      |                    | * |   |
|   | * |     benefits are subject to the   |                    | * |   |
|   | A |     definitions, limitations and  |                    | A |   |
|   | * |     exclusions in this brochure   |                    | * |   |
|   | * |     and are payable only when we  |                    | * |   |
|   |   |     determine they are medically  |                    |   |   |
|   | * |     necessary.                    |                    | * |   |
|   | * |                                   |                    | * |   |
|   | N | -   Be sure to read Section 4,    |                    | N |   |
|   | * |     *Your costs for covered       |                    | * |   |
|   | * |     services,* for valuable       |                    | * |   |
|   |   |     information about how cost    |                    |   |   |
|   | * |     sharing works, with special   |                    | * |   |
|   | * |     sections for members who are  |                    | * |   |
|   | T |     age 65 or over. Also read     |                    | T |   |
|   | * |     Section 10 about coordinating |                    | * |   |
|   | * |     benefits with other coverage, |                    | * |   |
|   |   |     including with Medicare.      |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | **You Pay**        |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| B |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| D |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| N |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
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| e |   |                                   |                    |   |   |
| : |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
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| s |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
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| o |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
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| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
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| r |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
| C |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| m |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| - |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
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| i |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
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| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | ###                |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| P |   |                                   |                    |   |   |
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+---+---+-----------------------------------+--------------------+---+---+
| O |   |                                   | > Nothing          |   |   |
| n |   |                                   |                    |   |   |
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+---+---+-----------------------------------+--------------------+---+---+
| R |   |                                   | > Nothing          |   |   |
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| 1 |   |                                   |                    |   |   |
| 0 |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
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| a |   |                                   |                    |   |   |
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| y |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
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| t |   |                                   |                    |   |   |
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| a |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
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| a |   |                                   |                    |   |   |
| g |   |                                   |                    |   |   |
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|   |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| 4 |   |                                   |                    |   |   |
| 5 |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+

+------------------------------------------+---------------------------+
| ### Preventive care, children            | ### You Pay               |
+------------------------------------------+---------------------------+
| Routine office visits, examinations and  | > Nothing                 |
| laboratory tests as follows:             |                           |
|                                          |                           |
| -   Six visits the first year (to age 1) |                           |
|                                          |                           |
| -   Three visits the second year (age    |                           |
|     1-2)                                 |                           |
|                                          |                           |
| -   Annual visits from age 2 through age |                           |
|     18                                   |                           |
+------------------------------------------+---------------------------+
| Routine immunizations:                   | > Nothing                 |
|                                          |                           |
| -   Two doses of Hepatitis A             |                           |
|                                          |                           |
| -   Three doses of Hepatitis B           |                           |
|                                          |                           |
| -   Six doses of Diphtheria, Tetanus,    |                           |
|     Pertussis (DtaP)                     |                           |
|                                          |                           |
| -   Four doses of Haemophilus Influenza  |                           |
|     type b                               |                           |
|                                          |                           |
| -   Four doses of Polio                  |                           |
|                                          |                           |
| -   Four doses of Pneumococcal Conjugate |                           |
|                                          |                           |
| -   Two doses of Varicella               |                           |
|                                          |                           |
| -   Two doses of Measles, Mumps, Rubella |                           |
+------------------------------------------+---------------------------+
| Routine screenings:                      | > Nothing                 |
|                                          |                           |
| -   Lead level testing, one between ages |                           |
|     9 to 12 months and one between 12    |                           |
|     and 24 months                        |                           |
|                                          |                           |
| -   Vision screening at ages 3, 4, 5, 6, |                           |
|     8, 10, 12, 15, and 18                |                           |
|                                          |                           |
| -   Hearing screening at ages 4, 5, 6,   |                           |
|     8, 10, 12, 15, and 18                |                           |
|                                          |                           |
| -   Pap smear and routine pelvic exam    |                           |
|     annually beginning at age 18 or the  |                           |
|     onset of sexual activity, whichever  |                           |
|     comes first.                         |                           |
+------------------------------------------+---------------------------+

+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| S |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| 6 |   |                                   |                    |   |   |
| ( |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| ) |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
| P |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| C |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| A |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| ( |   |                                   |                    |   |   |
| P |   |                                   |                    |   |   |
| C |   |                                   |                    |   |   |
| A |   |                                   |                    |   |   |
| ) |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
|   | * | **Here are some important things  |                    | * |   |
|   | * | you should keep in mind about     |                    | * |   |
|   | I | your Personal Care Account:**     |                    | I |   |
|   | * |                                   |                    | * |   |
|   | * | -   All eligible health care      |                    | * |   |
|   |   |     expenses (except in-network   |                    |   |   |
|   | * |     preventive care) are paid     |                    | * |   |
|   | * |     first from your Personal Care |                    | * |   |
|   | M |     Account (PCA). Traditional    |                    | M |   |
|   | * |     Health Coverage (Section      |                    | * |   |
|   | * |     6(c)) will only start once    |                    | * |   |
|   |   |     your Personal Care Account is |                    |   |   |
|   | * |     exhausted.                    |                    | * |   |
|   | * |                                   |                    | * |   |
|   | P | -   Note that in-network          |                    | P |   |
|   | * |     preventive care covered under |                    | * |   |
|   | * |     Section 6(a) does NOT count   |                    | * |   |
|   |   |     against your PCA.             |                    |   |   |
|   | * |                                   |                    | * |   |
|   | * | -   The Personal Care Account     |                    | * |   |
|   | O |     provides full coverage for    |                    | O |   |
|   | * |     both in-network and           |                    | * |   |
|   | * |     out-of-network providers.     |                    | * |   |
|   |   |     However your Personal Care    |                    |   |   |
|   | * |     Account will generally go     |                    | * |   |
|   | * |     much further when you use     |                    | * |   |
|   | R |     network providers because     |                    | R |   |
|   | * |     network providers agree to    |                    | * |   |
|   | * |     discount their fees.          |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   You have flexibility about    |                    | * |   |
|   | * |     how to spend your PCA, and    |                    | * |   |
|   | T |     the Plan provides you with    |                    | T |   |
|   | * |     the resources to manage your  |                    | * |   |
|   | * |     PCA. You can track your PCA   |                    | * |   |
|   |   |     on your personal private Web  |                    |   |   |
|   | * |     site, by telephone at         |                    | * |   |
|   | * |     866/333-4648 (toll-free), or  |                    | * |   |
|   | A |     with quarterly statements     |                    | A |   |
|   | * |     mailed directly to you at     |                    | * |   |
|   | * |     home.                         |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   If you join this Plan during  |                    | * |   |
|   | * |     Open Season, you receive the  |                    | * |   |
|   | N |     full PCA (\$1,000 per Self    |                    | N |   |
|   | * |     Only or \$2,000 per Self and  |                    | * |   |
|   | * |     Family enrollment) as of your |                    | * |   |
|   |   |     effective date of coverage.   |                    |   |   |
|   | * |     If you join at any other time |                    | * |   |
|   | * |     during the year, your PCA for |                    | * |   |
|   | T |     your first year will be       |                    | T |   |
|   | * |     prorated at a rate of \$83    |                    | * |   |
|   | * |     per month for Self Only or    |                    | * |   |
|   |   |     \$167 per month for Self and  |                    |   |   |
|   |   |     Family for each full month of |                    |   |   |
|   |   |     coverage remaining in that    |                    |   |   |
|   |   |     calendar year.                |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   Please remember that all      |                    |   |   |
|   |   |     benefits are subject to the   |                    |   |   |
|   |   |     definitions, limitations and  |                    |   |   |
|   |   |     exclusions in this brochure   |                    |   |   |
|   |   |     and are payable only when we  |                    |   |   |
|   |   |     determine they are medically  |                    |   |   |
|   |   |     necessary.                    |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   Under the Consumer-driven     |                    |   |   |
|   |   |     Option, there is no calendar  |                    |   |   |
|   |   |     year deductible.              |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   Be sure to read Section 4,    |                    |   |   |
|   |   |     *Your costs for covered       |                    |   |   |
|   |   |     services,* for valuable       |                    |   |   |
|   |   |     information about how cost    |                    |   |   |
|   |   |     sharing works, with special   |                    |   |   |
|   |   |     sections for members who are  |                    |   |   |
|   |   |     age 65 or over. Also read     |                    |   |   |
|   |   |     Section 10 about coordinating |                    |   |   |
|   |   |     benefits with other coverage, |                    |   |   |
|   |   |     including with Medicare.      |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   **YOU MUST GET                |                    |   |   |
|   |   |     PRECERTIFICATION OF HOSPITAL  |                    |   |   |
|   |   |     STAYS; FAILURE TO DO SO WILL  |                    |   |   |
|   |   |     RESULT IN A MINIMUM \$500     |                    |   |   |
|   |   |     PENALTY.** Please refer to    |                    |   |   |
|   |   |     the precertification          |                    |   |   |
|   |   |     information shown in Section  |                    |   |   |
|   |   |     3 to confirm which services   |                    |   |   |
|   |   |     require precertification.     |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | **You Pay**        |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| B |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| f |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| D |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
| # |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| N |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| : |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| T |   |                                   |                    |   |   |
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| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| y |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| b |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| C |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| m |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| - |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| O |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| > |   |                                   | > In-network and   |   |   |
|   |   |                                   | > Out-of-Network:  |   |   |
| A |   |                                   | > Nothing up to    |   |   |
| > |   |                                   | > \$1,000 for a    |   |   |
|   |   |                                   | > Self Only        |   |   |
| P |   |                                   | > enrollment or    |   |   |
| e |   |                                   | > \$2,000 for a    |   |   |
| r |   |                                   | > Self and Family  |   |   |
| s |   |                                   | > enrollment       |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| C |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| A |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| u |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| ( |   |                                   |                    |   |   |
| P |   |                                   |                    |   |   |
| C |   |                                   |                    |   |   |
| A |   |                                   |                    |   |   |
| ) |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| s |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
|   |   |                                   |                    |   |   |
| p |   |                                   |                    |   |   |
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| d |   |                                   |                    |   |   |
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| d |   |                                   |                    |   |   |
| > |   |                                   |                    |   |   |
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| > |   |                                   |                    |   |   |
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| > |   |                                   |                    |   |   |
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| n |   |                                   |                    |   |   |
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| A |   |                                   |                    |   |   |
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+---+---+-----------------------------------+--------------------+---+---+

+------------------------------------------+---------------------------+
| ### Benefit Description                  | ### You Pay               |
|                                          |                           |
| ###                                      |                           |
+------------------------------------------+---------------------------+
| > There are two types of eligible        | > (see above)             |
| > expenses covered by your PCA.          |                           |
|                                          |                           |
| -   **Basic PCA Expenses** are the same  |                           |
|     medical, surgical, hospital,         |                           |
|     emergency, mental health and         |                           |
|     substance abuse, and prescription    |                           |
|     drug services and supplies covered   |                           |
|     under the Traditional Health         |                           |
|     Coverage (see Section 6(c) for       |                           |
|     details)                             |                           |
|                                          |                           |
| -   **Extra PCA Expenses** include:      |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Dental and/or vision services up to  |                           |
|     a combined maximum of \$400 per Self |                           |
|     Only enrollment or \$800 per Self    |                           |
|     and Family enrollment each calendar  |                           |
|     year, including:                     |                           |
|                                          |                           |
| -   Vision exam performed by an          |                           |
|     optometrist or ophthalmologist       |                           |
|                                          |                           |
| -   Eyeglasses and contact lenses        |                           |
|                                          |                           |
| -   Dental treatment (including          |                           |
|     examinations, cleanings, fillings,   |                           |
|     restorative treatment, endodontics,  |                           |
|     and periodontics                     |                           |
|                                          |                           |
| -   Costs for in-network preventive care |                           |
|     services not included under Section  |                           |
|     6(a) -- In-network Preventive Care   |                           |
|     benefits                             |                           |
|                                          |                           |
| -   Costs for out-of-network preventive  |                           |
|     care including amounts in excess of  |                           |
|     the Plan allowance, limited to       |                           |
|     services shown as covered under      |                           |
|     Section 6(a)                         |                           |
|                                          |                           |
| -   Amounts in excess of the Plan        |                           |
|     allowance for services received      |                           |
|     out-of-network and covered under     |                           |
|     Basic PCA Expenses                   |                           |
|                                          |                           |
| > **Note: Both Basic and Extra PCA       |                           |
| > Expenses are covered at 100% as long   |                           |
| > as you have not used up your Personal  |                           |
| > Care Account.**                        |                           |
| >                                        |                           |
| > **Note: Extra PCA Expenses are covered |                           |
| > under your PCA only and are combined   |                           |
| > with your Basic PCA Expenses up to the |                           |
| > PCA account limit. These expenses do   |                           |
| > not count toward your Member           |                           |
| > Responsibility and are not covered     |                           |
| > under Traditional Health Coverage.**   |                           |
| >                                        |                           |
| > To make the most of your Personal Care |                           |
| > Account, you should:                   |                           |
|                                          |                           |
| -   Use the network providers wherever   |                           |
|     possible;                            |                           |
|                                          |                           |
| -   Use generic prescriptions wherever   |                           |
|     possible; and                        |                           |
|                                          |                           |
| -   Only use your PCA for Extra PCA      |                           |
|     Expenses if you expect to have an    |                           |
|     unused balance in your PCA at the    |                           |
|     end of the calendar year.            |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Orthodontia*                        |                           |
|                                          |                           |
| -   *Dental treatment for cosmetic       |                           |
|     purposes*                            |                           |
|                                          |                           |
| -   *Out-of-network preventive care      |                           |
|     services not included under Section  |                           |
|     6(a)*                                |                           |
|                                          |                           |
| -   *Services or supplies shown as not   |                           |
|     covered under Traditional Health     |                           |
|     Coverage (see Section 6(c)) and not  |                           |
|     included under Extra PCA Expenses    |                           |
|     above*                               |                           |
+------------------------------------------+---------------------------+
| **PCA Rollover**                         |                           |
|                                          |                           |
| Any unused, remaining balance in your    |                           |
| PCA at the end of the calendar year may  |                           |
| be rolled over to subsequent years up to |                           |
| a maximum PCA account of \$4,000 per     |                           |
| Self Only enrollment or \$6,000 per Self |                           |
| and Family enrollment, thereby           |                           |
| increasing your PCA in the following     |                           |
| year(s).                                 |                           |
+------------------------------------------+---------------------------+

+---+---+-----------------------------------+--------------------+---+---+
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| S |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| 6 |   |                                   |                    |   |   |
| ( |   |                                   |                    |   |   |
| c |   |                                   |                    |   |   |
| ) |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
| T |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| d |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| i |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| n |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| H |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| l |   |                                   |                    |   |   |
| t |   |                                   |                    |   |   |
| h |   |                                   |                    |   |   |
| C |   |                                   |                    |   |   |
| o |   |                                   |                    |   |   |
| v |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| r |   |                                   |                    |   |   |
| a |   |                                   |                    |   |   |
| g |   |                                   |                    |   |   |
| e |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
| * |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
|   | * | **Here are some important things  |                    | * |   |
|   | * | you should keep in mind about     |                    | * |   |
|   | I | these benefits:**                 |                    | I |   |
|   | * |                                   |                    | * |   |
|   | * | -   Please remember that all      |                    | * |   |
|   |   |     benefits are subject to the   |                    |   |   |
|   | * |     definitions, limitations and  |                    | * |   |
|   | * |     exclusions in this brochure   |                    | * |   |
|   | M |     and are payable only when we  |                    | M |   |
|   | * |     determine they are medically  |                    | * |   |
|   | * |     necessary.                    |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   In-network preventive care is |                    | * |   |
|   | * |     covered at 100% under Section |                    | * |   |
|   | P |     6(a) and does not count       |                    | P |   |
|   | * |     against your Personal Care    |                    | * |   |
|   | * |     Account.                      |                    | * |   |
|   |   |                                   |                    |   |   |
|   | * | -   Your Personal Care Account    |                    | * |   |
|   | * |     **must** be used first for    |                    | * |   |
|   | O |     eligible health care          |                    | O |   |
|   | * |     expenses.                     |                    | * |   |
|   | * |                                   |                    | * |   |
|   |   | -   If your Personal Care Account |                    |   |   |
|   | * |     has been exhausted, you must  |                    | * |   |
|   | * |     pay your Member               |                    | * |   |
|   | R |     Responsibility before your    |                    | R |   |
|   | * |     Traditional Health Coverage   |                    | * |   |
|   | * |     may begin. Your Member        |                    | * |   |
|   |   |     Responsibility applies to all |                    |   |   |
|   | * |     benefits in this section      |                    | * |   |
|   | * |                                   |                    | * |   |
|   | T | -   The Consumer-driven Option    |                    | T |   |
|   | * |     provides coverage for both    |                    | * |   |
|   | * |     in-network and out-of-network |                    | * |   |
|   |   |     providers. The out-of-network |                    |   |   |
|   | * |     benefits are the standard     |                    | * |   |
|   | * |     benefits under the            |                    | * |   |
|   | A |     Traditional Health Coverage.  |                    | A |   |
|   | * |     In-network benefits apply     |                    | * |   |
|   | * |     only when you use a provider  |                    | * |   |
|   |   |     from the large, national      |                    |   |   |
|   | * |     network. When a network       |                    | * |   |
|   | * |     provider is not available,    |                    | * |   |
|   | N |     out-of-network benefits       |                    | N |   |
|   | * |     apply.                        |                    | * |   |
|   | * |                                   |                    | * |   |
|   |   | -   If you join at any time       |                    |   |   |
|   | * |     during the year other than    |                    | * |   |
|   | * |     Open Season, your Member      |                    | * |   |
|   | T |     Responsibility for your first |                    | T |   |
|   | * |     year will be prorated at a    |                    | * |   |
|   | * |     rate of \$50 per month for    |                    | * |   |
|   |   |     Self Only or \$100 per month  |                    |   |   |
|   |   |     for Self and Family for each  |                    |   |   |
|   |   |     full month of coverage        |                    |   |   |
|   |   |     remaining in that calendar    |                    |   |   |
|   |   |     year.                         |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   When you use a network        |                    |   |   |
|   |   |     hospital, keep in mind that   |                    |   |   |
|   |   |     the professionals who provide |                    |   |   |
|   |   |     services to you in the        |                    |   |   |
|   |   |     hospital, such as             |                    |   |   |
|   |   |     radiologists, emergency room  |                    |   |   |
|   |   |     physicians,                   |                    |   |   |
|   |   |     anesthesiologists, and        |                    |   |   |
|   |   |     pathologists, may not all be  |                    |   |   |
|   |   |     network providers. If they    |                    |   |   |
|   |   |     are not, they will be paid by |                    |   |   |
|   |   |     this Plan as out-of-network   |                    |   |   |
|   |   |     providers under the           |                    |   |   |
|   |   |     Traditional Health Coverage.  |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   Be sure to read Section 4,    |                    |   |   |
|   |   |     *Your costs for covered       |                    |   |   |
|   |   |     services,* for valuable       |                    |   |   |
|   |   |     information about how cost    |                    |   |   |
|   |   |     sharing works, with special   |                    |   |   |
|   |   |     sections for members who are  |                    |   |   |
|   |   |     age 65 or over. Also read     |                    |   |   |
|   |   |     Section 10 about coordinating |                    |   |   |
|   |   |     benefits with other coverage, |                    |   |   |
|   |   |     including with Medicare.      |                    |   |   |
|   |   |                                   |                    |   |   |
|   |   | -   **YOU MUST GET                |                    |   |   |
|   |   |     PRECERTIFICATION OF HOSPITAL  |                    |   |   |
|   |   |     STAYS; FAILURE TO DO SO WILL  |                    |   |   |
|   |   |     RESULT IN A MINIMUM \$500     |                    |   |   |
|   |   |     PENALTY.** Please refer to    |                    |   |   |
|   |   |     the precertification          |                    |   |   |
|   |   |     information shown in Section  |                    |   |   |
|   |   |     3 to confirm which services   |                    |   |   |
|   |   |     require precertification.     |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | **You Pay**        |   |   |
| # |   |                                   |                    |   |   |
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+---+---+-----------------------------------+--------------------+---+---+
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+---+---+-----------------------------------+--------------------+---+---+
| # |   |                                   | ###                |   |   |
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+---+---+-----------------------------------+--------------------+---+---+
| > |   |                                   | > In-netwo         |   |   |
|   |   |                                   | rk/Out-of-network: |   |   |
| I |   |                                   | > \$600 per Self   |   |   |
| f |   |                                   | > Only enrollment  |   |   |
| > |   |                                   | > or \$1,200 per   |   |   |
|   |   |                                   | > Self and Family  |   |   |
| y |   |                                   | > enrollment       |   |   |
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| * |   |                                   |                    |   |   |
| . |   |                                   |                    |   |   |
+---+---+-----------------------------------+--------------------+---+---+

+------------------------------------------+---------------------------+
| #                                        | ### You pay               |
| ## Member responsibility before Traditio |                           |
| nal Health Coverage begins *(continued)* |                           |
+------------------------------------------+---------------------------+
| > In year one, therefore, the member     | > (see above)             |
| > responsibility is \$600 for Self Only  |                           |
| > and \$1,200 for Self and Family        |                           |
| > enrollment.                            |                           |
|                                          |                           |
|   ------                                 |                           |
| -------------- ------------------------- |                           |
| ---------------------------------------- |                           |
| ---------------------------------------- |                           |
| ------- -------------------------------- |                           |
| ---------------------------------------- |                           |
| ---------------------------------------- |                           |
|                        Self Onl          |                           |
| y                                        |                           |
|                                          |                           |
|                          Self and Family |                           |
|                                          |                           |
|   Basic PCA Expenses                     |                           |
| \$1,000                                  |                           |
|                                          |                           |
|                                  \$2,000 |                           |
|   paid by PCA                            |                           |
|                                          |                           |
|                                          |                           |
|                                          |                           |
|                                          |                           |
|   Member                                 |                           |
| \$ 600                                   |                           |
|                                          |                           |
|                                  \$1,200 |                           |
|   Responsibility                         |                           |
|  paid                                    |                           |
|                                          |                           |
|                                          |                           |
|   by you                                 |                           |
|                                          |                           |
|                                          |                           |
|                                          |                           |
|                                          |                           |
|                                          |                           |
|                  \_\_\_\_\_\_\_\_\_\_\_\ |                           |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                           |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                           |
| _\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                           |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                           |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                           |
|                                          |                           |
|   Traditional Health                     |                           |
| \$1,600                                  |                           |
|                                          |                           |
|                                  \$3,200 |                           |
|   Coverage start                         |                           |
| s                                        |                           |
|                                          |                           |
|                                          |                           |
|   after                                  |                           |
|                                          |                           |
|                                          |                           |
|                                          |                           |
|   ------                                 |                           |
| -------------- ------------------------- |                           |
| ---------------------------------------- |                           |
| ---------------------------------------- |                           |
| ------- -------------------------------- |                           |
| ---------------------------------------- |                           |
| ---------------------------------------- |                           |
|                                          |                           |
| > Any PCA dollars that you rollover at   |                           |
| > the end of the year will reduce your   |                           |
| > Member Responsibility next year.       |                           |
| >                                        |                           |
| > In future years, the amount of your    |                           |
| > Member Responsibility may be lower if  |                           |
| > you rollover PCA dollars at the end of |                           |
| > the year. For example, if you rollover |                           |
| > \$300 at the end of the year:          |                           |
|                                          |                           |
|   ------                                 |                           |
| -------------- ------------------------- |                           |
| ---------------------------------------- |                           |
| ---------------------------------------- |                           |
| ------- -------------------------------- |                           |
| ---------------------------------------- |                           |
| ---------------------------------------- |                           |
|                        Self Onl          |                           |
| y                                        |                           |
|                                          |                           |
|                          Self and Family |                           |
|                                          |                           |
|   PCA for year 2\      \                 |                           |
| $1,000\                                  |                           |
|                                          |                           |
|                                 \$2,000\ |                           |
|   Rollover from year 1 [+ 300]{.unde     |                           |
| rline}\                                  |                           |
|                                          |                           |
|                     [+ 300]{.underline}\ |                           |
|                                          |                           |
| \$1,300                                  |                           |
|                                          |                           |
|                                  \$2,300 |                           |
|                                          |                           |
|   **Member             **                |                           |
| + 300**                                  |                           |
|                                          |                           |
|                                **+ 900** |                           |
|   Responsibility                         |                           |
|  paid                                    |                           |
|                                          |                           |
|                                          |                           |
|   by you**                               |                           |
|                                          |                           |
|                                          |                           |
|                                          |                           |
|                                          |                           |
|                                          |                           |
|                  \_\_\_\_\_\_\_\_\_\_\_\ |                           |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                           |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                           |
| _\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                           |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                           |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                           |
|                                          |                           |
|   Traditional Health                     |                           |
| \$1,600                                  |                           |
|                                          |                           |
|                                  \$3,200 |                           |
|   Coverage start                         |                           |
| s when                                   |                           |
|                                          |                           |
|                                          |                           |
|   eligible expen                         |                           |
| ses                                      |                           |
|                                          |                           |
|                                          |                           |
|   total                                  |                           |
|                                          |                           |
|                                          |                           |
|                                          |                           |
|   ------                                 |                           |
| -------------- ------------------------- |                           |
| ---------------------------------------- |                           |
| ---------------------------------------- |                           |
| ------- -------------------------------- |                           |
| ---------------------------------------- |                           |
| ---------------------------------------- |                           |
|                                          |                           |
| > If you decide to use your PCA for      |                           |
| > Extra PCA Expenses, you may increase   |                           |
| > your Member Responsibility. For        |                           |
| > example, if you buy eyeglasses for     |                           |
| > \$150 and **later** have an accident   |                           |
| > that leads to a hospital stay, you     |                           |
| > will have to pay your Member           |                           |
| > Responsibility plus "make up" the      |                           |
| > \$150 dollars you spent on Extra PCA   |                           |
| > Expenses.                              |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ####### Traditional Health Coverage      | **You Pay**               |
+------------------------------------------+---------------------------+
| ### Note:                                |                           |
| The services listed below are Covered Ex |                           |
| penses under Traditional Health Coverage |                           |
+------------------------------------------+---------------------------+
| ### Medical                              | ###                       |
| services and supplies provided by physic |                           |
| ians and other health care professionals |                           |
+------------------------------------------+---------------------------+
| > **Diagnostic and treatment services**  |                           |
+------------------------------------------+---------------------------+
| Professional services of physicians      | > In-network: 15% of the  |
|                                          | > Plan allowance          |
| -   In physician's office                | >                         |
|                                          | > Out-of-network: 40% of  |
| -   At home                              | > the Plan allowance and  |
|                                          | > any difference between  |
| -   In an urgent care center             | > our allowance and the   |
|                                          | > billed amount           |
| -   During a hospital stay               |                           |
|                                          |                           |
| -   Initial examination of a newborn     |                           |
|     child covered under a family         |                           |
|     enrollment                           |                           |
|                                          |                           |
| -   In a skilled nursing facility        |                           |
|                                          |                           |
| -   Second surgical opinion              |                           |
+------------------------------------------+---------------------------+
| > **Lab, X-ray and other diagnostic      |                           |
| > tests**                                |                           |
+------------------------------------------+---------------------------+
| Tests, such as:                          | > In-network: 15% of the  |
|                                          | > Plan allowance          |
| -   Blood tests                          | >                         |
|                                          | > Out-of-network: 40% of  |
| -   Urinalysis                           | > the Plan allowance and  |
|                                          | > any difference between  |
| -   Non-routine pap tests                | > our allowance and the   |
|                                          | > billed amount           |
| -   Pathology                            | >                         |
|                                          | > Note: If your network   |
| -   X-rays                               | > provider uses an        |
|                                          | > out-of-network lab or   |
| -   Non-routine Mammograms               | > radiologist, we will    |
|                                          | > pay out-of-network      |
| -   CAT Scans/MRI/PET                    | > benefits for any lab    |
|                                          | > and\                    |
| -   Ultrasound                           | > X-ray charges.          |
|                                          |                           |
| -   Electrocardiogram and EEG            |                           |
+------------------------------------------+---------------------------+
| *Not covered: Professional fees for      | > *All charges*           |
| automated lab tests*                     |                           |
+------------------------------------------+---------------------------+
| > **Maternity care**                     |                           |
+------------------------------------------+---------------------------+
| Complete maternity (obstetrical) care,   | > In-network: 15% of the  |
| such as:                                 | > Plan allowance          |
|                                          | >                         |
| -   Prenatal care                        | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
| -   Delivery                             | > any difference between  |
|                                          | > our allowance and the   |
| -   Postnatal care                       | > billed amount           |
|                                          |                           |
| Note: Here are some things to keep in    |                           |
| mind:                                    |                           |
|                                          |                           |
| -   You do not need to precertify your   |                           |
|     normal delivery; see pages 13 and 14 |                           |
|     for other circumstances, such as     |                           |
|     extended stays for you or your baby. |                           |
|                                          |                           |
| -   You may remain in the hospital up to |                           |
|     48 hours after a regular delivery    |                           |
|     and 96 hours after a cesarean        |                           |
|     delivery. We will cover an extended  |                           |
|     stay if medically necessary, but     |                           |
|     you, your representative, your       |                           |
|     doctor, or your hospital must        |                           |
|     precertify.                          |                           |
+------------------------------------------+---------------------------+

*Maternity care benefits -- continued on next page*

+------------------------------------------+---------------------------+
| ### Medical services and s               | ### You Pay               |
| upplies provided by physicians and other |                           |
|  health care professionals *(continued)* |                           |
+------------------------------------------+---------------------------+
| > **Maternity care** *(continued)*       |                           |
+------------------------------------------+---------------------------+
| -   We cover routine nursery care of the | > (see above)             |
|     newborn child during the covered     |                           |
|     portion of the mother's maternity    |                           |
|     stay. We will cover the initial      |                           |
|     examination of the infant and other  |                           |
|     care of an infant who requires       |                           |
|     non-routine treatment if we cover    |                           |
|     the infant under a Self and Family   |                           |
|     enrollment. We cover circumcision of |                           |
|     a covered newborn under Surgical     |                           |
|     benefits. See Surgery benefits       |                           |
|     below.                               |                           |
|                                          |                           |
| -   We pay hospitalization and surgeon   |                           |
|     services (delivery) the same as for  |                           |
|     illness and injury. See Hospital     |                           |
|     benefits and Surgery benefits below. |                           |
+------------------------------------------+---------------------------+
| > *Not covered: Amniocentesis if for     | > *All charges*           |
| > diagnosing multiple births*            |                           |
+------------------------------------------+---------------------------+
| > **Family planning**                    |                           |
+------------------------------------------+---------------------------+
| A range of voluntary family planning     | > In-network: 15% of the  |
| services, limited to:                    | > Plan allowance          |
|                                          | >                         |
| -   Voluntary sterilization (See         | > Out-of-network: 40% of  |
|     Surgical procedures below)           | > the Plan allowance and  |
|                                          | > any difference between  |
| -   Surgically implanted contraceptives  | > our allowance and the   |
|                                          | > billed amount           |
| -   Injectable contraceptive drugs (such |                           |
|     as Depo provera)                     |                           |
|                                          |                           |
| -   Intrauterine devices (IUDs)          |                           |
|                                          |                           |
| -   Diaphragms                           |                           |
|                                          |                           |
| Note: We cover oral contraceptives under |                           |
| the prescription drug benefit.           |                           |
+------------------------------------------+---------------------------+
| *Not covered: Reversal of voluntary      | > *All charges*           |
| surgical sterilization and genetic       |                           |
| counseling*                              |                           |
+------------------------------------------+---------------------------+
| > **Infertility services**               |                           |
+------------------------------------------+---------------------------+
| Diagnosis and treatment of infertility,  | > In-network: 15% of the  |
| except as shown in *Not covered*         | > Plan allowance and any  |
|                                          | > amount over \$2,500     |
|                                          | >                         |
|                                          | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
|                                          | > any difference between  |
|                                          | > our allowance and the   |
|                                          | > billed amount and any   |
|                                          | > amount over \$2,500     |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Infertility services after          |                           |
|     voluntary sterilization*             |                           |
|                                          |                           |
| -   *Assisted reproductive technology    |                           |
|     (ART) procedures, such as:*          |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *artificial insemination (all        |                           |
|     procedures)*                         |                           |
|                                          |                           |
| -   *in vitro fertilization*             |                           |
|                                          |                           |
| -   *embryo transfer and gamete          |                           |
|     intrafallopian transfer (GIFT)*      |                           |
|                                          |                           |
| -   *intravaginal insemination (IVI)*    |                           |
|                                          |                           |
| -   *intracervical insemination (ICI)*   |                           |
|                                          |                           |
| -   *intrauterine insemination (IUI)*    |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   *Services and supplies related to    |                           |
|     ART procedures*                      |                           |
|                                          |                           |
| -   *Cost of donor sperm*                |                           |
|                                          |                           |
| -   *Cost of donor egg*                  |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ### Medical services and s               | ### You Pay               |
| upplies provided by physicians and other |                           |
|  health care professionals *(continued)* |                           |
+------------------------------------------+---------------------------+
| > **Allergy care**                       |                           |
+------------------------------------------+---------------------------+
| Testing and treatment, including         | > In-network: 15% of the  |
| materials (such as allergy serum)        | > Plan allowance          |
|                                          | >                         |
| Allergy injections                       | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
|                                          | > any difference between  |
|                                          | > our allowance and the   |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| *Not covered: Provocative food testing   | > *All charges*           |
| and sublingual allergy desensitization*  |                           |
+------------------------------------------+---------------------------+
| > **Treatment therapies**                |                           |
+------------------------------------------+---------------------------+
| -   Chemotherapy and radiation therapy   | > In-network: 15% of the  |
|                                          | > Plan allowance          |
| Note: High dose chemotherapy in          | >                         |
| association with autologous bone marrow  | > Out-of-network: 40% of  |
| transplants is limited to those          | > the Plan allowance and  |
| transplants listed on page 66.           | > any difference between  |
|                                          | > our allowance and the   |
| -   Dialysis -- hemodialysis and         | > billed amount           |
|     peritoneal dialysis                  |                           |
|                                          |                           |
| -   Intravenous (IV)/Infusion Therapy -- |                           |
|     Home IV and antibiotic therapy       |                           |
|                                          |                           |
| -   Growth hormone therapy (GHT)         |                           |
|                                          |                           |
| Note: Growth hormone is covered under    |                           |
| the prescription drug benefit.           |                           |
|                                          |                           |
| Note: We only cover IV/Infusion therapy  |                           |
| and GHT when we are\                     |                           |
| pre-notified of the treatment. Call      |                           |
| Definity Health at 866/333-4648 for      |                           |
| pre-notification. Definity Health will   |                           |
| ask you to submit information that       |                           |
| establishes that GHT is medically        |                           |
| necessary. You should pre-notify before  |                           |
| you begin treatment. If you do not ask   |                           |
| or if we determine GHT is not medically  |                           |
| necessary, we will not cover GHT or      |                           |
| related services and supplies. See       |                           |
| *Services requiring our prior approval*  |                           |
| in Section 3.                            |                           |
|                                          |                           |
| -   Respiratory and inhalation therapies |                           |
+------------------------------------------+---------------------------+
| > **Physical and occupational            |                           |
| > therapies**                            |                           |
+------------------------------------------+---------------------------+
| Physical therapy and occupational        | > In-network: 15% of the  |
| therapy provided by a licensed           | > Plan allowance          |
| registered therapist up to a combined 60 | >                         |
| visits per calendar year                 | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
| Note: Pre-notification of rehabilitative | > any difference between  |
| therapies is required. Call Definity     | > our allowance and the   |
| Health at 866/333-4648 for               | > billed amount           |
| pre-notification.                        |                           |
|                                          |                           |
| Note: We only cover physical and         |                           |
| occupational therapy to restore bodily   |                           |
| function when there has been a total or  |                           |
| partial loss of bodily function due to   |                           |
| illness or injury and when a physician:  |                           |
|                                          |                           |
| 1\) Orders the care                      |                           |
|                                          |                           |
| 2\) Identifies the specific professional |                           |
| skills the patient requires and the      |                           |
| medical necessity for skilled services;  |                           |
| and                                      |                           |
|                                          |                           |
| 3\) Indicates the length of time the     |                           |
| services are needed                      |                           |
+------------------------------------------+---------------------------+

*Physical and occupational therapies* *benefits -- continued on next
page*

+------------------------------------------+---------------------------+
| ### Medical services and s               | ### You Pay               |
| upplies provided by physicians and other |                           |
|  health care professionals *(continued)* |                           |
+------------------------------------------+---------------------------+
| > **Physical and occupational            |                           |
| > therapies** *(continued)*              |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Maintenance therapies*              |                           |
|                                          |                           |
| -   *Exercise programs*                  |                           |
|                                          |                           |
| -   *Physical and occupational therapies |                           |
|     without preauthorization*            |                           |
+------------------------------------------+---------------------------+
| > **Speech therapy**                     |                           |
+------------------------------------------+---------------------------+
| Speech therapy where medically necessary | > In-network: 15% of the  |
| and provided by a licensed therapist     | > Plan allowance          |
|                                          | >                         |
| Note: Pre-notification of speech therapy | > Out-of-network: 40% of  |
| is required. Call Definity Health at     | > the Plan allowance and  |
| 866/333-4648 for pre-notification.       | > any difference between  |
|                                          | > our allowance and the   |
| Note: Speech therapy is combined with 60 | > billed amount           |
| visits per year for the services of      |                           |
| physical therapy and/or occupational     |                           |
| therapy (see above).                     |                           |
+------------------------------------------+---------------------------+
| > **Hearing services (testing,           |                           |
| > treatment, and supplies)**             |                           |
+------------------------------------------+---------------------------+
| Audiologist to diagnose a hearing        | > In-network: 15% of the  |
| problem                                  | > Plan allowance          |
|                                          | >                         |
|                                          | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
|                                          | > any difference between  |
|                                          | > our allowance and the   |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Hearing aids, testing and           |                           |
|     examinations for them*               |                           |
+------------------------------------------+---------------------------+
| > **Vision services (testing, treatment, |                           |
| > and supplies)**                        |                           |
+------------------------------------------+---------------------------+
| -   Internal (implant) ocular lenses     | > In-network: 15% of the  |
|     and/or the first contact lenses      | > Plan allowance          |
|     required to correct an impairment    | >                         |
|     caused by accident or illness. The   | > Out-of-network: 40% of  |
|     services of an optometrist are       | > the Plan allowance and  |
|     limited to the testing, evaluation   | > any difference between  |
|     and fitting of the first contact     | > our allowance and the   |
|     lenses required to correct an        | > billed amount           |
|     impairment caused by accident or     |                           |
|     illness.                             |                           |
|                                          |                           |
| Note: See page 51 - Preventive care,     |                           |
| children, for eye exams for children     |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Eyeglasses or contact lenses and    |                           |
|     examinations for them except under   |                           |
|     PCA*                                 |                           |
|                                          |                           |
| -   *Eye exercises and visual training*  |                           |
|                                          |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ### Medical services and s               | ### You Pay               |
| upplies provided by physicians and other |                           |
|  health care professionals *(continued)* |                           |
+------------------------------------------+---------------------------+
| > **Foot care**                          |                           |
+------------------------------------------+---------------------------+
| Routine foot care when you are under     | > In-network: 15% of the  |
| active treatment for a metabolic or      | > Plan allowance          |
| peripheral vascular disease, such as     | >                         |
| diabetes                                 | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
| See Orthopedic and prosthetic devices    | > any difference between  |
| for information on podiatric shoe        | > our allowance and the   |
| inserts                                  | > billed amount           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Cutting, trimming or removal of     |                           |
|     corns, calluses, or the free edge of |                           |
|     toenails, and similar routine        |                           |
|     treatment of conditions of the foot, |                           |
|     except as stated above*              |                           |
|                                          |                           |
| -   *Treatment of weak, strained or flat |                           |
|     feet or bunions or spurs; and of any |                           |
|     instability, imbalance or            |                           |
|     subluxation of the foot (unless the  |                           |
|     treatment is by open cutting         |                           |
|     surgery)*                            |                           |
+------------------------------------------+---------------------------+
| # Orthopedic and prosthetic devices      | #                         |
+------------------------------------------+---------------------------+
| -   Artificial limbs and eyes; stump     | > In-network: 15% of the  |
|     hose                                 | > Plan allowance          |
|                                          | >                         |
| -   Externally worn breast prostheses    | > Out-of-network: 40% of  |
|     and surgical bras, including         | > the Plan allowance and  |
|     necessary replacements following a   | > any difference between  |
|     mastectomy                           | > our allowance and the   |
|                                          | > billed amount           |
| -   Leg, arm, neck and back braces       |                           |
|                                          |                           |
| -   Internal prosthetic devices, such as |                           |
|     artificial joints, pacemakers,       |                           |
|     cochlear implants, and surgically    |                           |
|     implanted breast implant following   |                           |
|     mastectomy. Note: See Surgical       |                           |
|     benefits below for coverage of the   |                           |
|     surgery to insert the device.        |                           |
|                                          |                           |
| Note: We recommend pre-notification of   |                           |
| orthopedic and prosthetic devices. Call  |                           |
| Definity Health at 866/333-4648 for      |                           |
| pre-notification.                        |                           |
|                                          |                           |
| Note: We will pay only for the cost of   |                           |
| the standard item. Coverage for          |                           |
| specialty items, such as bionics, is     |                           |
| limited to the cost of the standard      |                           |
| item.                                    |                           |
+------------------------------------------+---------------------------+
| *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*                  |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ### Medical services and s               | ### You Pay               |
| upplies provided by physicians and other |                           |
|  health care professionals *(continued)* |                           |
+------------------------------------------+---------------------------+
| > **Durable medical equipment (DME)**    |                           |
+------------------------------------------+---------------------------+
| > Durable medical equipment (DME) is     | > In-network: 15% of the  |
| > equipment and supplies that:           | > Plan allowance          |
|                                          | >                         |
| 1)  Are prescribed by your attending     | > Out-of-network: 40% of  |
|     physician (i.e., the physician who   | > the Plan allowance and  |
|     is treating your illness or injury)  | > any difference between  |
|                                          | > our allowance and the   |
| 2)  Are medically necessary              | > billed amount           |
|                                          |                           |
| 3)  Are primarily and customarily used   |                           |
|     only for a medical purpose           |                           |
|                                          |                           |
| 4)  Are generally useful only to a       |                           |
|     person with an illness or injury     |                           |
|                                          |                           |
| 5)  Are designed for prolonged use; and  |                           |
|                                          |                           |
| 6)  Serve a specific therapeutic purpose |                           |
|     in the treatment of an illness or    |                           |
|     injury                               |                           |
|                                          |                           |
| > We cover rental or purchase, at our    |                           |
| > option, including repair and           |                           |
| > adjustment, of durable medical         |                           |
| > equipment, such as oxygen and dialysis |                           |
| > equipment. Under this benefit, we also |                           |
| > cover equipment such as:               |                           |
|                                          |                           |
| -   Hospital beds                        |                           |
|                                          |                           |
| -   Wheelchairs                          |                           |
|                                          |                           |
| -   Ostomy supplies (including supplies  |                           |
|     purchased at a pharmacy)             |                           |
|                                          |                           |
| -   Crutches; and                        |                           |
|                                          |                           |
| -   Walkers                              |                           |
|                                          |                           |
| > Note: Call Definity Health at          |                           |
| > 866/333-4648 as soon as your physician |                           |
| > prescribes this equipment because      |                           |
| > pre-notification is required.          |                           |
| >                                        |                           |
| > Note: We will pay only for the cost of |                           |
| > the standard item. Coverage for        |                           |
| > specialty equipment, such as           |                           |
| > all-terrain wheelchairs, is limited to |                           |
| > the cost of the standard equipment.    |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Whirlpool equipment*                |                           |
|                                          |                           |
| -   *Sun and heat lamps*                 |                           |
|                                          |                           |
| -   *Light boxes*                        |                           |
|                                          |                           |
| -   *Heating pads*                       |                           |
|                                          |                           |
| -   *Exercise devices*                   |                           |
|                                          |                           |
| -   *Stair glides*                       |                           |
|                                          |                           |
| -   *Elevators*                          |                           |
|                                          |                           |
| -   *Air Purifiers*                      |                           |
|                                          |                           |
| -   *Computer "story boards", "light     |                           |
|     talkers", or other communication     |                           |
|     aids for communication-impaired      |                           |
|     individuals*                         |                           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ### Medical services and s               | ### You Pay               |
| upplies provided by physicians and other |                           |
|  health care professionals *(continued)* |                           |
+------------------------------------------+---------------------------+
| > **Home health services**               |                           |
+------------------------------------------+---------------------------+
| > Services for skilled nursing care up   | > In-network: 15% of the  |
| > to 25 visits per calendar year, not to | > Plan allowance; all     |
| > exceed a maximum plan payment of \$90  | > charges after we pay    |
| > per day, when preauthorized and:       | > \$90 per day            |
|                                          | >                         |
| -   A registered nurse (R.N.), licensed  | > Out-of-network: 40% of  |
|     practical nurse (L.P.N.) or licensed | > the Plan allowance and  |
|     vocational nurse (L.V.N.) provides   | > any difference between  |
|     the services                         | > our allowance and the   |
|                                          | > billed amount; all      |
| -   The attending physician orders the   | > charges after we pay    |
|     care                                 | > \$90 per day            |
|                                          |                           |
| -   The physician identifies the         |                           |
|     specific professional skills         |                           |
|     required by the patient and the      |                           |
|     medical necessity for skilled        |                           |
|     services; and                        |                           |
|                                          |                           |
| -   The physician indicates the length   |                           |
|     of time the services are needed      |                           |
|                                          |                           |
| Note: Skilled nursing care must be       |                           |
| preauthorized. Call Definity Health at   |                           |
| 866/333-4648 for pre-notification.       |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Nursing care requested by, or for   |                           |
|     the convenience of, the patient or   |                           |
|     the patient's family*                |                           |
|                                          |                           |
| -   *Home care primarily for personal    |                           |
|     assistance that does not include a   |                           |
|     medical component and is not         |                           |
|     diagnostic, therapeutic, or          |                           |
|     rehabilitative*                      |                           |
|                                          |                           |
| -   *Services of nurses aides or home    |                           |
|     health aides*                        |                           |
+------------------------------------------+---------------------------+
| > **Chiropractic**                       |                           |
+------------------------------------------+---------------------------+
| > Chiropractic treatment limited to 12   | > In-network: 15% of the  |
| > visits and/or manipulations per year   | > Plan allowance          |
|                                          | >                         |
|                                          | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
|                                          | > any difference between  |
|                                          | > our allowance and the   |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+

+------------------------------------------+---------------------------+
| ### Medical services and s               | ### You Pay               |
| upplies provided by physicians and other |                           |
|  health care professionals *(continued)* |                           |
+------------------------------------------+---------------------------+
| > **Alternative treatments**             |                           |
+------------------------------------------+---------------------------+
| > Acupuncture -- by a doctor of medicine | > In-network: 15% of the  |
| > or osteopathy                          | > Plan allowance          |
|                                          | >                         |
|                                          | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
|                                          | > any difference between  |
|                                          | > our allowance and the   |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| ## Not covered:                          | > *All charges*           |
|                                          |                           |
| -   *Services of any provider not listed |                           |
|     as covered; see Covered providers on |                           |
|     page 11*                             |                           |
|                                          |                           |
| ##                                       |                           |
|                                          |                           |
| > *Note: Benefits of certain alternative |                           |
| > treatment providers may be covered in  |                           |
| > medically underserved areas; see page  |                           |
| > 11.*                                   |                           |
+------------------------------------------+---------------------------+
| > **Educational classes and programs**   |                           |
+------------------------------------------+---------------------------+
| > Coverage is limited to:                | > In-network: 15% of the  |
|                                          | > Plan allowance          |
| -   Smoking Cessation -- Up to \$100 for | >                         |
|     one smoking cessation program per    | > Out-of-network: 40% of  |
|     member per lifetime                  | > the Plan allowance and  |
|                                          | > any difference between  |
|                                          | > our allowance and the   |
|                                          | > billed amount           |
+------------------------------------------+---------------------------+
| ### Surgical an                          | ### You Pay               |
| d anesthesia services provided by physic |                           |
| ians and other health care professionals |                           |
+------------------------------------------+---------------------------+
| > **Surgical procedures**                |                           |
+------------------------------------------+---------------------------+
| A comprehensive range of services, such  | > In-network: 15% of the  |
| as:                                      | > Plan allowance          |
|                                          | >                         |
| -   Operative procedures                 | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
| -   Treatment of fractures, including    | > any difference between  |
|     casting                              | > our allowance and the   |
|                                          | > billed amount           |
| -   Normal pre- and post-operative care  |                           |
|     by the surgeon                       |                           |
|                                          |                           |
| -   Correction of amblyopia and          |                           |
|     strabismus                           |                           |
|                                          |                           |
| -   Endoscopy procedures                 |                           |
|                                          |                           |
| -   Biopsy procedures                    |                           |
|                                          |                           |
| -   Electroconvulsive therapy            |                           |
|                                          |                           |
| -   Removal of tumors and cysts          |                           |
|                                          |                           |
| -   Correction of congenital anomalies   |                           |
|     (see Reconstructive surgery)         |                           |
|                                          |                           |
| -   Surgical treatment of morbid obesity |                           |
|                                          |                           |
| -   Insertion of internal prosthetic     |                           |
|     devices (see Orthopedic and          |                           |
|     prosthetic devices above for device  |                           |
|     coverage information)                |                           |
|                                          |                           |
| -   Voluntary sterilization (e.g., Tubal |                           |
|     ligation, Vasectomy)                 |                           |
|                                          |                           |
| -   Surgically implanted contraceptives  |                           |
|                                          |                           |
| -   Intrauterine devices (IUDs)          |                           |
|                                          |                           |
| -   Treatment of burns                   |                           |
|                                          |                           |
| -   Assistant surgeons - We cover up to  |                           |
|     20% of our allowance for the         |                           |
|     surgeon's charge                     |                           |
+------------------------------------------+---------------------------+

*Surgical procedures benefits -- continued on next page*

+------------------------------------------+---------------------------+
| ### Surgical and anesthesia s            | ### You Pay               |
| ervices provided by physicians and other |                           |
|  health care professionals *(continued)* |                           |
+------------------------------------------+---------------------------+
| > **Surgical procedures** *(continued)*  |                           |
+------------------------------------------+---------------------------+
| > When multiple or bilateral surgical    | > In-network: 15% of the  |
| > procedures performed during the same   | > Plan allowance for the  |
| > operative session add time or          | > primary procedure and   |
| > complexity to patient care, our        | > 15% of one-half of the  |
| > benefits are:                          | > Plan allowance for the  |
|                                          | > secondary procedure(s)  |
| -   For the primary procedure:           | >                         |
|                                          | > Out-of-network: 40% of  |
| ```{=html}                               | > the Plan allowance for  |
| <!-- -->                                 | > the primary procedure   |
| ```                                      | > and 40% of one-half of  |
| -   In-network: 85% of the Plan          | > the Plan allowance for  |
|     allowance or                         | > the secondary           |
|                                          | > procedure(s); and any   |
| -   Out-of-network: 60% of the Plan      | > difference between our  |
|     allowance                            | > payment and the billed  |
|                                          | > amount                  |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   For the secondary procedure(s):      |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   In-network: 85% of one-half of the   |                           |
|     Plan allowance or                    |                           |
|                                          |                           |
| -   Out-of-network: 60% of one-half of   |                           |
|     > the Plan allowance                 |                           |
|                                          |                           |
| > Note: Multiple or bilateral surgical   |                           |
| > procedures performed through the same  |                           |
| > incision are "incidental" to the       |                           |
| > primary surgery. That is, the          |                           |
| > procedure would not add time or        |                           |
| > complexity to patient care. We do not  |                           |
| > pay extra for incidental procedures.   |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Cosmetic surgery and other related  |                           |
|     expenses if not preauthorized*       |                           |
|                                          |                           |
| -   *Reversal of voluntary               |                           |
|     sterilization*                       |                           |
|                                          |                           |
| -   *Services of a standby surgeon,      |                           |
|     except during angioplasty or other   |                           |
|     high risk procedures when we         |                           |
|     determine standbys are medically     |                           |
|     necessary*                           |                           |
|                                          |                           |
| -   *Radial keratotomy and other         |                           |
|     refractive surgery*                  |                           |
+------------------------------------------+---------------------------+
| > **Reconstructive surgery**             |                           |
+------------------------------------------+---------------------------+
| -   Surgery to correct a functional      | > In-network: 15% of the  |
|     defect                               | > Plan allowance          |
|                                          | >                         |
| -   Surgery to correct a condition       | > Out-of-network: 40% of  |
|     caused by injury or illness if:      | > the Plan allowance and  |
|                                          | > any difference between  |
| ```{=html}                               | > our allowance and the   |
| <!-- -->                                 | > billed amount           |
| ```                                      |                           |
| -   The condition produced a major       |                           |
|     effect on the member's appearance    |                           |
|     and                                  |                           |
|                                          |                           |
| -   The condition can reasonably be      |                           |
|     expected to be corrected by such     |                           |
|     surgery                              |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Surgery to correct a condition that  |                           |
|     existed at or from birth and is a    |                           |
|     significant deviation from the       |                           |
|     common form or norm. Examples of     |                           |
|     congenital anomalies are: protruding |                           |
|     ear deformities; cleft lip; cleft    |                           |
|     palate; birth marks (including port  |                           |
|     wine stains); and webbed fingers and |                           |
|     toes.                                |                           |
|                                          |                           |
| -   All stages of breast reconstruction  |                           |
|     surgery following a mastectomy, such |                           |
|     as:                                  |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Surgery to produce a symmetrical     |                           |
|     appearance of breast                 |                           |
|                                          |                           |
| -   Treatment of any physical            |                           |
|     complications, such as lymphedemas   |                           |
|                                          |                           |
| -   Breast prostheses; and surgical bras |                           |
|     and replacements (see Prosthetic     |                           |
|     devices for coverage)                |                           |
+------------------------------------------+---------------------------+

*Reconstructive surgery benefits -- continued on next page*

+------------------------------------------+---------------------------+
| ### Surgical and anesthesia s            | ### You Pay               |
| ervices provided by physicians and other |                           |
|  health care professionals *(continued)* |                           |
+------------------------------------------+---------------------------+
| > **Reconstructive surgery**             |                           |
| > *(continued)*                          |                           |
+------------------------------------------+---------------------------+
| > Note: We pay for internal breast       | > (see above)             |
| > prostheses as hospital benefits.       |                           |
| >                                        |                           |
| > Note: If you need a mastectomy, you    |                           |
| > may choose to have the procedure       |                           |
| > performed on an inpatient basis and    |                           |
| > remain in the hospital up to 48 hours  |                           |
| > after the procedure.                   |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | > *All charges*           |
|                                          |                           |
| -   *Cosmetic surgery-- any surgical     |                           |
|     procedure (or any portion of a       |                           |
|     procedure) performed primarily to    |                           |
|     improve physical appearance through  |                           |
|     change in bodily form, except repair |                           |
|     of accidental injury if repair is    |                           |
|     initiated within two years of the    |                           |
|     accident*                            |                           |
|                                          |                           |
| -   *Surgeries related to sex            |                           |
|     transformation, sexual dysfunction   |                           |
|     or sexual inadequacy except if       |                           |
|     preauthorized for organic impotence* |                           |
+------------------------------------------+---------------------------+
| > **Oral and maxillofacial surgery**     |                           |
+------------------------------------------+---------------------------+
| Oral surgical procedures, limited to:    | > In-network: 15% of the  |
|                                          | > Plan allowance          |
| -   Reduction of fractures of the jaws   | >                         |
|     or facial bones                      | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
| -   Surgical correction of cleft lip,    | > any difference between  |
|     cleft plate or severe functional     | > our allowance and the   |
|     malocclusion                         | > billed amount           |
|                                          |                           |
| -   Removal of stones from salivary      |                           |
|     ducts                                |                           |
|                                          |                           |
| -   Excision of leukoplakia or           |                           |
|     malignancies                         |                           |
|                                          |                           |
| -   Excision of cysts and incision of    |                           |
|     abscesses when done as independent   |                           |
|     procedures                           |                           |
|                                          |                           |
| -   Other surgical procedures that do    |                           |
|     not involve the teeth or their       |                           |
|     supporting structures                |                           |
|                                          |                           |
| -   Extraction of impacted (unerupted)   |                           |
|     teeth                                |                           |
|                                          |                           |
| -   Alveoplasty, partial ostectomy and   |                           |
|     radical resection of mandible with   |                           |
|     bone graft unrelated to tooth        |                           |
|     structure                            |                           |
|                                          |                           |
| -   Excision of bony cysts of the jaw    |                           |
|     unrelated to tooth structure         |                           |
|                                          |                           |
| -   Excision of tori, tumors, and        |                           |
|     premalignant lesions, and biopsy of  |                           |
|     hard and soft oral tissues           |                           |
|                                          |                           |
| -   Reduction of dislocations and        |                           |
|     excision, manipulation,              |                           |
|     arthrocentesis, aspiration or        |                           |
|     injection of temporomandibular       |                           |
|     joints                               |                           |
|                                          |                           |
| -   Removal of foreign body, skin,       |                           |
|     subcutaneous alveolar tissue,        |                           |
|     reaction-producing foreign bodies in |                           |
|     the musculoskeletal system and       |                           |
|     salivary stones                      |                           |
|                                          |                           |
| -   Incision/excision of salivary glands |                           |
|     and ducts                            |                           |
|                                          |                           |
| -   Repair of traumatic wounds           |                           |
|                                          |                           |
| -   Sinusotomy, including repair of      |                           |
|     oroantral and oromaxillary fistula   |                           |
|     and/or root recovery                 |                           |
|                                          |                           |
| -   Surgical treatment of trigeminal     |                           |
|     neuralgia                            |                           |
|                                          |                           |
| -   Frenectomy or frenotomy, skin graft  |                           |
|     or vestibuloplasty-stomatoplasty     |                           |
|     unrelated to periodontal disease     |                           |
|                                          |                           |
| ```{=html}                               |                           |
| <!-- -->                                 |                           |
| ```                                      |                           |
| -   Incision and drainage of cellulitis  |                           |
|     unrelated to tooth structure         |                           |
|                                          |                           |
| > Note: We suggest you call us at        |                           |
| > 866/333-4648 to determine whether a    |                           |
| > procedure is covered.                  |                           |
+------------------------------------------+---------------------------+

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

+------------------------------------------+---------------------------+
| ### Surgical and anesthesia s            | ### You Pay               |
| ervices provided by physicians and other |                           |
|  health care professionals *(continued)* |                           |
+------------------------------------------+---------------------------+
| > **Oral and maxillofacial surgery**     |                           |
| > *(continued)*                          |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Oral implants and transplants*      |                           |
|                                          |                           |
| -   *Procedures that involve the teeth   |                           |
|     or their supporting structures (such |                           |
|     as the periodontal membrane, gingiva |                           |
|     and alveolar bone)*                  |                           |
|                                          |                           |
| -   *Dental bridges, replacement of      |                           |
|     natural teeth,                       |                           |
|     dental/orthodontic/temporomandibular |                           |
|     joint dysfunction appliances and any |                           |
|     related expenses*                    |                           |
|                                          |                           |
| -   *Treatment of periodontal disease    |                           |
|     and gingival tissues, and abscesses* |                           |
|                                          |                           |
| -   *Charges related to orthodontic      |                           |
|     treatment*                           |                           |
+------------------------------------------+---------------------------+
| > **Organ/tissue transplants**           |                           |
+------------------------------------------+---------------------------+
| > Limited to:                            | > In-network: 15% of the  |
|                                          | > Plan allowance          |
| -   Cornea                               | >                         |
|                                          | > Out-of-network: 40% of  |
| -   Heart                                | > the Plan allowance and  |
|                                          | > any difference between  |
| -   Heart/lung                           | > our allowance and the   |
|                                          | > billed amount and any   |
| -   Kidney                               | > amount over \$100,000   |
|                                          |                           |
| -   Kidney/Pancreas                      |                           |
|                                          |                           |
| -   Liver                                |                           |
|                                          |                           |
| -   Lung: Single -- only for the         |                           |
|     following end-stage pulmonary        |                           |
|     diseases: pulmonary fibrosis,        |                           |
|     primary pulmonary hypertension, or   |                           |
|     emphysema; Double -- only for        |                           |
|     patients with cystic fibrosis        |                           |
|                                          |                           |
| -   Pancreas                             |                           |
|                                          |                           |
| -   Allogeneic bone marrow transplants   |                           |
|     are limited to patients with         |                           |
|     leukemia, advanced Hodgkin's         |                           |
|     lymphoma, advanced non-Hodgkin's     |                           |
|     lymphoma, aplastic anemia, severe    |                           |
|     combined immuno-deficiency disease   |                           |
|     or Wiskott-Aldrich syndrome          |                           |
|                                          |                           |
| -   Autologous bone marrow transplants   |                           |
|     and autologous peripheral stem cell  |                           |
|     support are limited to patients with |                           |
|     acute leukemia in remission,         |                           |
|     relapsed non-Hodgkin's lymphomas     |                           |
|     responding to treatment, resistant   |                           |
|     or recurrent neuroblastoma, relapsed |                           |
|     Hodgkin's disease responding to      |                           |
|     treatment, testicular cancer,        |                           |
|     mediastinal cancer, retroperitoneal  |                           |
|     cancer, ovarian germ cell tumors,    |                           |
|     epithelial ovarian cancer, breast    |                           |
|     cancer and multiple myeloma          |                           |
|                                          |                           |
| -   Intestinal transplants (small        |                           |
|     intestine) and the small intestine   |                           |
|     with the liver or small intestine    |                           |
|     with multiple organs such as the     |                           |
|     liver, stomach, and pancreas only    |                           |
|     for those patients with irreversible |                           |
|     intestinal failure who have failed   |                           |
|     TPN (total parenteral nutrition)     |                           |
|                                          |                           |
| > The Plan uses specific Plan-designated |                           |
| > organ/tissue transplant facilities.    |                           |
| > Before your initial evaluation as a    |                           |
| > potential candidate for a transplant   |                           |
| > procedure, you or your doctor **must** |                           |
| > contact Definity Health at             |                           |
| > 866/333-4648 and ask to speak to a     |                           |
| > Transplant Case Manager. You will be   |                           |
| > provided with information about        |                           |
| > transplant preferred providers. If you |                           |
| > choose a Plan-designated transplant    |                           |
| > facility, you may receive prior        |                           |
| > approval for travel and lodging costs. |                           |
+------------------------------------------+---------------------------+

*Organ/tissue transplant benefits -- continued on next page*

+------------------------------------------+---------------------------+
| ### Surgical and anesthesia s            | ### You Pay               |
| ervices provided by physicians and other |                           |
|  health care professionals *(continued)* |                           |
+------------------------------------------+---------------------------+
| > **Organ/tissue transplants**           |                           |
| > *(continued)*                          |                           |
+------------------------------------------+---------------------------+
| > Limited Benefits -- If you don't use a | > In-network: 15% of the  |
| > Plan-designated transplant facility,   | > Plan allowance          |
| > benefits for pretransplant evaluation, | >                         |
| > organ procurement, inpatient hospital, | > Out-of-network: 40% of  |
| > surgical and medical expenses for      | > the Plan allowance and  |
| > covered transplants, whether incurred  | > any difference between  |
| > by the recipient or donor, are limited | > our allowance and the   |
| > to a maximum of \$100,000 for each     | > billed amount and any   |
| > listed transplant, including multiple  | > amount over \$100,000   |
| > organ transplants.                     |                           |
|                                          |                           |
| Note: We cover related medical and       |                           |
| hospital expenses of the donor when we   |                           |
| cover the recipient.                     |                           |
+------------------------------------------+---------------------------+
| > *Not covered:*                         | > *All charges*           |
|                                          |                           |
| -   *Donor screening tests and donor     |                           |
|     search expenses, except those        |                           |
|     performed for the actual donor*      |                           |
|                                          |                           |
| -   *Services or supplies for, or        |                           |
|     related to, surgical transplant      |                           |
|     procedures for artificial or human   |                           |
|     organ transplants not listed as      |                           |
|     specifically covered. Related        |                           |
|     services include administration of   |                           |
|     high dose chemotherapy when          |                           |
|     supported by autologous bone marrow  |                           |
|     transplant*                          |                           |
|                                          |                           |
| -   *Transplants not listed as covered*  |                           |
+------------------------------------------+---------------------------+
| > **Anesthesia**                         |                           |
+------------------------------------------+---------------------------+
| > Professional services for              | > In-network: 15% of the  |
| > administration of anesthesia           | > Plan allowance          |
|                                          | >                         |
|                                          | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
|                                          | > any difference between  |
|                                          | > our allowance and the   |
|                                          | > billed amount           |
|                                          | >                         |
|                                          | > Note: If your network   |
|                                          | > provider uses an        |
|                                          | > out-of-network          |
|                                          | > anesthesiologist, we    |
|                                          | > will pay out-of-network |
|                                          | > benefits for any        |
|                                          | > anesthesia charges.     |
+------------------------------------------+---------------------------+
| ### Services provided by a hospital or   | ### You Pay               |
|  other facility, and ambulance services  |                           |
+------------------------------------------+---------------------------+
| > **Inpatient hospital**                 |                           |
+------------------------------------------+---------------------------+
| > Room and board, such as:               | > In-network: 15% of the  |
|                                          | > Plan allowance          |
| -   Ward, semiprivate, or intensive care | >                         |
|     accommodations                       | > Out-of-network: 40% of  |
|                                          | > the Plan allowance and  |
| -   General nursing care                 | > any difference between  |
|                                          | > our allowance and the   |
| -   Meals and special diets              | > billed amount           |
|                                          | >                         |
| > Note: We only cover a private room     | > Note: If you use a      |
| > when you must be isolated to prevent   | > network provider and a  |
| > contagion. Otherwise, we will pay the  | > network facility, we    |
| > hospital's average charge for          | > may still pay           |
| > semiprivate accommodations. If the     | > out-of-network benefits |
| > hospital only has private rooms, we    | > on any services         |
| > base our payment on the average        | > received from a         |
| > semiprivate rate of comparable         | > radiologist,            |
| > hospitals in the area.                 | > pathologist, or         |
| >                                        | > anesthesiologist who is |
| > > Note: When the out-of-network        | > not a network provider. |
| > > hospital bills a flat rate, we       |                           |
| > > prorate the charges to determine how |                           |
| > > to pay them, as follows: 30% room    |                           |
| > > and board and 70% other charges.     |                           |
+------------------------------------------+---------------------------+

*Inpatient hospital benefits -- continued on next page*

+------------------------------------------+---+---------------------------+
| ### Service                              | # |                           |
| s provided by a hospital or other facili | # |                           |
| ty, and ambulance services *(continued)* | # |                           |
|                                          |   |                           |
|                                          | Y |                           |
|                                          | o |                           |
|                                          | u |                           |
|                                          |   |                           |
|                                          | P |                           |
|                                          | a |                           |
|                                          | y |                           |
+------------------------------------------+---+---------------------------+
| > **Inpatient hospital** *(continued)*   |   |                           |
+------------------------------------------+---+---------------------------+
| > Other hospital services and supplies,  |   | > In-network: 15% of the  |
| > such as:                               |   | > Plan allowance          |
|                                          |   | >                         |
| -   Operating, recovery, maternity, and  |   | > Out-of-network: 40% of  |
|     other treatment rooms                |   | > the Plan allowance and  |
|                                          |   | > any difference between  |
| -   Prescribed drugs and medicines       |   | > our allowance and the   |
|                                          |   | > billed amount           |
| -   Diagnostic laboratory tests and      |   |                           |
|     X-rays                               |   |                           |
|                                          |   |                           |
| -   Blood or blood plasma, if not        |   |                           |
|     donated or replaced                  |   |                           |
|                                          |   |                           |
| -   Dressings, splints, casts, and       |   |                           |
|     sterile tray services                |   |                           |
|                                          |   |                           |
| -   Medical supplies and equipment,      |   |                           |
|     including oxygen                     |   |                           |
|                                          |   |                           |
| -   Anesthetics, including nurse         |   |                           |
|     anesthetist services                 |   |                           |
|                                          |   |                           |
| > Note: We base payment on whether the   |   |                           |
| > facility or a health care professional |   |                           |
| > bills for the services or supplies.    |   |                           |
| > For example, when the hospital bills   |   |                           |
| > for its nurse anesthetists' services,  |   |                           |
| > we pay Hospital benefits and when the  |   |                           |
| > anesthesiologist bills, we pay Surgery |   |                           |
| > benefits.                              |   |                           |
+------------------------------------------+---+---------------------------+
| > *Not covered:*                         |   | > *All charges*           |
|                                          |   |                           |
| -   *Any part of a hospital admission    |   |                           |
|     that is not medically necessary (see |   |                           |
|     definition), such as when you do not |   |                           |
|     need acute hospital inpatient        |   |                           |
|     (overnight) care, but could receive  |   |                           |
|     care in some other setting without   |   |                           |
|     adversely affecting your condition   |   |                           |
|     or the quality of your medical care. |   |                           |
|     Note: In this event, we pay benefits |   |                           |
|     for services and supplies other than |   |                           |
|     room and board and in-hospital       |   |                           |
|     physician care at the level they     |   |                           |
|     would have been covered if provided  |   |                           |
|     in an alternative setting*           |   |                           |
|                                          |   |                           |
| -   *Custodial care; see definition*     |   |                           |
|                                          |   |                           |
| -   *Non-covered facilities, such as     |   |                           |
|     nursing homes, skilled nursing       |   |                           |
|     facilities, residential treatment    |   |                           |
|     facilities, day and evening care     |   |                           |
|     centers, and schools*                |   |                           |
|                                          |   |                           |
| -   *Personal comfort items such as      |   |                           |
|     radio, television, air conditioners, |   |                           |
|     beauty and barber services, guest    |   |                           |
|     meals and beds*                      |   |                           |
|                                          |   |                           |
| -   *Services of a private duty nurse    |   |                           |
|     that would normally be provided by   |   |                           |
|     hospital nursing staff*              |   |                           |
+------------------------------------------+---+---------------------------+

+------------------------------------------+---+---------------------------+
| ### Service                              | # |                           |
| s provided by a hospital or other facili | # |                           |
| ty, and ambulance services *(continued)* | # |                           |
|                                          |   |                           |
|                                          | Y |                           |
|                                          | o |                           |
|                                          | u |                           |
|                                          |   |                           |
|                                          | P |                           |
|                                          | a |                           |
|                                          | y |                           |
+------------------------------------------+---+---------------------------+
| > **Outpatient hospital or ambulatory    |   |                           |
| > surgical center**                      |   |                           |
+------------------------------------------+---+---------------------------+
| -   Operating, recovery, and other       |   | > In-network: 15% of the  |
|     treatment rooms                      |   | > Plan allowance          |
|                                          |   | >                         |
| -   Prescribed drugs and medicines       |   | > Out-of-network: 40% of  |
|                                          |   | > the Plan allowance and  |
| -   Diagnostic laboratory tests, X-rays, |   | > any difference between  |
|     and pathology services               |   | > our allowance and the   |
|                                          |   | > billed amount           |
| -   Administration of blood, blood       |   |                           |
|     plasma, and other biologicals        |   |                           |
|                                          |   |                           |
| -   Blood and blood plasma, if not       |   |                           |
|     donated or replaced                  |   |                           |
|                                          |   |                           |
| -   Pre-surgical testing                 |   |                           |
|                                          |   |                           |
| -   Dressings, casts, and sterile tray   |   |                           |
|     services                             |   |                           |
|                                          |   |                           |
| -   Medical supplies, including oxygen   |   |                           |
|                                          |   |                           |
| -   Anesthetics and anesthesia service   |   |                           |
|                                          |   |                           |
| > Note: We cover hospital services and   |   |                           |
| > supplies related to dental procedures  |   |                           |
| > when necessitated by a non-dental      |   |                           |
| > physical impairment. We do not cover   |   |                           |
| > the dental procedures.                 |   |                           |
| >                                        |   |                           |
| > Note: We cover outpatient services and |   |                           |
| > supplies of a hospital or              |   |                           |
| > free-standing ambulatory facility the  |   |                           |
| > day of a surgical procedure (including |   |                           |
| > change of cast), hemophilia treatment, |   |                           |
| > hyperalimentation, rabies shots, cast  |   |                           |
| > or suture removal, oral surgery, foot  |   |                           |
| > treatment, chemotherapy for treatment  |   |                           |
| > of cancer, and radiation therapy.      |   |                           |
+------------------------------------------+---+---------------------------+
| > **Extended care benefits/Skilled       |   |                           |
| > nursing care facility benefits**       |   |                           |
+------------------------------------------+---+---------------------------+
| > No benefit                             |   | > All charges             |
+------------------------------------------+---+---------------------------+
| > **Hospice care**                       |   |                           |
+------------------------------------------+---+---------------------------+
| > Hospice is a coordinated program of    |   | > Any amount over the     |
| > home and inpatient supportive care for |   | > annual maximums shown   |
| > the terminally ill patient and the     |   |                           |
| > patient's family provided by a         |   |                           |
| > medically supervised specialized team  |   |                           |
| > under the direction of a duly licensed |   |                           |
| > or certified Hospice Care Program.     |   |                           |
|                                          |   |                           |
| -   We pay \$3,000 annually for          |   |                           |
|     outpatient services and \$2,000      |   |                           |
|     annually for inpatient services      |   |                           |
|                                          |   |                           |
| -   We pay a \$200 annual bereavement    |   |                           |
|     benefit per family unit              |   |                           |
+------------------------------------------+---+---------------------------+
| > **Ambulance**                          |   |                           |
+------------------------------------------+---+---------------------------+
| -   Local professional ambulance service |   | > In-network: 15% of the  |
|     when medically appropriate           |   | > Plan allowance          |
|     immediately before or after an       |   | >                         |
|     inpatient admission                  |   | > Out-of-network: 40% of  |
|                                          |   | > the Plan allowance and  |
|                                          |   | > any difference between  |
|                                          |   | > our allowance and the   |
|                                          |   | > billed amount           |
+------------------------------------------+---+---------------------------+
| *Not covered:*                           |   | > *All charges*           |
|                                          |   |                           |
| -   *Ambulance service used for routine  |   |                           |
|     transport*                           |   |                           |
+------------------------------------------+---+---------------------------+

+------------------------------------------+---+---+---------------------------+
| ### Emergency services/accidents         |   | # |                           |
|                                          |   | # |                           |
|                                          |   | # |                           |
|                                          |   |   |                           |
|                                          |   | Y |                           |
|                                          |   | o |                           |
|                                          |   | u |                           |
|                                          |   |   |                           |
|                                          |   | P |                           |
|                                          |   | a |                           |
|                                          |   | y |                           |
+------------------------------------------+---+---+---------------------------+
| > **What is an accidental injury?**      |   |   |                           |
|                                          |   |   |                           |
| An accidental injury is a bodily injury  |   |   |                           |
| sustained solely through violent,        |   |   |                           |
| external, and accidental means, such as  |   |   |                           |
| broken bones, animal bites, and          |   |   |                           |
| poisonings.                              |   |   |                           |
+------------------------------------------+---+---+---------------------------+
| **What is a medical emergency?**         |   |   |                           |
|                                          |   |   |                           |
| A medical emergency is the sudden and    |   |   |                           |
| unexpected onset of a condition or an    |   |   |                           |
| injury that you believe endangers your   |   |   |                           |
| life or could result in serious injury   |   |   |                           |
| or disability, and requires immediate    |   |   |                           |
| medical or surgical care. Some problems  |   |   |                           |
| are emergencies because, if not treated  |   |   |                           |
| promptly, they might become more         |   |   |                           |
| serious; examples include deep cuts and  |   |   |                           |
| broken bones. Others are emergencies     |   |   |                           |
| because they are potentially             |   |   |                           |
| life-threatening, such as heart attacks, |   |   |                           |
| strokes, poisonings, gunshot wounds, or  |   |   |                           |
| sudden inability to breathe. There are   |   |   |                           |
| many other acute conditions that we may  |   |   |                           |
| determine are medical emergencies --     |   |   |                           |
| what they all have in common is the need |   |   |                           |
| for quick action.                        |   |   |                           |
|                                          |   |   |                           |
| > Note: If you use an emergency room for |   |   |                           |
| > other than a recognized medical        |   |   |                           |
| > emergency, facility fees and supplies  |   |   |                           |
| > will not be covered.                   |   |   |                           |
+------------------------------------------+---+---+---------------------------+
| > **Accidental injury**                  |   |   |                           |
+------------------------------------------+---+---+---------------------------+
| If you receive care for your accidental  | > |   |                           |
| injury within 24 hours, we cover:        |   |   |                           |
|                                          | I |   |                           |
| -   Physician services and supplies      | n |   |                           |
|                                          | - |   |                           |
| -   Related outpatient hospital services | n |   |                           |
|                                          | e |   |                           |
| Note: We pay Hospital benefits if you    | t |   |                           |
| are admitted.                            | w |   |                           |
|                                          | o |   |                           |
| If you receive care for your accidental  | r |   |                           |
| injury after 24 hours, we cover:         | k |   |                           |
|                                          | : |   |                           |
| -   Physician services and supplies      | > |   |                           |
|                                          |   |   |                           |
| Note: We pay Hospital benefits if you    | 1 |   |                           |
| are admitted.                            | 5 |   |                           |
|                                          | % |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | o |   |                           |
|                                          | f |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | t |   |                           |
|                                          | h |   |                           |
|                                          | e |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | P |   |                           |
|                                          | l |   |                           |
|                                          | a |   |                           |
|                                          | n |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | a |   |                           |
|                                          | l |   |                           |
|                                          | l |   |                           |
|                                          | o |   |                           |
|                                          | w |   |                           |
|                                          | a |   |                           |
|                                          | n |   |                           |
|                                          | c |   |                           |
|                                          | e |   |                           |
|                                          | > |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | O |   |                           |
|                                          | u |   |                           |
|                                          | t |   |                           |
|                                          | - |   |                           |
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|                                          | f |   |                           |
|                                          | - |   |                           |
|                                          | n |   |                           |
|                                          | e |   |                           |
|                                          | t |   |                           |
|                                          | w |   |                           |
|                                          | o |   |                           |
|                                          | r |   |                           |
|                                          | k |   |                           |
|                                          | : |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | 1 |   |                           |
|                                          | 5 |   |                           |
|                                          | % |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | o |   |                           |
|                                          | f |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | t |   |                           |
|                                          | h |   |                           |
|                                          | e |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | P |   |                           |
|                                          | l |   |                           |
|                                          | a |   |                           |
|                                          | n |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | a |   |                           |
|                                          | l |   |                           |
|                                          | l |   |                           |
|                                          | o |   |                           |
|                                          | w |   |                           |
|                                          | a |   |                           |
|                                          | n |   |                           |
|                                          | c |   |                           |
|                                          | e |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | a |   |                           |
|                                          | n |   |                           |
|                                          | d |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | a |   |                           |
|                                          | n |   |                           |
|                                          | y |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | d |   |                           |
|                                          | i |   |                           |
|                                          | f |   |                           |
|                                          | f |   |                           |
|                                          | e |   |                           |
|                                          | r |   |                           |
|                                          | e |   |                           |
|                                          | n |   |                           |
|                                          | c |   |                           |
|                                          | e |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | b |   |                           |
|                                          | e |   |                           |
|                                          | t |   |                           |
|                                          | w |   |                           |
|                                          | e |   |                           |
|                                          | e |   |                           |
|                                          | n |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | o |   |                           |
|                                          | u |   |                           |
|                                          | r |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | a |   |                           |
|                                          | l |   |                           |
|                                          | l |   |                           |
|                                          | o |   |                           |
|                                          | w |   |                           |
|                                          | a |   |                           |
|                                          | n |   |                           |
|                                          | c |   |                           |
|                                          | e |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | a |   |                           |
|                                          | n |   |                           |
|                                          | d |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | t |   |                           |
|                                          | h |   |                           |
|                                          | e |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | b |   |                           |
|                                          | i |   |                           |
|                                          | l |   |                           |
|                                          | l |   |                           |
|                                          | e |   |                           |
|                                          | d |   |                           |
|                                          | > |   |                           |
|                                          |   |   |                           |
|                                          | a |   |                           |
|                                          | m |   |                           |
|                                          | o |   |                           |
|                                          | u |   |                           |
|                                          | n |   |                           |
|                                          | t |   |                           |
+------------------------------------------+---+---+---------------------------+
| > **Medical emergency**                  |   |   |                           |
+------------------------------------------+---+---+---------------------------+
| -   Outpatient facility charges in an    |   |   | > In-network: 15% of the  |
|     Urgent Care Center                   |   |   | > Plan allowance          |
|                                          |   |   | >                         |
| -   Outpatient medical or surgical       |   |   | > Out-of-network: 15% of  |
|     services and supplies, other than an |   |   | > the Plan allowance and  |
|     Urgent Care Center                   |   |   | > any difference between  |
|                                          |   |   | > our allowance and the   |
|                                          |   |   | > billed amount           |
+------------------------------------------+---+---+---------------------------+
| > **Ambulance**                          |   |   |                           |
+------------------------------------------+---+---+---------------------------+
| -   Professional ambulance service       |   |   | > In-network: 15% of the  |
|     within 24 hours of an accidental     |   |   | > Plan allowance          |
|     injury or medical emergency          |   |   | >                         |
|                                          |   |   | > Out-of-network: 15% of  |
| -   Air ambulance if medically necessary |   |   | > the Plan allowance and  |
|     for transport to the closest         |   |   | > any difference between  |
|     appropriate facility for treatment   |   |   | > our allowance and the   |
|     within 24 hours of an accidental     |   |   | > billed amount           |
|     injury                               |   |   |                           |
|                                          |   |   |                           |
| Note: See Hospital benefits above for    |   |   |                           |
| non-emergency service.                   |   |   |                           |
+------------------------------------------+---+---+---------------------------+

+---------------+--------------------------+---+---------------------------+
| ### Men       |                          |   | ### You Pay               |
| tal health an |                          |   |                           |
| d substance a |                          |   |                           |
| buse benefits |                          |   |                           |
+---------------+--------------------------+---+---------------------------+
| >             |                          |   |                           |
|  **In-network |                          |   |                           |
| > benefits**  |                          |   |                           |
+---------------+--------------------------+---+---------------------------+
| # A           |                          | > |                           |
| ll diagnostic |                          |   |                           |
|  and treatmen |                          | Y |                           |
| t services co |                          | o |                           |
| ntained in a  |                          | u |                           |
| treatment pla |                          | r |                           |
| n that we app |                          | > |                           |
| rove. The tre |                          |   |                           |
| atment plan m |                          | c |                           |
| ay include se |                          | o |                           |
| rvices, drugs |                          | s |                           |
| , and supplie |                          | t |                           |
| s described e |                          | > |                           |
| lsewhere in t |                          |   |                           |
| his brochure. |                          | s |                           |
|               |                          | h |                           |
| Note:         |                          | a |                           |
| In-network    |                          | r |                           |
| benefits are  |                          | i |                           |
| payable only  |                          | n |                           |
| when we       |                          | g |                           |
| determine the |                          | > |                           |
| care is       |                          |   |                           |
| clinically    |                          | r |                           |
| appropriate   |                          | e |                           |
| to treat your |                          | s |                           |
| condition and |                          | p |                           |
| only when you |                          | o |                           |
| receive the   |                          | n |                           |
| care as part  |                          | s |                           |
| of a          |                          | i |                           |
| treatment     |                          | b |                           |
| plan that we  |                          | i |                           |
| approve.      |                          | l |                           |
|               |                          | i |                           |
|               |                          | t |                           |
|               |                          | i |                           |
|               |                          | e |                           |
|               |                          | s |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | a |                           |
|               |                          | r |                           |
|               |                          | e |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | n |                           |
|               |                          | o |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | g |                           |
|               |                          | r |                           |
|               |                          | e |                           |
|               |                          | a |                           |
|               |                          | t |                           |
|               |                          | e |                           |
|               |                          | r |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | t |                           |
|               |                          | h |                           |
|               |                          | a |                           |
|               |                          | n |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | f |                           |
|               |                          | o |                           |
|               |                          | r |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | o |                           |
|               |                          | t |                           |
|               |                          | h |                           |
|               |                          | e |                           |
|               |                          | r |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | i |                           |
|               |                          | l |                           |
|               |                          | l |                           |
|               |                          | n |                           |
|               |                          | e |                           |
|               |                          | s |                           |
|               |                          | s |                           |
|               |                          | e |                           |
|               |                          | s |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | o |                           |
|               |                          | r |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | c |                           |
|               |                          | o |                           |
|               |                          | n |                           |
|               |                          | d |                           |
|               |                          | i |                           |
|               |                          | t |                           |
|               |                          | i |                           |
|               |                          | o |                           |
|               |                          | n |                           |
|               |                          | s |                           |
+---------------+--------------------------+---+---------------------------+
| -             |                          | # |                           |
|  Professional |                          |   |                           |
|     services, |                          | 1 |                           |
|     including |                          | 5 |                           |
|               |                          | % |                           |
|    individual |                          |   |                           |
|     or group  |                          | o |                           |
|     therapy   |                          | f |                           |
|     by        |                          |   |                           |
|     providers |                          | t |                           |
|     such as   |                          | h |                           |
|     p         |                          | e |                           |
| sychiatrists, |                          |   |                           |
|     p         |                          | P |                           |
| sychologists, |                          | l |                           |
|     licensed  |                          | a |                           |
|     social    |                          | n |                           |
|     workers,  |                          |   |                           |
|     or        |                          | a |                           |
|     licensed  |                          | l |                           |
|     intensive |                          | l |                           |
|               |                          | o |                           |
|    outpatient |                          | w |                           |
|     treatment |                          | a |                           |
|     centers   |                          | n |                           |
|               |                          | c |                           |
| -             |                          | e |                           |
|    Medication |                          |   |                           |
|               |                          |   |                           |
|    management |                          |   |                           |
+---------------+--------------------------+---+---------------------------+
| -             |                          | # |                           |
|    Diagnostic |                          |   |                           |
|     tests     |                          | 1 |                           |
|               |                          | 5 |                           |
|               |                          | % |                           |
|               |                          |   |                           |
|               |                          | o |                           |
|               |                          | f |                           |
|               |                          |   |                           |
|               |                          | t |                           |
|               |                          | h |                           |
|               |                          | e |                           |
|               |                          |   |                           |
|               |                          | P |                           |
|               |                          | l |                           |
|               |                          | a |                           |
|               |                          | n |                           |
|               |                          |   |                           |
|               |                          | a |                           |
|               |                          | l |                           |
|               |                          | l |                           |
|               |                          | o |                           |
|               |                          | w |                           |
|               |                          | a |                           |
|               |                          | n |                           |
|               |                          | c |                           |
|               |                          | e |                           |
+---------------+--------------------------+---+---------------------------+
| -   Inpatient |                          | # |                           |
|     services  |                          |   |                           |
|     provided  |                          | 1 |                           |
|     by a      |                          | 5 |                           |
|     hospital  |                          | % |                           |
|     or other  |                          |   |                           |
|     facility  |                          | o |                           |
|               |                          | f |                           |
| -   Services  |                          |   |                           |
|     in        |                          | t |                           |
|     approved  |                          | h |                           |
|     partial   |                          | e |                           |
|     ho        |                          |   |                           |
| spitalization |                          | P |                           |
|     setting   |                          | l |                           |
|               |                          | a |                           |
|               |                          | n |                           |
|               |                          |   |                           |
|               |                          | a |                           |
|               |                          | l |                           |
|               |                          | l |                           |
|               |                          | o |                           |
|               |                          | w |                           |
|               |                          | a |                           |
|               |                          | n |                           |
|               |                          | c |                           |
|               |                          | e |                           |
+---------------+--------------------------+---+---------------------------+
| > *Not        |                          | # |                           |
| > covered:    |                          |   |                           |
| > Services we |                          | * |                           |
| > have not    |                          | A |                           |
| > approved*   |                          | l |                           |
| >             |                          | l |                           |
| > *Note: OPM  |                          |   |                           |
| > will base   |                          | c |                           |
| > its review  |                          | h |                           |
| > of disputes |                          | a |                           |
| > about       |                          | r |                           |
| > treatment   |                          | g |                           |
| > plans on    |                          | e |                           |
| > the         |                          | s |                           |
| > treatment   |                          | * |                           |
| > plan's      |                          |   |                           |
| > clinical    |                          |   |                           |
| > app         |                          |   |                           |
| ropriateness. |                          |   |                           |
| > OPM will    |                          |   |                           |
| > generally   |                          |   |                           |
| > not order   |                          |   |                           |
| > us to pay   |                          |   |                           |
| > or provide  |                          |   |                           |
| > one         |                          |   |                           |
| > clinically  |                          |   |                           |
| > appropriate |                          |   |                           |
| > treatment   |                          |   |                           |
| > plan in     |                          |   |                           |
| > favor of    |                          |   |                           |
| > another.*   |                          |   |                           |
+---------------+--------------------------+---+---------------------------+
| > **Preau     | To be eligible to        |   |                           |
| thorization** | receive these enhanced   |   |                           |
|               | mental health and        |   |                           |
|               | substance abuse benefits |   |                           |
|               | you must obtain a        |   |                           |
|               | treatment plan and       |   |                           |
|               | follow all of the        |   |                           |
|               | following network        |   |                           |
|               | authorization processes: |   |                           |
|               |                          |   |                           |
|               | -   Inpatient careYou   |   |                           |
|               |     must get             |   |                           |
|               |     preauthorization of  |   |                           |
|               |     hospital stays;      |   |                           |
|               |     failure to do so     |   |                           |
|               |     will result in a     |   |                           |
|               |     minimum \$500        |   |                           |
|               |     penalty. Please      |   |                           |
|               |     refer to the         |   |                           |
|               |     precertification     |   |                           |
|               |     information shown in |   |                           |
|               |     Section 3. To obtain |   |                           |
|               |     preauthorization of  |   |                           |
|               |     an admission for     |   |                           |
|               |     mental conditions or |   |                           |
|               |     substance abuse,     |   |                           |
|               |     call ValueOptions at |   |                           |
|               |     888/700-7965.        |   |                           |
|               |                          |   |                           |
|               | -   Outpatient careYou  |   |                           |
|               |     must get             |   |                           |
|               |     preauthorization of  |   |                           |
|               |     outpatient care for  |   |                           |
|               |     mental conditions or |   |                           |
|               |     substance abuse.     |   |                           |
|               |     Preauthorization     |   |                           |
|               |     must be obtained by  |   |                           |
|               |     calling ValueOptions |   |                           |
|               |     at 888/700-7965.     |   |                           |
|               |                          |   |                           |
|               | -   We do not make       |   |                           |
|               |     available provider   |   |                           |
|               |     directories for      |   |                           |
|               |     mental health or     |   |                           |
|               |     substance abuse      |   |                           |
|               |     providers.           |   |                           |
|               |     ValueOptions will    |   |                           |
|               |     provide you with a   |   |                           |
|               |     choice of network    |   |                           |
|               |     providers when you   |   |                           |
|               |     call to preauthorize |   |                           |
|               |     your care.           |   |                           |
+---------------+--------------------------+---+---------------------------+
| > **O         |                          |   |                           |
| ut-of-network |                          |   |                           |
| > benefits**  |                          |   |                           |
+---------------+--------------------------+---+---------------------------+
| Professional  |                          | > |                           |
| outpatient    |                          |   |                           |
| care to treat |                          | 4 |                           |
| mental        |                          | 0 |                           |
| conditions    |                          | % |                           |
| and substance |                          | > |                           |
| abuse         |                          |   |                           |
|               |                          | o |                           |
|               |                          | f |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | o |                           |
|               |                          | u |                           |
|               |                          | r |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | a |                           |
|               |                          | l |                           |
|               |                          | l |                           |
|               |                          | o |                           |
|               |                          | w |                           |
|               |                          | a |                           |
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|               |                          | e |                           |
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|               |                          | o |                           |
|               |                          | r |                           |
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|               |                          | p |                           |
|               |                          | > |                           |
|               |                          |   |                           |
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|               |                          | o |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | 1 |                           |
|               |                          | 5 |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | v |                           |
|               |                          | i |                           |
|               |                          | s |                           |
|               |                          | i |                           |
|               |                          | t |                           |
|               |                          | s |                           |
|               |                          | ; |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | a |                           |
|               |                          | l |                           |
|               |                          | l |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | c |                           |
|               |                          | h |                           |
|               |                          | a |                           |
|               |                          | r |                           |
|               |                          | g |                           |
|               |                          | e |                           |
|               |                          | s |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | a |                           |
|               |                          | f |                           |
|               |                          | t |                           |
|               |                          | e |                           |
|               |                          | r |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | 1 |                           |
|               |                          | 5 |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | v |                           |
|               |                          | i |                           |
|               |                          | s |                           |
|               |                          | i |                           |
|               |                          | t |                           |
|               |                          | s |                           |
+---------------+--------------------------+---+---------------------------+
| Inpatient     |                          | > |                           |
| care to treat |                          |   |                           |
| mental        |                          | 4 |                           |
| conditions    |                          | 0 |                           |
| includes ward |                          | % |                           |
| or            |                          | > |                           |
| semiprivate   |                          |   |                           |
| a             |                          | o |                           |
| ccommodations |                          | f |                           |
| and other     |                          | > |                           |
| hospital      |                          |   |                           |
| charges       |                          | c |                           |
|               |                          | h |                           |
|               |                          | a |                           |
|               |                          | r |                           |
|               |                          | g |                           |
|               |                          | e |                           |
|               |                          | s |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | f |                           |
|               |                          | o |                           |
|               |                          | r |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | u |                           |
|               |                          | p |                           |
|               |                          | > |                           |
|               |                          |   |                           |
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|               |                          | o |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | 3 |                           |
|               |                          | 0 |                           |
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|               |                          | d |                           |
|               |                          | a |                           |
|               |                          | y |                           |
|               |                          | s |                           |
|               |                          | > |                           |
|               |                          |   |                           |
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|               |                          | a |                           |
|               |                          | l |                           |
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|               |                          | n |                           |
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|               |                          |   |                           |
|               |                          | y |                           |
|               |                          | e |                           |
|               |                          | a |                           |
|               |                          | r |                           |
|               |                          | ; |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | a |                           |
|               |                          | l |                           |
|               |                          | l |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | c |                           |
|               |                          | h |                           |
|               |                          | a |                           |
|               |                          | r |                           |
|               |                          | g |                           |
|               |                          | e |                           |
|               |                          | s |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | a |                           |
|               |                          | f |                           |
|               |                          | t |                           |
|               |                          | e |                           |
|               |                          | r |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | 3 |                           |
|               |                          | 0 |                           |
|               |                          | > |                           |
|               |                          |   |                           |
|               |                          | d |                           |
|               |                          | a |                           |
|               |                          | y |                           |
|               |                          | s |                           |
+---------------+--------------------------+---+---------------------------+

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

+---------------+--------------------------+---+---+---------------------------+
| ### Ment      |                          | # |   |                           |
| al health and |                          | # |   |                           |
|  substance ab |                          | # |   |                           |
| use benefits  |                          |   |   |                           |
| *(continued)* |                          | Y |   |                           |
|               |                          | o |   |                           |
|               |                          | u |   |                           |
|               |                          |   |   |                           |
|               |                          | P |   |                           |
|               |                          | a |   |                           |
|               |                          | y |   |                           |
+---------------+--------------------------+---+---+---------------------------+
| > **O         |                          |   |   |                           |
| ut-of-network |                          |   |   |                           |
| > benefits**  |                          |   |   |                           |
| >             |                          |   |   |                           |
| *(continued)* |                          |   |   |                           |
+---------------+--------------------------+---+---+---------------------------+
| Inpatient     |                          |   | > |                           |
| care to treat |                          |   |   |                           |
| substance     |                          |   | 4 |                           |
| abuse         |                          |   | 0 |                           |
| includes room |                          |   | % |                           |
| and board and |                          |   | > |                           |
| ancillary     |                          |   |   |                           |
| charges for   |                          |   | o |                           |
| confinements  |                          |   | f |                           |
| in a          |                          |   | > |                           |
| treatment     |                          |   |   |                           |
| facility for  |                          |   | c |                           |
| r             |                          |   | h |                           |
| ehabilitative |                          |   | a |                           |
| treatment of  |                          |   | r |                           |
| alcoholism or |                          |   | g |                           |
| substance     |                          |   | e |                           |
| abuse         |                          |   | s |                           |
|               |                          |   | > |                           |
|               |                          |   |   |                           |
|               |                          |   | f |                           |
|               |                          |   | o |                           |
|               |                          |   | r |                           |
|               |                          |   | > |                           |
|               |                          |   |   |                           |
|               |                          |   | o |                           |
|               |                          |   | n |                           |
|               |                          |   | e |                           |
|               |                          |   | > |                           |
|               |                          |   |   |                           |
|               |                          |   | t |                           |
|               |                          |   | r |                           |
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|               |                          |   | a |                           |
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|               |                          |   | m |                           |
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|               |                          |   | m |                           |
|               |                          |   | > |                           |
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|               |                          |   |   |                           |
|               |                          |   | \ |                           |
|               |                          |   | $ |                           |
|               |                          |   | 3 |                           |
|               |                          |   | , |                           |
|               |                          |   | 0 |                           |
|               |                          |   | 0 |                           |
|               |                          |   | 0 |                           |
|               |                          |   | ; |                           |
|               |                          |   | > |                           |
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|               |                          |   | l |                           |
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|               |                          |   | > |                           |
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|               |                          |   | > |                           |
|               |                          |   |   |                           |
|               |                          |   | o |                           |
|               |                          |   | v |                           |
|               |                          |   | e |                           |
|               |                          |   | r |                           |
|               |                          |   | > |                           |
|               |                          |   |   |                           |
|               |                          |   | \ |                           |
|               |                          |   | $ |                           |
|               |                          |   | 3 |                           |
|               |                          |   | , |                           |
|               |                          |   | 0 |                           |
|               |                          |   | 0 |                           |
|               |                          |   | 0 |                           |
|               |                          |   | > |                           |
|               |                          |   |   |                           |
|               |                          |   | p |                           |
|               |                          |   | e |                           |
|               |                          |   | r |                           |
|               |                          |   | > |                           |
|               |                          |   |   |                           |
|               |                          |   | l |                           |
|               |                          |   | i |                           |
|               |                          |   | f |                           |
|               |                          |   | e |                           |
|               |                          |   | t |                           |
|               |                          |   | i |                           |
|               |                          |   | m |                           |
|               |                          |   | e |                           |
+---------------+--------------------------+---+---+---------------------------+
| ## N          |                          |   | > |                           |
| ot covered ou |                          |   |   |                           |
| t-of-network: |                          |   | * |                           |
|               |                          |   | A |                           |
| -             |                          |   | l |                           |
|    *Treatment |                          |   | l |                           |
|     for       |                          |   | > |                           |
|     learning  |                          |   |   |                           |
|               |                          |   | c |                           |
|  disabilities |                          |   | h |                           |
|     and       |                          |   | a |                           |
|     mental    |                          |   | r |                           |
|               |                          |   | g |                           |
|  retardation* |                          |   | e |                           |
|               |                          |   | s |                           |
| -   *Services |                          |   | * |                           |
|     rendered  |                          |   |   |                           |
|     or billed |                          |   |   |                           |
|     by a      |                          |   |   |                           |
|     school or |                          |   |   |                           |
|     halfway   |                          |   |   |                           |
|     house or  |                          |   |   |                           |
|     a member  |                          |   |   |                           |
|     of its    |                          |   |   |                           |
|     staff*    |                          |   |   |                           |
|               |                          |   |   |                           |
| -             |                          |   |   |                           |
| *Phototherapy |                          |   |   |                           |
|     for       |                          |   |   |                           |
|     treatment |                          |   |   |                           |
|     of        |                          |   |   |                           |
|     Seasonal  |                          |   |   |                           |
|     Affective |                          |   |   |                           |
|     Disorder  |                          |   |   |                           |
|     (SAD)*    |                          |   |   |                           |
+---------------+--------------------------+---+---+---------------------------+
| > **Lifetime  | Out-of-network inpatient |   |   |                           |
| > maximum**   | care for the treatment   |   |   |                           |
|               | of alcoholism and drug   |   |   |                           |
|               | abuse is limited to one  |   |   |                           |
|               | treatment program per    |   |   |                           |
|               | lifetime not to exceed   |   |   |                           |
|               | \$3,000.                 |   |   |                           |
+---------------+--------------------------+---+---+---------------------------+
| > **Prece     | -   Inpatient care --    |   |   |                           |
| rtification** |     You must get         |   |   |                           |
|               |     preauthorization of  |   |   |                           |
|               |     hospital stays;      |   |   |                           |
|               |     failure to do so     |   |   |                           |
|               |     will result in a     |   |   |                           |
|               |     minimum \$500        |   |   |                           |
|               |     penalty. Please      |   |   |                           |
|               |     refer to the         |   |   |                           |
|               |     precertification     |   |   |                           |
|               |     information shown in |   |   |                           |
|               |     Section 3. To obtain |   |   |                           |
|               |     preauthorization of  |   |   |                           |
|               |     an admission for     |   |   |                           |
|               |     mental conditions or |   |   |                           |
|               |     substance abuse,     |   |   |                           |
|               |     call ValueOptions at |   |   |                           |
|               |     888/700-7965         |   |   |                           |
|               |                          |   |   |                           |
|               | -   Outpatient care --   |   |   |                           |
|               |     You must get         |   |   |                           |
|               |     preauthorization of  |   |   |                           |
|               |     outpatient care for  |   |   |                           |
|               |     mental conditions or |   |   |                           |
|               |     substance abuse.     |   |   |                           |
|               |     Preauthorization     |   |   |                           |
|               |     must be obtained by  |   |   |                           |
|               |     calling ValueOptions |   |   |                           |
|               |     at 888/700-7965      |   |   |                           |
+---------------+--------------------------+---+---+---------------------------+
| > See these   |                          |   |   |                           |
| > sections of |                          |   |   |                           |
| > the         |                          |   |   |                           |
| > brochure    |                          |   |   |                           |
| > for more    |                          |   |   |                           |
| > valuable    |                          |   |   |                           |
| > information |                          |   |   |                           |
| > about these |                          |   |   |                           |
| > benefits:   |                          |   |   |                           |
|               |                          |   |   |                           |
| -   Section   |                          |   |   |                           |
|     4, *Your  |                          |   |   |                           |
|     costs for |                          |   |   |                           |
|     covered   |                          |   |   |                           |
|               |                          |   |   |                           |
|    services*, |                          |   |   |                           |
|     for       |                          |   |   |                           |
|               |                          |   |   |                           |
|   information |                          |   |   |                           |
|     about     |                          |   |   |                           |
|               |                          |   |   |                           |
|  catastrophic |                          |   |   |                           |
|               |                          |   |   |                           |
|    protection |                          |   |   |                           |
|     for these |                          |   |   |                           |
|     benefits. |                          |   |   |                           |
|               |                          |   |   |                           |
| -   Section   |                          |   |   |                           |
|     8,        |                          |   |   |                           |
|     *Filing a |                          |   |   |                           |
|     claim for |                          |   |   |                           |
|     covered   |                          |   |   |                           |
|               |                          |   |   |                           |
|    services*, |                          |   |   |                           |
|     for       |                          |   |   |                           |
|               |                          |   |   |                           |
|   information |                          |   |   |                           |
|     about     |                          |   |   |                           |
|               |                          |   |   |                           |
|    submitting |                          |   |   |                           |
|     o         |                          |   |   |                           |
| ut-of-network |                          |   |   |                           |
|     claims.   |                          |   |   |                           |
+---------------+--------------------------+---+---+---------------------------+
| ###           |                          |   |   | ### You Pay               |
| Prescription  |                          |   |   |                           |
| drug benefits |                          |   |   |                           |
+---------------+--------------------------+---+---+---------------------------+
| ##            |                          |   |   | ###                       |
| ###### Covere |                          |   |   |                           |
| d medications |                          |   |   |                           |
|  and supplies |                          |   |   |                           |
+---------------+--------------------------+---+---+---------------------------+
| > > Each new  |                          |   | - |                           |
| > > enrollee  |                          |   |   |                           |
| > > will      |                          |   |   |                           |
| > > receive a |                          |   |   |                           |
| >             |                          |   | N |                           |
| > description |                          |   | e |                           |
| > > of our    |                          |   | t |                           |
| > >           |                          |   | w |                           |
|  prescription |                          |   | o |                           |
| > > drug      |                          |   | r |                           |
| > > program   |                          |   | k |                           |
| > >           |                          |   |   |                           |
|  administered |                          |   |   |                           |
| > > by Medco  |                          |   |   |                           |
| > > Health, a |                          |   |   |                           |
| > > combined  |                          |   | R |                           |
| > >           |                          |   | e |                           |
|  prescription |                          |   | t |                           |
| > > drug/Plan |                          |   | a |                           |
| > > i         |                          |   | i |                           |
| dentification |                          |   | l |                           |
| > > card, a   |                          |   | : |                           |
| > > mail      |                          |   |   |                           |
| > > order     |                          |   |   |                           |
| > >           |                          |   |   |                           |
|  form/patient |                          |   |   |                           |
| > > profile   |                          |   | 2 |                           |
| > > and a     |                          |   | 5 |                           |
| > > reply     |                          |   | % |                           |
| > > envelope. |                          |   |   |                           |
| >             |                          |   |   |                           |
| > You may     |                          |   |   |                           |
| > purchase    |                          |   |   |                           |
| > the         |                          |   | o |                           |
| > following   |                          |   | f |                           |
| > medications |                          |   |   |                           |
| > and         |                          |   |   |                           |
| > supplies    |                          |   |   |                           |
| > prescribed  |                          |   |   |                           |
| > by a        |                          |   | c |                           |
| > physician   |                          |   | h |                           |
| > from either |                          |   | a |                           |
| > a network   |                          |   | r |                           |
| > pharmacy or |                          |   | g |                           |
| > by mail:    |                          |   | e |                           |
|               |                          |   |   |                           |
| -   Drugs and |                          |   |   |                           |
|               |                          |   |   |                           |
|    medicines, |                          |   |   |                           |
|     including |                          |   | w |                           |
|     those for |                          |   | i |                           |
|     smoking   |                          |   | t |                           |
|               |                          |   | h |                           |
|    cessation, |                          |   |   |                           |
|     for use   |                          |   |   |                           |
|     at home   |                          |   |   |                           |
|     that are  |                          |   |   |                           |
|               |                          |   | a |                           |
|    obtainable |                          |   |   |                           |
|     only upon |                          |   |   |                           |
|     a         |                          |   |   |                           |
|     doctor's  |                          |   |   |                           |
|               |                          |   | m |                           |
|  prescription |                          |   | i |                           |
|               |                          |   | n |                           |
| -   Drugs and |                          |   | i |                           |
|     medicines |                          |   | m |                           |
|               |                          |   | u |                           |
|    (including |                          |   | m |                           |
|     those     |                          |   |   |                           |
|               |                          |   |   |                           |
|  administered |                          |   |   |                           |
|     during a  |                          |   |   |                           |
|               |                          |   | o |                           |
|   non-covered |                          |   | f |                           |
|     admission |                          |   |   |                           |
|     or in a   |                          |   |   |                           |
|               |                          |   |   |                           |
|   non-covered |                          |   |   |                           |
|     facility) |                          |   | \ |                           |
|     that by   |                          |   | $ |                           |
|     Federal   |                          |   | 8 |                           |
|     law of    |                          |   |   |                           |
|     the       |                          |   |   |                           |
|     United    |                          |   |   |                           |
|     States    |                          |   |   |                           |
|     require a |                          |   | p |                           |
|               |                          |   | e |                           |
|   physician's |                          |   | r |                           |
|               |                          |   |   |                           |
|  prescription |                          |   |   |                           |
|     for their |                          |   |   |                           |
|     purchase, |                          |   |   |                           |
|     except    |                          |   | p |                           |
|     those     |                          |   | r |                           |
|     listed as |                          |   | e |                           |
|     *Not      |                          |   | s |                           |
|     covered*  |                          |   | c |                           |
|               |                          |   | r |                           |
| -   Insulin   |                          |   | i |                           |
|     and       |                          |   | p |                           |
|     reagent   |                          |   | t |                           |
|     strips    |                          |   | i |                           |
|     for known |                          |   | o |                           |
|     diabetics |                          |   | n |                           |
|               |                          |   |   |                           |
| -   Needles   |                          |   | - |                           |
|     and       |                          |   |   |                           |
|     syringes  |                          |   |   |                           |
|     for the   |                          |   |   |                           |
|     a         |                          |   | N |                           |
| dministration |                          |   | e |                           |
|     of        |                          |   | t |                           |
|     covered   |                          |   | w |                           |
|               |                          |   | o |                           |
|   medications |                          |   | r |                           |
|               |                          |   | k |                           |
| -   Full      |                          |   |   |                           |
|     range of  |                          |   |   |                           |
|               |                          |   |   |                           |
|  FDA-approved |                          |   |   |                           |
|     drugs,    |                          |   | R |                           |
|     p         |                          |   | e |                           |
| rescriptions, |                          |   | t |                           |
|     and       |                          |   | a |                           |
|     devices   |                          |   | i |                           |
|     for birth |                          |   | l |                           |
|     control   |                          |   |   |                           |
|               |                          |   |   |                           |
| -   Approved  |                          |   |   |                           |
|     drugs for |                          |   |   |                           |
|     organic   |                          |   | M |                           |
|     impotence |                          |   | e |                           |
|     subject   |                          |   | d |                           |
|     to prior  |                          |   | i |                           |
|     Plan      |                          |   | c |                           |
|     approval  |                          |   | a |                           |
|     and       |                          |   | r |                           |
|               |                          |   | e |                           |
|   limitations |                          |   | : |                           |
|     on dosage |                          |   |   |                           |
|     and       |                          |   |   |                           |
|     quantity  |                          |   |   |                           |
|               |                          |   |   |                           |
| Note: If you  |                          |   | 2 |                           |
| do not use    |                          |   | 5 |                           |
| your          |                          |   | % |                           |
| i             |                          |   |   |                           |
| dentification |                          |   |   |                           |
| card at a     |                          |   |   |                           |
| network       |                          |   |   |                           |
| pharmacy, or  |                          |   | o |                           |
| if you use a  |                          |   | f |                           |
| non-network   |                          |   |   |                           |
| pharmacy, the |                          |   |   |                           |
| Plan provides |                          |   |   |                           |
| no benefit    |                          |   |   |                           |
| and you must  |                          |   | c |                           |
| pay the full  |                          |   | h |                           |
| cost of your  |                          |   | a |                           |
| purchases.    |                          |   | r |                           |
| Non-network   |                          |   | g |                           |
| retail drugs  |                          |   | e |                           |
| will be       |                          |   |   |                           |
| covered under |                          |   |   |                           |
| the           |                          |   |   |                           |
| in-network    |                          |   |   |                           |
| benefit only  |                          |   | w |                           |
| if necessary  |                          |   | i |                           |
| and           |                          |   | t |                           |
| prescribed    |                          |   | h |                           |
| for sudden    |                          |   |   |                           |
| illness while |                          |   |   |                           |
| traveling     |                          |   |   |                           |
| outside of    |                          |   |   |                           |
| the United    |                          |   | a |                           |
| States        |                          |   |   |                           |
| (including    |                          |   |   |                           |
| Puerto Rico). |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | m |                           |
|               |                          |   | i |                           |
|               |                          |   | n |                           |
|               |                          |   | i |                           |
|               |                          |   | m |                           |
|               |                          |   | u |                           |
|               |                          |   | m |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | o |                           |
|               |                          |   | f |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | \ |                           |
|               |                          |   | $ |                           |
|               |                          |   | 8 |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | p |                           |
|               |                          |   | e |                           |
|               |                          |   | r |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | p |                           |
|               |                          |   | r |                           |
|               |                          |   | e |                           |
|               |                          |   | s |                           |
|               |                          |   | c |                           |
|               |                          |   | r |                           |
|               |                          |   | i |                           |
|               |                          |   | p |                           |
|               |                          |   | t |                           |
|               |                          |   | i |                           |
|               |                          |   | o |                           |
|               |                          |   | n |                           |
|               |                          |   |   |                           |
|               |                          |   | - |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | N |                           |
|               |                          |   | e |                           |
|               |                          |   | t |                           |
|               |                          |   | w |                           |
|               |                          |   | o |                           |
|               |                          |   | r |                           |
|               |                          |   | k |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | M |                           |
|               |                          |   | a |                           |
|               |                          |   | i |                           |
|               |                          |   | l |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | O |                           |
|               |                          |   | r |                           |
|               |                          |   | d |                           |
|               |                          |   | e |                           |
|               |                          |   | r |                           |
|               |                          |   | : |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | 2 |                           |
|               |                          |   | 5 |                           |
|               |                          |   | % |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | o |                           |
|               |                          |   | f |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | c |                           |
|               |                          |   | h |                           |
|               |                          |   | a |                           |
|               |                          |   | r |                           |
|               |                          |   | g |                           |
|               |                          |   | e |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | w |                           |
|               |                          |   | i |                           |
|               |                          |   | t |                           |
|               |                          |   | h |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | a |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | m |                           |
|               |                          |   | i |                           |
|               |                          |   | n |                           |
|               |                          |   | i |                           |
|               |                          |   | m |                           |
|               |                          |   | u |                           |
|               |                          |   | m |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | o |                           |
|               |                          |   | f |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | \ |                           |
|               |                          |   | $ |                           |
|               |                          |   | 8 |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | p |                           |
|               |                          |   | e |                           |
|               |                          |   | r |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | p |                           |
|               |                          |   | r |                           |
|               |                          |   | e |                           |
|               |                          |   | s |                           |
|               |                          |   | c |                           |
|               |                          |   | r |                           |
|               |                          |   | i |                           |
|               |                          |   | p |                           |
|               |                          |   | t |                           |
|               |                          |   | i |                           |
|               |                          |   | o |                           |
|               |                          |   | n |                           |
|               |                          |   |   |                           |
|               |                          |   | - |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | N |                           |
|               |                          |   | e |                           |
|               |                          |   | t |                           |
|               |                          |   | w |                           |
|               |                          |   | o |                           |
|               |                          |   | r |                           |
|               |                          |   | k |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | M |                           |
|               |                          |   | a |                           |
|               |                          |   | i |                           |
|               |                          |   | l |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | O |                           |
|               |                          |   | r |                           |
|               |                          |   | d |                           |
|               |                          |   | e |                           |
|               |                          |   | r |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | M |                           |
|               |                          |   | e |                           |
|               |                          |   | d |                           |
|               |                          |   | i |                           |
|               |                          |   | c |                           |
|               |                          |   | a |                           |
|               |                          |   | r |                           |
|               |                          |   | e |                           |
|               |                          |   | : |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | 2 |                           |
|               |                          |   | 5 |                           |
|               |                          |   | % |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | o |                           |
|               |                          |   | f |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | c |                           |
|               |                          |   | h |                           |
|               |                          |   | a |                           |
|               |                          |   | r |                           |
|               |                          |   | g |                           |
|               |                          |   | e |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | w |                           |
|               |                          |   | i |                           |
|               |                          |   | t |                           |
|               |                          |   | h |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | a |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | m |                           |
|               |                          |   | i |                           |
|               |                          |   | n |                           |
|               |                          |   | i |                           |
|               |                          |   | m |                           |
|               |                          |   | u |                           |
|               |                          |   | m |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | o |                           |
|               |                          |   | f |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | \ |                           |
|               |                          |   | $ |                           |
|               |                          |   | 8 |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | p |                           |
|               |                          |   | e |                           |
|               |                          |   | r |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   |   |                           |
|               |                          |   | p |                           |
|               |                          |   | r |                           |
|               |                          |   | e |                           |
|               |                          |   | s |                           |
|               |                          |   | c |                           |
|               |                          |   | r |                           |
|               |                          |   | i |                           |
|               |                          |   | p |                           |
|               |                          |   | t |                           |
|               |                          |   | i |                           |
|               |                          |   | o |                           |
|               |                          |   | n |                           |
+---------------+--------------------------+---+---+---------------------------+
| *Not          |                          |   | > |                           |
| covered:*     |                          |   |   |                           |
|               |                          |   | * |                           |
| -   *Drugs    |                          |   | A |                           |
|     and       |                          |   | l |                           |
|     supplies  |                          |   | l |                           |
|     for       |                          |   | > |                           |
|     cosmetic  |                          |   |   |                           |
|     purposes* |                          |   | c |                           |
|               |                          |   | h |                           |
| -             |                          |   | a |                           |
|    *Vitamins, |                          |   | r |                           |
|     minerals, |                          |   | g |                           |
|               |                          |   | e |                           |
|   nutritional |                          |   | s |                           |
|               |                          |   | * |                           |
|  supplements, |                          |   |   |                           |
|     and       |                          |   |   |                           |
|     enteral   |                          |   |   |                           |
|     formulas  |                          |   |   |                           |
|     (liquid   |                          |   |   |                           |
|     food      |                          |   |   |                           |
|               |                          |   |   |                           |
| supplements)* |                          |   |   |                           |
|               |                          |   |   |                           |
| -   *Medical  |                          |   |   |                           |
|     supplies  |                          |   |   |                           |
|     such as   |                          |   |   |                           |
|     dressings |                          |   |   |                           |
|     and       |                          |   |   |                           |
|               |                          |   |   |                           |
|  antiseptics* |                          |   |   |                           |
|               |                          |   |   |                           |
| -   *No       |                          |   |   |                           |
| nprescription |                          |   |   |                           |
|               |                          |   |   |                           |
|    medicines* |                          |   |   |                           |
|               |                          |   |   |                           |
| -             |                          |   |   |                           |
|  *Non-network |                          |   |   |                           |
|     retail    |                          |   |   |                           |
|     drugs     |                          |   |   |                           |
|     (unless   |                          |   |   |                           |
|     for a     |                          |   |   |                           |
|     sudden    |                          |   |   |                           |
|     illness   |                          |   |   |                           |
|     while     |                          |   |   |                           |
|     traveling |                          |   |   |                           |
|     outside   |                          |   |   |                           |
|     the       |                          |   |   |                           |
|     United    |                          |   |   |                           |
|     States or |                          |   |   |                           |
|     Puerto    |                          |   |   |                           |
|     Rico)*    |                          |   |   |                           |
+---------------+--------------------------+---+---+---------------------------+

+----------------------+-----------------------------------------------+
| **Section 6 (d).     |                                               |
| Health tools and     |                                               |
| resources**          |                                               |
+----------------------+-----------------------------------------------+
| > **Special          | > **Description**                             |
| > features**         |                                               |
+----------------------+-----------------------------------------------+
| **Online tools and   | > Your personal, private Web site accessible  |
| resources**          | > by Internet or telephone (866/333-4648)     |
|                      | > featuring:                                  |
|                      |                                               |
|                      | -   Your Personal Care Account balance and    |
|                      |     activity (also mailed quarterly)          |
|                      |                                               |
|                      | -   Your complete claims payment history      |
|                      |                                               |
|                      | -   A consumer health encyclopedia and        |
|                      |     interactive services                      |
|                      |                                               |
|                      | -   Online health risk assessment to help     |
|                      |     determine your risk for certain           |
|                      |     conditions and steps to manage them       |
+----------------------+-----------------------------------------------+
| **Consumer choice    | > Each member is provided access by Internet  |
| information**        | > or telephone (866/333-4648) to information  |
|                      | > which you may use to support your important |
|                      | > health and wellness decisions, including:   |
|                      |                                               |
|                      | -   Online provider directory with complete   |
|                      |     national network and provider information |
|                      |     (i.e., address, telephone, specialty,     |
|                      |     practice hours, languages spoken)         |
|                      |                                               |
|                      | -   Network provider discounted pricing for   |
|                      |     comparative shopping                      |
|                      |                                               |
|                      | -   Pricing information for prescription      |
|                      |     drugs                                     |
|                      |                                               |
|                      | -   General cost information for surgical and |
|                      |     diagnostic procedures and for comparison  |
|                      |     of different treatment options            |
|                      |                                               |
|                      | -   Provider quality information              |
|                      |                                               |
|                      | -   Health calculators on medical and         |
|                      |     wellness topics                           |
+----------------------+-----------------------------------------------+
| **Care support**     | > A 24-hour nurse advisory service for your   |
|                      | > use. This program is strictly voluntary and |
|                      | > confidential. You may call toll-free at     |
|                      | > 866/333-4648 to discuss an existing medical |
|                      | > concern or to receive information about     |
|                      | > numerous health care and self-care issues.  |
|                      | > This also includes health coaching with a   |
|                      | > registered nurse when you want to discuss   |
|                      | > significant medical decisions. TTY/TDD      |
|                      | > callers, please call the National Relay     |
|                      | > Center at 800/855-2880 and ask for          |
|                      | > 866/333-4648.                               |
|                      | >                                             |
|                      | > Identification and notification of          |
|                      | > potential patient safety issues (e.g., drug |
|                      | > interactions).                              |
|                      | >                                             |
|                      | > Individual support with a health care       |
|                      | > professional for numerous medical           |
|                      | > conditions including maternity, asthma,     |
|                      | > diabetes, congestive heart failure, and     |
|                      | > more.                                       |
+----------------------+-----------------------------------------------+

  -----------------------------------------------------------------------
  Section 7. General exclusions \-- things we don't cover

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

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

We do not cover the following:

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

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

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

-   Experimental or investigational procedures, treatments, drugs or
    devices

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

-   Services, drugs, or supplies related to sex transformations, sexual
    dysfunction or sexual inadequacy except for organic impotence as
    shown on pages 31, 33, 44, 65 and 73

-   Services, drugs, or supplies for weight reduction/control or
    treatment of obesity except as shown under Surgical benefits,
    Sections 5(b) and 6(c)

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

-   Services, drugs and supplies for which no charge would be made if
    the covered individual had no health insurance coverage

-   Computer "story boards", "light talkers", or other communication
    aids for communication-impaired individuals

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

-   Services, drugs and supplies furnished by immediate relatives or
    household members, such as spouse, parent, child, brother, or sister
    by blood, marriage, or adoption

-   Services and supplies furnished or billed by a noncovered facility,
    except that medically necessary prescription drugs and physical,
    speech and occupational therapy rendered by a qualified professional
    therapist on an outpatient basis are covered subject to plan limits

-   Services, supplies and drugs not specifically listed as covered

-   Services, supplies and drugs furnished or billed by someone other
    than a covered provider as defined on page 11

-   Any portion of a provider's fee or charge ordinarily due from the
    enrollee but that has been waived. If a provider routinely waives
    (does not require the enrollee to pay) a deductible, copay or
    coinsurance, we will calculate the actual provider fee or charge by
    reducing the fee or charge by the amount waived

-   Charges which you or we have no legal obligation to pay, such as
    excess charges for an annuitant age 65 or older who is not covered
    by Medicare Parts A and/or B (see pages 20 and 21), doctor charges
    exceeding the amount specified by the Department of Health and Human
    Services when benefits are payable under Medicare (limiting charge)
    (see page 21), or State premium taxes however applied

-   Biofeedback; nonmedical self care or self help training, such as
    recreational, educational, or milieu therapy; or

-   Charges that we determine to be in excess of the Plan allowance.

+----------------------+-----------------------------------------------+
| Section 8. Filing a  |                                               |
| claim for covered    |                                               |
| services             |                                               |
+----------------------+-----------------------------------------------+
| **How to claim       | **High Option:** to obtain claim forms or     |
| benefits**           | other claims filing advice or answers about   |
|                      | our benefits, contact us at 800/222-APWU, or  |
|                      | at our Web site at                            |
|                      | [www.apwuhp.com](http://www.apwuhp.com/).     |
|                      |                                               |
|                      | **Consumer-driven Option:** contact Definity  |
|                      | Health at 866/333-4648 or visit their Web     |
|                      | site at [www.definityhealth.com]{.underline}. |
|                      | User ID: APWUHP Password: HPINFO              |
|                      |                                               |
|                      | In most cases, providers and facilities file  |
|                      | claims for you. Your physician must file on   |
|                      | the form HCFA-1500, Health Insurance Claim    |
|                      | Form. Your facility will file on the UB-92    |
|                      | form. For claims questions and assistance,    |
|                      | call us at 800/222-APWU.                      |
|                      |                                               |
|                      | When you must file a claim, such as when you  |
|                      | use non-PPO providers, for services you       |
|                      | receive overseas or when another group health |
|                      | plan is primary, submit it on the HCFA-1500   |
|                      | or a claim form that includes the information |
|                      | shown below. Bills and receipts should be     |
|                      | itemized and show:                            |
|                      |                                               |
|                      | -   Name of patient and relationship to       |
|                      |     enrollee                                  |
|                      |                                               |
|                      | -   Plan identification number of the         |
|                      |     enrollee                                  |
|                      |                                               |
|                      | -   Name, address and taxpayer identification |
|                      |     number of person or firm providing the    |
|                      |     service or supply                         |
|                      |                                               |
|                      | -   Dates that services or supplies were      |
|                      |     furnished                                 |
|                      |                                               |
|                      | -   Diagnosis                                 |
|                      |                                               |
|                      | -   Type of each service or supply; and       |
|                      |                                               |
|                      | -   The charge for each service or supply     |
|                      |                                               |
|                      | Note: Canceled checks, cash register          |
|                      | receipts, or balance due statements are not   |
|                      | acceptable substitutes for itemized bills.    |
|                      |                                               |
|                      | In addition:                                  |
|                      |                                               |
|                      | -   You must send a copy of the explanation   |
|                      |     of benefits (EOB) from any primary payer  |
|                      |     (such as the Medicare Summary Notice      |
|                      |     (MSN)) with your claim                    |
|                      |                                               |
|                      | -   Bills for home nursing care must show     |
|                      |     that the nurse is a registered nurse,     |
|                      |     licensed practical nurse or licensed      |
|                      |     vocational nurse                          |
|                      |                                               |
|                      | -   Claims for rental or purchase of durable  |
|                      |     medical equipment; private duty nursing;  |
|                      |     and physical, occupational, and speech    |
|                      |     therapy require a written statement from  |
|                      |     the physician specifying the medical      |
|                      |     necessity for the service or supply and   |
|                      |     the length of time needed                 |
|                      |                                               |
|                      | -   Claims for prescription drugs and         |
|                      |     supplies that are not obtained from a     |
|                      |     network pharmacy or through the Mail      |
|                      |     Service Prescription Drug Program must    |
|                      |     include receipts that include the         |
|                      |     prescription number, the National Drug    |
|                      |     Code (NDC) number, name of drug or        |
|                      |     supply, prescribing physician's name,     |
|                      |     date, and charge                          |
|                      |                                               |
|                      | -   You should provide an English translation |
|                      |     and currency conversion rate at the time  |
|                      |     of services for claims for overseas       |
|                      |     (foreign) services                        |
+----------------------+-----------------------------------------------+
| **Records**          | Keep a separate record of the medical         |
|                      | expenses of each covered family member as     |
|                      | deductibles and maximum allowances apply      |
|                      | separately to each person. Save copies of all |
|                      | medical bills, including those you accumulate |
|                      | to satisfy a deductible. In most instances    |
|                      | they will serve as evidence of your claim. We |
|                      | will not provide duplicate or year-end        |
|                      | statements.                                   |
+----------------------+-----------------------------------------------+
| **Deadline for       | Send us all of the documents for your claim   |
| filing 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. Once we pay benefits,    |
|                      | there is a three-year limitation on the       |
|                      | reissuance of uncashed checks.                |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| **Overseas claims**  | For covered services you receive in hospitals |
|                      | outside the United States and Puerto Rico and |
|                      | performed by physicians outside the United    |
|                      | States, send a completed Claim Form and the   |
|                      | itemized bills to the following address. Also |
|                      | send any written inquiries concerning the     |
|                      | processing of overseas claims to:             |
|                      |                                               |
|                      | -   **High Option:** APWU Health Plan, P.O.   |
|                      |     Box 967, Silver Spring, MD 20910.         |
|                      |                                               |
|                      | -   **Consumer-driven Option:** Definity      |
|                      |     Health at the claims address shown on the |
|                      |     back of your Definity Health ID card.     |
+----------------------+-----------------------------------------------+
| **When we need more  | Please reply promptly when we ask for         |
| information**        | additional information. We may delay          |
|                      | processing or deny your claim if you do not   |
|                      | respond.                                      |
+----------------------+-----------------------------------------------+

  -----------------------------------------------------------------------
  Section 9. The disputed claims process

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

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

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) Write to us within 6 months from the date of our decision;   |
| * |     and                                                          |
| * |                                                                  |
|   | (b) Send your High Option request to us at: APWU Health Plan,    |
|   |     P.O. Box 3279, Silver Spring, MD 20918 or send your          |
|   |     Consumer-driven Option request to: Definity Health, Attn:    |
|   |     Appeals, 1600 Utica Ave., So., Suite 900, St. Louis Park, MN |
|   |     55416; and                                                   |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians' letters, operative reports, bills, medical       |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or, if applicable, arrange for the health     |
| * |     care provider to give you the care); or                      |
| * |                                                                  |
|   | (b) Write to you and maintain our denial \-- go to step 4; or    |
|   |                                                                  |
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request \-- go |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us \-- if we did not       |
|   |     answer that request in some way within 30 days; or           |
|   |                                                                  |
|   | -   120 days after we asked for additional information           |
+---+------------------------------------------------------------------+
|   | Write to OPM at: United States Office of Personnel Management,   |
|   | Insurance Services Programs, Health Insurance Group 2, 1900 E    |
|   | Street, NW, Washington, D.C. 20415-3620.                         |
+---+------------------------------------------------------------------+
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure        |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians' letters, operative reports, bills, medical       |
|   |     records, and explanation of benefits (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.                                                         |
+---+------------------------------------------------------------------+
| * |                                                                  |
| * |                                                                  |
| T |                                                                  |
| h |                                                                  |
| e |                                                                  |
| d |                                                                  |
| i |                                                                  |
| s |                                                                  |
| p |                                                                  |
| u |                                                                  |
| t |                                                                  |
| e |                                                                  |
| d |                                                                  |
| c |                                                                  |
| l |                                                                  |
| a |                                                                  |
| i |                                                                  |
| m |                                                                  |
| s |                                                                  |
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| u |                                                                  |
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| d |                                                                  |
| ) |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | 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.                                             |
+---+------------------------------------------------------------------+
| * |                                                                  |
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+---+------------------------------------------------------------------+

+----------------------+-----------------------------------------------+
| Section 10.          |                                               |
| Coordinating         |                                               |
| benefits with other  |                                               |
| coverage             |                                               |
+----------------------+-----------------------------------------------+
| **When you have      | You must tell us if you or a covered family   |
| other health         | member have coverage under another group      |
| coverage**           | health plan or have automobile insurance that |
|                      | pays health care expenses without regard to   |
|                      | fault. This is called "double coverage."      |
|                      |                                               |
|                      | When you have double coverage, one plan       |
|                      | normally pays its benefits in full as the     |
|                      | primary payer and the other plan pays a       |
|                      | reduced benefit as the secondary payer. We,   |
|                      | like other insurers, determine which coverage |
|                      | is primary according to the National          |
|                      | Association of Insurance Commissioners'       |
|                      | guidelines.                                   |
|                      |                                               |
|                      | When we are the primary payer, we will pay    |
|                      | the benefits described in this brochure.      |
|                      |                                               |
|                      | When we are the secondary payer, we will      |
|                      | determine our allowance. After the primary    |
|                      | plan pays, we will pay what is left of our    |
|                      | allowance, up to our regular benefit. We will |
|                      | not pay more than our allowance. When we are  |
|                      | secondary payer, we will not waive specified  |
|                      | visit limits.                                 |
+----------------------+-----------------------------------------------+
| **What is            | Medicare is a Health Insurance Program for:   |
| Medicare?**          |                                               |
|                      | -   People 65 years of age and older          |
|                      |                                               |
|                      | -   Some people with disabilities, under 65   |
|                      |     years of age                              |
|                      |                                               |
|                      | -   People with End-Stage Renal Disease       |
|                      |     (permanent kidney failure requiring       |
|                      |     dialysis or a transplant)                 |
|                      |                                               |
|                      | Medicare has two parts:                       |
|                      |                                               |
|                      | -   Part A (Hospital Insurance). Most people  |
|                      |     do not have to pay for Part A. If you or  |
|                      |     your spouse worked for at least 10 years  |
|                      |     in Medicare-covered employment, you       |
|                      |     should be able to qualify for             |
|                      |     premium-free Part A insurance. (Someone   |
|                      |     who was a Federal employee on January 1,  |
|                      |     1983 or since automatically qualifies.)   |
|                      |     Otherwise, if you are age 65 or older,    |
|                      |     you may be able to buy it. Contact        |
|                      |     800/MEDICARE (800/633-4227) for more      |
|                      |     information.                              |
|                      |                                               |
|                      | -   Part B (Medical Insurance). Most people   |
|                      |     pay monthly for Part B. Generally, Part B |
|                      |     premiums are withheld from your monthly   |
|                      |     Social Security check or your retirement  |
|                      |     check.                                    |
|                      |                                               |
|                      | If you are eligible for Medicare, you may     |
|                      | have choices in how you get your health care. |
|                      | Medicare+Choice is the term used to describe  |
|                      | the various health plan choices available to  |
|                      | Medicare beneficiaries. The information in    |
|                      | the next few pages shows how we coordinate    |
|                      | benefits with Medicare, depending on the type |
|                      | of Medicare+Choice plan you have.             |
+----------------------+-----------------------------------------------+
| -   **The Original   | The Original Medicare Plan (Original          |
|     Medicare**       | Medicare) is available everywhere in the      |
|     **Plan\          | United States. It is the way everyone used to |
|     (Part A or Part  | get Medicare benefits and is the way most     |
|     B)**             | people get their Medicare Part A and Part B   |
|                      | benefits now. You may go to any doctor,       |
|                      | specialist, or hospital that accepts          |
|                      | Medicare. The Original Medicare Plan pays its |
|                      | share and you pay your share. Some things are |
|                      | not covered under Original Medicare, like     |
|                      | prescription drugs.                           |
|                      |                                               |
|                      | When you are enrolled in Original Medicare,   |
|                      | along with this Plan, you still need to       |
|                      | follow the rules in this brochure for us to   |
|                      | cover your care.                              |
|                      |                                               |
|                      | **Claims process when you have the Original   |
|                      | Medicare Plan:** You probably will never have |
|                      | to file a claim form when you have both our   |
|                      | Plan and the Original Medicare Plan:          |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| -   **The Original   | -   When we are the primary payer, we process |
|     Medicare**       |     the claim first. In this case, we do not  |
|     **Plan (Part A   |     waive any out-of-pocket costs             |
|     or Part B)**     |                                               |
|     *(Continued)*    | -   When Original Medicare is the primary     |
|                      |     payer, Medicare processes your claim      |
|                      |     first. In most cases, your claim will be  |
|                      |     coordinated automatically and we will     |
|                      |     then provide secondary benefits for       |
|                      |     covered charges. You will not need to do  |
|                      |     anything. To find out if you need to do   |
|                      |     something to file your claim, call us at  |
|                      |     800/222-APWU or contact us at our Web     |
|                      |     site at                                   |
|                      |     [www.apwuhp.com](http://www.apwuhp.com/)  |
|                      |                                               |
|                      | **We waive some costs if the Original         |
|                      | Medicare Plan is your primary payer.**        |
|                      |                                               |
|                      | **Under the High Option,** we will waive some |
|                      | out-of-pocket costs as follows:               |
|                      |                                               |
|                      | -   Inpatient hospital service. If you are    |
|                      |     enrolled in Medicare Part A, we will      |
|                      |     waive the deductible, copayment and       |
|                      |     coinsurance                               |
|                      |                                               |
|                      | -   Medical services and supplies provided by |
|                      |     physicians and other health care          |
|                      |     professionals. If you are enrolled in     |
|                      |     Medicare Part B, we will waive the        |
|                      |     deductible and coinsurance                |
|                      |                                               |
|                      | Under the Consumer-driven Option, when        |
|                      | Original Medicare (either Medicare Part A or  |
|                      | Medicare Part B) is the primary payer, we     |
|                      | will not waive any out-of-pocket costs.       |
|                      |                                               |
|                      | Note: We do not waive our deductible,         |
|                      | copayments or coinsurance for prescription    |
|                      | drugs or for services and supplies that       |
|                      | Medicare does not cover. Also, we do not      |
|                      | waive benefit limitations, such as the        |
|                      | 12-visit limit for chiropractic services or   |
|                      | the 60-visit limit for physical, occupational |
|                      | or speech therapy.                            |
+----------------------+-----------------------------------------------+

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**                           | *    |        |
|                                                     | *The |        |
|                                                     | pri  |        |
|                                                     | mary |        |
|                                                     | p    |        |
|                                                     | ayer |        |
|                                                     | for  |        |
|                                                     | t    |        |
|                                                     | he** |        |
|                                                     |      |        |
|                                                     | **in |        |
|                                                     | divi |        |
|                                                     | dual |        |
|                                                     | with |        |
|                                                     | Medi |        |
|                                                     | care |        |
|                                                     | is.  |        |
|                                                     | ..** |        |
+-----------------------------------------------------+------+--------+
|                                                     | **Me | **This |
|                                                     | dica | Plan** |
|                                                     | re** |        |
+-----------------------------------------------------+------+--------+
| **A. When you -- or your covered spouse -- are age  |      |        |
| 65 or over and have Medicare and you...**           |      |        |
+-----------------------------------------------------+------+--------+
| 1)  Are an active employee with the Federal         |      |        |
|     government and**...**                           |      |        |
|                                                     |      |        |
|     -   You have FEHB coverage on your own or       |      |        |
|         through your spouse who is also an active   |      |        |
|         employee                                    |      |        |
+-----------------------------------------------------+------+--------+
| -   You have FEHB coverage through your spouse who  |      |        |
|     is an annuitant                                 |      |        |
+-----------------------------------------------------+------+--------+
| 2)  Are an annuitant and**...**                     |      |        |
|                                                     |      |        |
|     -   You have FEHB coverage on your own or       |      |        |
|         through your spouse who is also an          |      |        |
|         annuitant                                   |      |        |
+-----------------------------------------------------+------+--------+
| -   You have FEHB coverage through your spouse who  |      |        |
|     is an active employee                           |      |        |
+-----------------------------------------------------+------+--------+
| 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    | se     |
|                                                     | serv | rvices |
|                                                     | 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  |      | for    |
|     already a Medicare beneficiary and**...**       |      | 30     |
|                                                     |      | -month |
| -   This Plan was the primary payer before          |      | coordi |
|     eligibility due to ESRD                         |      | nation |
|                                                     |      | period |
+-----------------------------------------------------+------+--------+
| -   Medicare was the primary payer before           |      |        |
|     eligibility due to ESRD                         |      |        |
+-----------------------------------------------------+------+--------+
| **C. When either you or your spouse are eligible    |      |        |
| for Medicare solely due to disability and you**     |      |        |
+-----------------------------------------------------+------+--------+
| 1\) Are an active employee with the Federal         |      |        |
| government and**...**                               |      |        |
|                                                     |      |        |
| -   You have FEHB coverage on your own or through   |      |        |
|     your spouse who is also an active employee      |      |        |
+-----------------------------------------------------+------+--------+
| -   You have FEHB coverage through your spouse who  |      |        |
|     is an annuitant                                 |      |        |
+-----------------------------------------------------+------+--------+
| 2\) Are an annuitant and**...**                     |      | []{    |
|                                                     |      | .mark} |
| -   You have FEHB coverage on your own or through   |      |        |
|     your spouse who is also an annuitant            |      |        |
+-----------------------------------------------------+------+--------+
| -   You have FEHB coverage through your spouse who  |      |        |
|     is an active employee                           |      |        |
+-----------------------------------------------------+------+--------+
| **D. Are covered under the FEHB Spouse Equity       |      |        |
| provision as a former spouse**                      |      |        |
+-----------------------------------------------------+------+--------+

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

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

+---------------------+------------------------------------------------+
| -   **Medicare +    | If you are eligible for Medicare, you may      |
|     Choice**        | 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 prescriptions drugs. To     |
|                     | learn more about enrolling in a Medicare +     |
|                     | Choice plan, contact Medicare at 800/MEDICARE  |
|                     | (800/633-4227) or at                           |
|                     | [www.medicare.gov](http://www.medicare.gov/).  |
|                     |                                                |
|                     | If you enroll in a Medicare + Choice plan, the |
|                     | following options are available to you:        |
|                     |                                                |
|                     | **This Plan and another plan's Medicare +      |
|                     | Choice plan:** You may enroll in another       |
|                     | plan's Medicare + Choice plan and also remain  |
|                     | enrolled in our FEHB plan. We will still       |
|                     | provide benefits when your Medicare + Choice   |
|                     | plan is primary, even out of the Medicare +    |
|                     | Choice plan's network and/or service area, but |
|                     | we will not waive any of our copayments,       |
|                     | coinsurance, or deductibles. If you enroll in  |
|                     | a Medicare managed care plan, tell us. We will |
|                     | need to know whether you are in the Original   |
|                     | Medicare Plan or in a Medicare + Choice plan   |
|                     | so we can correctly coordinate benefits with   |
|                     | Medicare.                                      |
|                     |                                                |
|                     | **Suspended FEHB coverage to enroll in a       |
|                     | Medicare + Choice plan:** If you are an        |
|                     | annuitant or former spouse, you can suspend    |
|                     | your FEHB coverage to enroll in a Medicare +   |
|                     | Choice plan, eliminating your FEHB premium.    |
|                     | (OPM does not contribute to your Medicare +    |
|                     | Choice plan premium.) For information on       |
|                     | suspending your FEHB enrollment, contact your  |
|                     | retirement office. If you later want to        |
|                     | re-enroll in the FEHB Program, generally you   |
|                     | may do so only at the next Open Season unless  |
|                     | you involuntarily lose coverage or move out of |
|                     | the Medicare + Choice plan's service area.     |
+---------------------+------------------------------------------------+
| -   **Private       | A physician may ask you to sign a private      |
|     contract with   | contract agreeing that you can be billed       |
|     your            | directly for services ordinarily covered by    |
|     physician**     | Original Medicare. Should you sign an          |
|                     | agreement, Medicare will not pay any portion   |
|                     | of the charges, and we will not increase our   |
|                     | payment. We will still limit our payment to    |
|                     | the amount we would have paid after Original   |
|                     | Medicare's payment.                            |
+---------------------+------------------------------------------------+
| **TRICARE** **AND   | TRICARE is the health care program for         |
| CHAMPVA**           | eligible dependents of military persons, and   |
|                     | retirees of the military. TRICARE includes the |
|                     | CHAMPUS program. CHAMPVA provides health       |
|                     | coverage to disabled Veterans and their        |
|                     | eligible dependents. If TRICARE or CHAMPVA and |
|                     | this Plan cover you, we pay first. See your    |
|                     | TRICARE or CHAMPVA Health Benefits Advisor if  |
|                     | you have questions about these programs.       |
|                     |                                                |
|                     | **Suspended FEHB coverage to enroll in TRICARE |
|                     | or CHAMPVA:** If you are an annuitant or       |
|                     | former spouse, you can suspend your FEHB       |
|                     | coverage to enroll in one of these programs,   |
|                     | eliminating your FEHB premium. (OPM does not   |
|                     | contribute to any applicable plan premiums.)   |
|                     | For information on suspending your FEHB        |
|                     | enrollment, contact your retirement office. If |
|                     | you later want to re-enroll in the FEHB        |
|                     | Program, generally you may do so only at the   |
|                     | next Open Season unless you involuntarily lose |
|                     | coverage under the program.                    |
+---------------------+------------------------------------------------+
| **Workers'          | We do not cover services that:                 |
| Compensation**      |                                                |
|                     | -   You need because of a workplace-related    |
|                     |     illness or injury that the Office of       |
|                     |     Workers' Compensation Programs (OWCP) or a |
|                     |     similar Federal or State agency determines |
|                     |     they must provide; or                      |
|                     |                                                |
|                     | -   OWCP or a similar agency pays for through  |
|                     |     a third party injury settlement or other   |
|                     |     similar proceeding that is based on a      |
|                     |     claim you filed under OWCP or similar laws |
|                     |                                                |
|                     | Once OWCP or similar agency pays its maximum   |
|                     | benefits for your treatment, we will cover     |
|                     | your care.                                     |
+---------------------+------------------------------------------------+

+----------------------+-----------------------------------------------+
| **Medicaid**         | When you have this Plan and Medicaid, we pay  |
|                      | first.                                        |
|                      |                                               |
|                      | **Suspended FEHB coverage to enroll in        |
|                      | Medicaid or a similar State-sponsored program |
|                      | of medical assistance:** If you are an        |
|                      | annuitant or former spouse, you can suspend   |
|                      | your FEHB coverage to enroll in one of these  |
|                      | State programs, eliminating your FEHB         |
|                      | premium. For information on suspending your   |
|                      | FEHB enrollment, contact your retirement      |
|                      | office. If you later want to re-enroll in the |
|                      | FEHB Program, generally you may do so only at |
|                      | the next Open Season unless you involuntarily |
|                      | lose coverage under the State program.        |
+----------------------+-----------------------------------------------+
| **When other         | We do not cover services and supplies when a  |
| Government agencies  | local, State, or Federal Government agency    |
| are responsible\     | directly or indirectly pays for them.         |
| for your care**      |                                               |
+----------------------+-----------------------------------------------+
| **When others are    | If you or your dependent's injury or illness  |
| responsible\         | is caused by another person or entity, the    |
| for injuries**       | Health Plan will pay benefits for that injury |
|                      | or illness according to the terms of the      |
|                      | Brochure in effect at the time services are   |
|                      | provided. If the Health Plan pays any         |
|                      | benefits for that injury or illness, when you |
|                      | or your dependent receive money or have a     |
|                      | right to receive money from any source,       |
|                      | including underinsured and uninsured          |
|                      | automobile coverage, as a result of this      |
|                      | injury or illness, your or your dependent     |
|                      | must reimburse the Health Plan up to the      |
|                      | total amount of benefits paid for that injury |
|                      | or illness. The amount owed to the Health     |
|                      | Plan will not be reduced for attorney's fees  |
|                      | or costs nor because you or your dependent    |
|                      | was not fully compensated or \"made whole\"   |
|                      | for the injury or illness, unless the Plan    |
|                      | agrees in writing to a reduction.             |
|                      |                                               |
|                      | If you do not seek damages you must agree to  |
|                      | let the Health Plan try. This includes the    |
|                      | right of the Plan to sue the responsible      |
|                      | person or entity in your or your dependent's  |
|                      | name. This is called subrogation. You must    |
|                      | inform the Plan promptly if your or your      |
|                      | dependent's injury or illness is caused by    |
|                      | another person. If you file a claim for       |
|                      | compensation, you must notify the Plan of the |
|                      | status of all stages of your claim and you    |
|                      | must tell us about any recoveries you obtain, |
|                      | whether in or out of court. The Health Plan   |
|                      | may seek a lien on the proceeds of your claim |
|                      | in order to reimburse the Plan to the full    |
|                      | amount of benefits we have paid or will pay.  |
|                      | You must agree that you will not do anything  |
|                      | that would prevent the Plan from being fully  |
|                      | reimbursed for the benefits it paid and will  |
|                      | cooperate in doing what is reasonably         |
|                      | necessary to assist the Plan in recovering    |
|                      | the benefits it paid because of that injury   |
|                      | or illness first. All money recovered and in  |
|                      | whatever manner it is recovered, and          |
|                      | regardless of how it is designated, must      |
|                      | first be used to reimburse the Plan before it |
|                      | is distributed in any form. If you or your    |
|                      | dependent receives a recovery due to an       |
|                      | injury or illness for which the Plan has paid |
|                      | medical benefits, the Plan may reduce any     |
|                      | subsequent benefit payments to you or any     |
|                      | provider who has provided you or your         |
|                      | dependents with medical care, until the       |
|                      | Health Plan\'s payments are recovered in      |
|                      | total.                                        |
|                      |                                               |
|                      | We may request that you assign to us (1) your |
|                      | right to bring an action or (2) your right to |
|                      | the proceeds of a claim for your injury. We   |
|                      | may delay processing of your claims until you |
|                      | provide the assignment. The Plan's right to   |
|                      | full reimbursement applies even if the Plan   |
|                      | has paid benefits before we know of the       |
|                      | accident or illness, and before we have asked |
|                      | you to sign a reimbursement agreement.        |
|                      |                                               |
|                      | If you need more information, please contact  |
|                      | us.                                           |
+----------------------+-----------------------------------------------+

  -----------------------------------------------------------------------
  Section 11. Definitions of terms we use in this brochure

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

+----------------------+-----------------------------------------------+
| **Accidental         | An injury resulting from a violent external   |
| injury**             | force.                                        |
+----------------------+-----------------------------------------------+
| **Admission**        | The period from entry (admission) into a      |
|                      | hospital or other covered facility until      |
|                      | discharge. In counting days of inpatient      |
|                      | care, the date of entry and the date of       |
|                      | discharge are counted as the same day.        |
+----------------------+-----------------------------------------------+
| **Assignment**       | Your authorization for us to pay benefits     |
|                      | directly to the provider. We reserve the      |
|                      | right to pay you directly for all covered     |
|                      | services.                                     |
+----------------------+-----------------------------------------------+
| **Calendar year**    | January 1 through December 31 of the same     |
|                      | year. For new enrollees, the calendar year    |
|                      | begins on the effective date of their         |
|                      | enrollment and ends on December 31 of the     |
|                      | same year.                                    |
+----------------------+-----------------------------------------------+
| **Coinsurance**      | Coinsurance is the percentage of our          |
|                      | allowance that you must pay for your care.    |
|                      | You may also be responsible for additional    |
|                      | amounts. See page 16.                         |
+----------------------+-----------------------------------------------+
| **Consumer-driven    | A fee-for-service option under the FEHB that  |
| option**             | offers you greater control over choices of    |
|                      | your health care expenditures. You decide     |
|                      | what health care services will be reimbursed  |
|                      | under the health plan funded Personal Care    |
|                      | Account (PCA). Unused funds from the PCA will |
|                      | roll over at the end of the year. If you      |
|                      | spend the entire PCA fund before the end of   |
|                      | the year, then you must satisfy a member      |
|                      | responsibility **before** benefits are        |
|                      | payable under the traditional type of         |
|                      | insurance covered by your Plan. You decide    |
|                      | whether to use in-network or out-of-network   |
|                      | providers to reach the maximum fund allowed   |
|                      | under your PCA.                               |
+----------------------+-----------------------------------------------+
| **Copayment**        | A copayment is a fixed amount of money you    |
|                      | pay when you receive covered services. See    |
|                      | page 16.                                      |
+----------------------+-----------------------------------------------+
| **Covered services** | Services we provide benefits for, as          |
|                      | described in this brochure.                   |
+----------------------+-----------------------------------------------+
| **Custodial care**   | Treatment or services, regardless of who      |
|                      | recommends them or where they are provided,   |
|                      | that could be rendered safely and reasonably  |
|                      | by a person not medically skilled, or that    |
|                      | are designed mainly to help the patient with  |
|                      | daily living activities. These activities     |
|                      | include, but are not limited to:              |
|                      |                                               |
|                      | -   Personal care such as help in: walking;   |
|                      |     getting in and out of bed; bathing;       |
|                      |     eating by spoon, tube or gastrostomy;     |
|                      |     exercising; dressing                      |
|                      |                                               |
|                      | -   Homemaking, such as preparing meals or    |
|                      |     special diets                             |
|                      |                                               |
|                      | -   Moving the patient                        |
|                      |                                               |
|                      | -   Acting as a companion or sitter           |
|                      |                                               |
|                      | -   Supervising medication that can usually   |
|                      |     be self administered; or                  |
|                      |                                               |
|                      | -   Treatment or services that any person may |
|                      |     be able to perform with minimal           |
|                      |     instruction, including but not limited to |
|                      |     recording temperature, pulse, and         |
|                      |     respirations, or administration and       |
|                      |     monitoring of feeding systems             |
|                      |                                               |
|                      | We determine which services are custodial     |
|                      | care. 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. See page 16.     |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| **Experimental or\   | A drug, device, or biological product is      |
| investigational      | experimental or investigational if the drug,  |
| services**           | device, or biological product cannot be       |
|                      | lawfully marketed without approval of the     |
|                      | U.S. Food and Drug Administration (FDA) and   |
|                      | approval for marketing has not been given at  |
|                      | the time it is furnished. Approval means all  |
|                      | forms of acceptance by the FDA.               |
|                      |                                               |
|                      | A medical treatment or procedure, or a drug,  |
|                      | device, or biological product is experimental |
|                      | or investigational if 1) reliable evidence    |
|                      | shows that it is the subject of ongoing phase |
|                      | I, II, or III clinical trials or under study  |
|                      | to determine its maximum tolerated dose, its  |
|                      | toxicity, its safety, its efficacy, or its    |
|                      | efficacy as compared with the standard means  |
|                      | of treatment or diagnosis; or 2) reliable     |
|                      | evidence shows that the consensus of opinion  |
|                      | among experts regarding the drug, device, or  |
|                      | biological product or medical treatment or    |
|                      | procedure is that further studies or clinical |
|                      | trials are necessary to determine its maximum |
|                      | tolerated dose, its toxicity, its safety, its |
|                      | efficacy, or its efficacy as compared with    |
|                      | the standard means of treatment or diagnosis. |
|                      |                                               |
|                      | Reliable evidence shall mean only published   |
|                      | reports and articles in the authoritative     |
|                      | medical and scientific literature; the        |
|                      | written protocol or protocols used by the     |
|                      | treating facility or the protocol(s) of       |
|                      | another facility studying substantially the   |
|                      | same drug, device, or medical treatment or    |
|                      | procedure; or the written informed consent    |
|                      | used by the treating facility or by another   |
|                      | facility studying substantially the same      |
|                      | drug, device, or medical treatment or         |
|                      | procedure.                                    |
|                      |                                               |
|                      | Determination of experimental/investigational |
|                      | status may require review by a specialty      |
|                      | appropriate board-certified health care       |
|                      | provider or appropriate government            |
|                      | publications such as those of the National    |
|                      | Institute of Health, National Cancer          |
|                      | Institute, Food and Drug Administration,      |
|                      | Agency of Health Care Policy & Research, and  |
|                      | the National Library of Medicine.             |
+----------------------+-----------------------------------------------+
| **Group health       | Health care coverage that a member is         |
| coverage**           | eligible for because of employment by,        |
|                      | membership in, or connection with, a          |
|                      | particular organization or group that         |
|                      | provides payment for hospital, medical, or    |
|                      | other health care services or supplies, or    |
|                      | that pays a specific amount for each day or   |
|                      | period of hospitalization if that specified   |
|                      | amount exceeds \$200 per day, including       |
|                      | extension of any of these benefits through    |
|                      | COBRA.                                        |
+----------------------+-----------------------------------------------+
| **Home health care   | An agency which meets all of the following:   |
| agency**             |                                               |
|                      | -   Is primarily engaged in providing, and is |
|                      |     duly licensed or certified to provide,    |
|                      |     skilled nursing care and therapeutic      |
|                      |     services                                  |
|                      |                                               |
|                      | -   Has policies established by a             |
|                      |     professional group associated with the    |
|                      |     agency or organization. This professional |
|                      |     group must include at least one           |
|                      |     registered nurse (R.N.) to direct the     |
|                      |     services provided and it must provide for |
|                      |     full-time supervision of each service by  |
|                      |     a physician or registered nurse           |
|                      |                                               |
|                      | -   Maintains a complete medical record on    |
|                      |     each individual; and                      |
|                      |                                               |
|                      | -   Has a full-time administrator             |
+----------------------+-----------------------------------------------+
| **Hospice care       | A coordinated program of home and inpatient   |
| program**            | palliative and supportive care for the        |
|                      | terminally ill patient and the patient\'s     |
|                      | family provided by a medically supervised     |
|                      | specialized team under the direction of a     |
|                      | duly licensed or certified Hospice Care       |
|                      | Program.                                      |
+----------------------+-----------------------------------------------+
| **Maintenance        | Includes but is not limited to physical,      |
| therapy**            | occupational, or speech therapy where         |
|                      | continued therapy is not expected to result   |
|                      | in significant restoration of a bodily        |
|                      | function but is utilized to maintain the      |
|                      | current status.                               |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| **Medically          | Services, drugs, supplies or equipment        |
| necessary**          | provided by a hospital or covered provider of |
|                      | health care services that we determine:       |
|                      |                                               |
|                      | -   Are appropriate to diagnose or treat the  |
|                      |     patient\'s condition, illness or injury   |
|                      |                                               |
|                      | -   Are consistent with standards of good     |
|                      |     medical practice in the United States     |
|                      |                                               |
|                      | -   Are not primarily for the personal        |
|                      |     comfort or convenience of the patient,    |
|                      |     the family, or the provider               |
|                      |                                               |
|                      | -   Are not a part of or associated with the  |
|                      |     scholastic education or vocational        |
|                      |     training of the patient; and              |
|                      |                                               |
|                      | -   In the case of inpatient care, cannot be  |
|                      |     provided safely on an outpatient basis    |
|                      |                                               |
|                      | The fact that a covered provider has          |
|                      | prescribed, recommended, or approved a        |
|                      | service, supply, drug or equipment does not,  |
|                      | in itself, make it medically necessary.       |
+----------------------+-----------------------------------------------+
| **Member             | Under the Consumer-driven Option, your Member |
| Responsibility**     | Responsibility is the amount you must pay, if |
|                      | you have exhausted your Personal Care         |
|                      | Account, before your Traditional Health       |
|                      | Coverage begins. See page 17.                 |
+----------------------+-----------------------------------------------+
| **Personal Care      | Under the Consumer-driven Option, your        |
| Account**            | Personal Care Account (PCA) is an established |
|                      | benefit amount which is available for you to  |
|                      | use first to pay for covered hospital,        |
|                      | medical, dental and vision care expenses. You |
|                      | determine how your PCA will be spent and any  |
|                      | unused amount at the end of the year may be   |
|                      | rolled over to increase your available PCA in |
|                      | the subsequent year(s).                       |
+----------------------+-----------------------------------------------+
| **Plan allowance**   | Our Plan allowance is the amount we use to    |
|                      | determine our payment and your coinsurance    |
|                      | for covered services. Fee-for-service plans   |
|                      | determine their allowances in different ways. |
|                      | We determine our allowance as follows:        |
|                      |                                               |
|                      | For PPO providers, our allowance is based on  |
|                      | negotiated rates. PPO providers always accept |
|                      | the Plan's allowance as their charge for      |
|                      | covered services.                             |
|                      |                                               |
|                      | For non-PPO providers, we base the Plan       |
|                      | allowance on the lesser of the provider's     |
|                      | actual charge or the reasonable and customary |
|                      | charge for the service you received. We       |
|                      | determine the reasonable and customary        |
|                      | allowance by using health care charges guides |
|                      | which compare charges of other providers for  |
|                      | similar services in the same geographical     |
|                      | area. For surgery, doctor's services, X-ray,  |
|                      | lab and therapies (physical, speech and       |
|                      | occupational), we use guides prepared by the  |
|                      | Health Insurance Association of America       |
|                      | (HIAA) and apply these guides under the High  |
|                      | Option at the 70^th^ percentile and under the |
|                      | Consumer-driven Option at the 80^th^          |
|                      | percentile. We update these charges guides at |
|                      | least once each year. If HIAA information is  |
|                      | not available, we will use other credible     |
|                      | sources including our own data.               |
|                      |                                               |
|                      | For more information, see *Differences        |
|                      | between our allowance and the bill* in\       |
|                      | Section 4.                                    |
+----------------------+-----------------------------------------------+
| **Rollover**         | Any unused, remaining balance in your PCA at  |
|                      | the end of the calendar year may be rolled    |
|                      | over to subsequent years up to a maximumPCA   |
|                      | account of \$4,000 per Self Only enrollment   |
|                      | or \$6,000 per Self and Family enrollment,    |
|                      | thereby increasing your PCA in the following  |
|                      | year(s). You must use any available PCA       |
|                      | benefits, including any amounts rolled over   |
|                      | from previous years, before Traditional       |
|                      | Health Coverage begins.                       |
+----------------------+-----------------------------------------------+
| **Rehabilitative     | Treatment that reasonably can be expected to  |
| care**               | restore and/or substantially restore a bodily |
|                      | function that was impaired as a result of     |
|                      | trauma or disease.                            |
+----------------------+-----------------------------------------------+
| **Us/We**            | Us and we refer to APWU Health Plan.          |
+----------------------+-----------------------------------------------+
| **You**              | You refers to the enrollee and each covered   |
|                      | family member.                                |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| Section 12. FEHB     |                                               |
| facts                |                                               |
+----------------------+-----------------------------------------------+
| **Coverage           |                                               |
| information**        |                                               |
+----------------------+-----------------------------------------------+
| **No pre-existing    | We will not refuse to cover the treatment of  |
| condition            | a condition that you had before you enrolled  |
| limitation**         | in this Plan solely because you had the       |
|                      | condition before you enrolled.                |
+----------------------+-----------------------------------------------+
| **Where you can get  | See                                           |
| information about    | [www.opm.gov/ins                              |
| enrolling in the\    | ure/health](http://www.opm.gov/insure/health) |
| FEHB Program**       | for enrollment as well as:                    |
|                      |                                               |
|                      | -   Information on the FEHB Program and plans |
|                      |     available to you                          |
|                      |                                               |
|                      | -   A health plan comparison tool             |
|                      |                                               |
|                      | -   A list of agencies who participate in     |
|                      |     Employee Express                          |
|                      |                                               |
|                      | -   A link to Employee Express                |
|                      |                                               |
|                      | -   Information on and links to other         |
|                      |     electronic enrollment systems             |
|                      |                                               |
|                      | Also, your employing or retirement office can |
|                      | answer your questions, and give you *a Guide  |
|                      | to Federal Employees Health Benefits Plans,*  |
|                      | brochures for other plans, and other          |
|                      | materials you need to make an informed        |
|                      | decision about your FEHB coverage. These      |
|                      | materials tell you:                           |
|                      |                                               |
|                      | -   When you may change your enrollment       |
|                      |                                               |
|                      | -   How you can cover your family members     |
|                      |                                               |
|                      | -   What happens when you transfer to another |
|                      |     Federal agency, go on leave without pay,  |
|                      |     enter military service, or retire         |
|                      |                                               |
|                      | -   When your enrollment ends; and            |
|                      |                                               |
|                      | -   When the next Open Season for enrollment  |
|                      |     begins                                    |
|                      |                                               |
|                      | We don't determine who is eligible for        |
|                      | coverage and, in most cases, cannot change    |
|                      | your enrollment status without information    |
|                      | from your employing or retirement office.     |
+----------------------+-----------------------------------------------+
| **Types of coverage  | Self Only coverage is for you alone. Self and |
| available\           | Family coverage is for you, your spouse, and  |
| for you and your     | your unmarried dependent children under age   |
| family**             | 22, including any foster children or          |
|                      | stepchildren your employing or retirement     |
|                      | office authorizes coverage for. Under certain |
|                      | circumstances, you may also continue coverage |
|                      | for a disabled child 22 years of age or older |
|                      | who is incapable of self-support.             |
|                      |                                               |
|                      | If you have a Self Only enrollment, you may   |
|                      | change to a Self and Family enrollment if you |
|                      | marry, give birth, or add a child to your     |
|                      | family. You may change your enrollment 31     |
|                      | days before to 60 days after that event. The  |
|                      | Self and Family enrollment begins on the      |
|                      | first day of the pay period in which the      |
|                      | child is born or becomes an eligible family   |
|                      | member. When you change to Self and Family    |
|                      | because you marry, the change is effective on |
|                      | the first day of the pay period that begins   |
|                      | after your employing office receives your     |
|                      | enrollment form; benefits will not be         |
|                      | available to your spouse until you marry.     |
|                      |                                               |
|                      | Your employing or retirement office will      |
|                      | **not** notify you when a family member is no |
|                      | longer eligible to receive health benefits,   |
|                      | nor will we. Please tell us immediately when  |
|                      | you add or remove family members from your    |
|                      | coverage for any reason, including divorce,   |
|                      | or when your child under age 22 marries or    |
|                      | turns 22.                                     |
|                      |                                               |
|                      | If you or one of your family members is       |
|                      | enrolled in one FEHB plan, that person may    |
|                      | not be enrolled in or covered as a family     |
|                      | member by another FEHB plan.                  |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| **Children's Equity  | OPM has implemented the Federal Employees     |
| Act**                | Health Benefits Children's Equity Act of      |
|                      | 2000. This law mandates that you be enrolled  |
|                      | for Self and Family coverage in the FEHB      |
|                      | Program, if you are an employee subject to a  |
|                      | court or administrative order requiring you   |
|                      | to provide health benefits for your           |
|                      | child(ren).                                   |
|                      |                                               |
|                      | If this law applies to you, you must enroll   |
|                      | for Self and Family coverage in a health plan |
|                      | that provides full benefits in the area where |
|                      | your children live or provide documentation   |
|                      | to your employing office that you have        |
|                      | obtained other health benefits coverage for   |
|                      | your children. If you do not do so, your      |
|                      | employing office will enroll you              |
|                      | involuntarily as follows:                     |
|                      |                                               |
|                      | -   If you have no FEHB coverage, your        |
|                      |     employing office will enroll you for Self |
|                      |     and Family coverage in the Blue Cross and |
|                      |     Blue Shield Service Benefit Plan's Basic  |
|                      |     Option;                                   |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   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 cannotcancel     |
|                      | your coverage, change to Self Only, or change |
|                      | to a plan that doesn\'t serve the area in     |
|                      | which your children live as long as the       |
|                      | court/administrative order is in effect.      |
|                      | Contact your employing office for further     |
|                      | information.                                  |
+----------------------+-----------------------------------------------+
| **When benefits and\ | The benefits in this brochure are effective   |
| premiums start**     | on January 1. If you joined this Plan during  |
|                      | Open Season, your coverage begins on the      |
|                      | first day of your first pay period that       |
|                      | starts on or after January 1. If you changed  |
|                      | plans or plan options during Open Season and  |
|                      | you receive care between January 1 and the    |
|                      | effective date of coverage under your new     |
|                      | plan or option, your claims will be paid      |
|                      | according to the 2004 benefits of your old    |
|                      | plan or option except when you are enrolled   |
|                      | under this Plan\'s Consumer-driven Option.    |
|                      | Under this Plan\'s Consumer-driven Option,    |
|                      | between January 1 and the effective date of   |
|                      | your new plan (or change to High Option of    |
|                      | this Plan) you will **not** receive a new     |
|                      | Personal Care Account (PCA) for 2004 but any  |
|                      | unused PCA benefits from 2003 will be         |
|                      | available to you. 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.                   |
|                      |                                               |
|                      | Under the Consumer-driven Option, if you      |
|                      | joined this Plan during Open Season, you      |
|                      | receive the full Personal Care Account (PCA)  |
|                      | as of your effective date of coverage. If you |
|                      | joined at any other time during the year,     |
|                      | your PCA and your Member Responsibility for   |
|                      | your first year will be prorated for each     |
|                      | full month of coverage remaining in that      |
|                      | calendar year.                                |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| **When you retire**  | When you retire, you can usually stay in the  |
|                      | FEHB Program. Generally, you must have been   |
|                      | enrolled in the FEHB Program for the last     |
|                      | five years of your Federal service. If you do |
|                      | not meet this requirement, you may be         |
|                      | eligible for other forms of coverage, such as |
|                      | Temporary Continuation of Coverage (TCC).     |
+----------------------+-----------------------------------------------+
| **When you lose      |                                               |
| benefits**           |                                               |
+----------------------+-----------------------------------------------+
| -   **When FEHB\     | You will receive an additional 31 days of     |
|     coverage ends**  | coverage, for no additional premium, when:    |
|                      |                                               |
|                      | -   Your enrollment ends, unless you cancel   |
|                      |     your enrollment, or                       |
|                      |                                               |
|                      | -   You are a family member no longer         |
|                      |     eligible for coverage.                    |
|                      |                                               |
|                      | You may be eligible for spouse equity         |
|                      | coverage or Temporary Continuation of         |
|                      | Coverage (TCC), or a conversion policy (a     |
|                      | non-FEHB individual policy).                  |
+----------------------+-----------------------------------------------+
| -   **Spouse equity  | If you are divorced from a Federal employee   |
|     coverage**       | 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       |
|                      | provide health coverage to you. But, you may  |
|                      | be eligible for your own FEHB coverage under  |
|                      | the spouse equity law or Temporary            |
|                      | Continuation of Coverage (TCC). If you are    |
|                      | recently divorced or are anticipating a       |
|                      | divorce, contact your ex-spouse's employing   |
|                      | or retirement office to get RI 70-5, the      |
|                      | *Guide to Federal Employees Health Benefits   |
|                      | Plans for Temporary Continuation of Coverage  |
|                      | and Former Spouse Enrollees*, or other        |
|                      | information about your coverage choices. You  |
|                      | can also download the guide from OPM's Web    |
|                      | site, [www.opm.gov/insure]{.underline}.       |
+----------------------+-----------------------------------------------+
| -   **Temporary      | If you leave Federal service, or if you lose  |
|     Continuation of  | coverage because you no longer qualify as a   |
|     Coverage (TCC)** | family member, you may be eligible for        |
|                      | Temporary Continuation of Coverage (TCC). For |
|                      | example, you can receive TCC if you are not   |
|                      | able to continue your FEHB enrollment after   |
|                      | you retire, if you lose your Federal job, if  |
|                      | you are a covered dependent child and you     |
|                      | turn 22 or marry, etc.                        |
|                      |                                               |
|                      | You may not elect TCC if you are fired from   |
|                      | your Federal job due to gross misconduct.     |
|                      |                                               |
|                      | **Enrolling in TCC.** Get the RI 79-27, which |
|                      | describes TCC, and the RI 70-5, the *Guide to |
|                      | Federal Employees Health Benefits Plans for   |
|                      | Temporary Continuation of Coverage and Former |
|                      | Spouse Enrollees*, from your employing or     |
|                      | retirement office or from                     |
|                      | [ww                                           |
|                      | w.opm.gov/insure](http://www.opm.gov/insure). |
|                      | It explains what you have to do to enroll.    |
+----------------------+-----------------------------------------------+
| -   **Converting to  | You may convert to a non-FEHB individual      |
|     individual       | policy if:                                    |
|     coverage**       |                                               |
|                      | -   Your coverage under TCC or the spouse     |
|                      |     equity law ends (If you canceled your     |
|                      |     coverage or did not pay your premium, you |
|                      |     cannot convert);                          |
|                      |                                               |
|                      | -   You decided not to receive coverage under |
|                      |     TCC or the spouse equity law; or          |
|                      |                                               |
|                      | -   You are not eligible for coverage under   |
|                      |     TCC or the spouse equity law.             |
|                      |                                               |
|                      | If you leave Federal service, your employing  |
|                      | office will notify you of your right to       |
|                      | convert. You must apply in writing to us      |
|                      | within 31 days after you receive this notice. |
|                      | However, if you are a family member who is    |
|                      | losing coverage, the employing or retirement  |
|                      | office will **not** notify you. You must      |
|                      | apply in writing to us within 31 days after   |
|                      | you are no longer eligible for coverage.      |
|                      |                                               |
|                      | Your benefits and rates will differ from      |
|                      | those under the FEHB Program; however, you    |
|                      | will not have to answer questions about your  |
|                      | health, and we will not impose a waiting      |
|                      | period or limit your coverage due to          |
|                      | pre-existing conditions.                      |
+----------------------+-----------------------------------------------+
| -   **Getting a      | The Health Insurance Portability and          |
|     Certificate of\  | Accountability Act of 1996 (HIPAA) is a       |
|     Group Health     | Federal law that offers limited Federal       |
|     Plan Coverage**  | protections for health coverage availability  |
|                      | and continuity to people who lose employer    |
|                      | group coverage. If you leave the FEHB         |
|                      | Program, we will give you a Certificate of    |
|                      | Group Health Plan Coverage that indicates how |
|                      | long you have been enrolled with us. You can  |
|                      | use this certificate when getting health      |
|                      | insurance or other health care coverage. Your |
|                      | new plan must reduce or eliminate waiting     |
|                      | periods, limitations, or exclusions for       |
|                      | health related conditions based on the        |
|                      | information in the certificate, as long as    |
|                      | you enroll within 63 days of losing coverage  |
|                      | under this Plan. If you have been enrolled    |
|                      | with us for less than 12 months, but were     |
|                      | previously enrolled in other FEHB plans, you  |
|                      | may also request a certificate from those     |
|                      | plans.                                        |
|                      |                                               |
|                      | For more information, get OPM pamphlet RI     |
|                      | 79-27, Temporary Continuation of Coverage     |
|                      | (TCC) under the FEHB Program. See also the    |
|                      | FEHB Web site                                 |
|                      | ([www.opm.gov/insur                           |
|                      | e/health](http://www.opm.gov/insure/health)); |
|                      | refer to the "TCC and HIPAA" frequently asked |
|                      | questions. These highlight HIPAA rules, such  |
|                      | as the requirement that Federal employees     |
|                      | must exhaust any TCC eligibility as one       |
|                      | condition for guaranteed access to individual |
|                      | health coverage under HIPAA, and have         |
|                      | information about Federal and State agencies  |
|                      | you can contact for more information.         |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| Two new Federal      |                                               |
| Programs complement  |                                               |
| FEHB benefits        |                                               |
+----------------------+-----------------------------------------------+
| ###### **Imp         | OPM wants to be sure you know about two new   |
| ortant Information** | 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     | It is a tax-favored benefit that allows you   |
|     FSA?**           | 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:                              |
+----------------------+-----------------------------------------------+
| **Health Care        | -   Covers eligible health care expenses not  |
| Flexible\            |     reimbursed by this Plan, or any other     |
| Spending Account\    |     medical, dental, or vision care plan you  |
| (HCFSA)**            |     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.         |
+----------------------+-----------------------------------------------+
| **Dependent Care     | -   Covers eligible dependent care expenses   |
| Flexible Spending    |     incurred so you can work, or if you are   |
| Account (DCFSA)**    |     married, so you and your spouse can work, |
|                      |     or your spouse can look for work or       |
|                      |     attend school full-time.                  |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Eligible dependents for this account      |
|                      |     include anyone you claim on your Federal  |
|                      |     income tax return as a qualified IRS      |
|                      |     dependent and/or with whom you jointly    |
|                      |     file your Federal income tax return.      |
|                      |                                               |
|                      | -   The maximum that can be allotted for the  |
|                      |     DCFSA is \$5,000 annually. The minimum    |
|                      |     amount is \$250 annually. ***Note:*** The |
|                      |     IRS limits contributions to a Dependent   |
|                      |     Care FSA. For single taxpayers and        |
|                      |     taxpayers filing a joint return, the      |
|                      |     maximum is \$5,000 per year. For          |
|                      |     taxpayers who file their taxes separately |
|                      |     with a spouse, the maximum is \$2,500 per |
|                      |     year. The limit includes any child care   |
|                      |     subsidy you may receive.                  |
+----------------------+-----------------------------------------------+
| -   **Enroll during  | You **must make an election** to enroll in an |
|     Open Season**    | 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 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 | If you are a Federal employee eligible for    |
| enroll?**            | 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       | Plan carefully when deciding how much to      |
|     should I         | contribute to an FSA. Because of the tax      |
|     contribute to my | benefits of an FSA, the IRS places strict     |
|     FSA?**           | 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    | Every FEHB health plan includes cost sharing  |
|     HCFSA pay for?** | features, such as deductibles you must meet   |
|                      | before the Plan provides benefits,            |
|                      | coinsurance or copayments that you pay when   |
|                      | you and the Plan share costs, and medical     |
|                      | services and supplies that are not covered by |
|                      | the Plan and for which you must pay. These    |
|                      | out-of-pocket costs are summarized on pages   |
|                      | 16 and 17 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 the High Option of this Plan, typical   |
|                      | out-of-pocket expenses include:               |
|                      |                                               |
|                      | -   Deductibles, copayments and coinsurance   |
|                      |     for doctors visits, prescription drugs    |
|                      |     and diagnostic tests                      |
|                      |                                               |
|                      | -   Non-covered services such as vision care, |
|                      |     many dental services or therapy visits in |
|                      |     excess of Plan maximums                   |
|                      |                                               |
|                      | Under the Consumer-driven Option of this      |
|                      | Plan, typical out-of-pocket expenses include: |
|                      |                                               |
|                      | -   Your Member Responsibility and            |
|                      |     coinsurance for doctors services and      |
|                      |     prescription drugs                        |
|                      |                                               |
|                      | -   Non-covered services such as              |
|                      |     vision/dental services in excess of your  |
|                      |     PCA maximum and treatment therapy and     |
|                      |     chiropractic visits in excess of Plan     |
|                      |     maximums                                  |
|                      |                                               |
|                      | The IRS governs expenses reimbursable by a    |
|                      | HCFSA. See Publication 502 for a              |
|                      | comprehensive list of tax-deductible medical  |
|                      | expenses.  **Note: While you will see         |
|                      | insurance premiums listed in Publication 502, |
|                      | they are NOT a reimbursable expense for FSA   |
|                      | purposes**.  Publication 502 can be found on  |
|                      | the IRS Web site at                           |
|                      | <http://www.irs.gov/pub/irs-pdf/p502.pdf>.    |
|                      | If you do not see your service or expense     |
|                      | listed in Publication 502, please call a      |
|                      | FSAFEDS Benefit Counselor at 877/FSAFEDS      |
|                      | (372-3337), who will be able to answer your   |
|                      | specific questions.                           |
+----------------------+-----------------------------------------------+

+----------------------+----------------------------+-------+---------+
| -   **Tax savings    | An FSA lets you allot      |       |         |
|     with an FSA**    | 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  | Without |
|                      |                            | FSA   | FSA     |
+----------------------+----------------------------+-------+---------+
|                      | If your taxable income is: | \$5   | \       |
|                      |                            | 0,000 | $50,000 |
+----------------------+----------------------------+-------+---------+
|                      | And you deposit this       | \$    | -\$0-   |
|                      | amount into a FSA:         | 2,000 |         |
+----------------------+----------------------------+-------+---------+
|                      | Your taxable income is now | \$4   | \       |
|                      |                            | 8,000 | $50,000 |
+----------------------+----------------------------+-------+---------+
|                      | Subtract Federal & Social  | \$1   | \       |
|                      | Security taxes:            | 3,807 | $14,383 |
+----------------------+----------------------------+-------+---------+
|                      | If you spend after-tax     | -\$0- | \$      |
|                      | dollars for expenses:      |       | 2.000   |
+----------------------+----------------------------+-------+---------+
|                      | Your real spendable income | \$3   | \       |
|                      | is:                        | 4,193 | $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    | You *cannot* claim         |       |         |
|     and deductions** | expenses on your Federal   |       |         |
|                      | income tax return if you   |       |         |
|                      | receive reimbursement for  |       |         |
|                      | them from your HCFSA or    |       |         |
|                      | DCFSA. Below are some      |       |         |
|                      | guidelines that may help   |       |         |
|                      | you decide whether to      |       |         |
|                      | participate in FSAFEDS.    |       |         |
+----------------------+----------------------------+-------+---------+
| **Health care        | The HCFSA is tax-free from |       |         |
| expenses**           | 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     | The DCFSA generally allows |       |         |
| expenses**           | many families to save more |       |         |
|                      | than they would with the   |       |         |
|                      |                            |       |         |
|                      | Federal tax credit for     |       |         |
|                      | dependent care expenses.   |       |         |
|                      | Note that you may only be  |       |         |
|                      | reimbursed from the DCFSA  |       |         |
|                      | up to your current account |       |         |
|                      | balance. If you file a     |       |         |
|                      | claim for more than your   |       |         |
|                      | current balance, it will   |       |         |
|                      | be held until additional   |       |         |
|                      | payroll allotments have    |       |         |
|                      | been added to your         |       |         |
|                      | account.                   |       |         |
|                      |                            |       |         |
|                      | Visit                      |       |         |
|                      | [www.fsafeds.com           |       |         |
|                      | ](http://www.fsafeds.com/) |       |         |
|                      | and download the Dependent |       |         |
|                      | Care Tax Credit Worksheet  |       |         |
|                      | 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   | Probably not. While there  |       |         |
|     me anything to   | is an administrative fee   |       |         |
|     participate in   | of \$4.00 per month for an |       |         |
|     FSAFEDS?**       | HCFSA and 1.5% of the      |       |         |
|                      | annual election for a      |       |         |
|                      | DCFSA, most agencies have  |       |         |
|                      | elected to pay these fees  |       |         |
|                      | out of their share of      |       |         |
|                      | employment tax savings. To |       |         |
|                      | be sure, check the         |       |         |
|                      | FSAFEDS.com Web site or    |       |         |
|                      | call 877/FSAFEDS           |       |         |
|                      | (372-3337). Also, remember |       |         |
|                      | that participating in      |       |         |
|                      | FSAFEDS can cost you money |       |         |
|                      | if don't spend your entire |       |         |
|                      | account balance by the end |       |         |
|                      | of the plan year and wind  |       |         |
|                      | up forfeiting your end of  |       |         |
|                      | year account balance, per  |       |         |
|                      | the IRS                    |       |         |
|                      | "use-it-or-lose-it" rule.  |       |         |
+----------------------+----------------------------+-------+---------+
| -   **Contact us**   | To find out more or to     |       |         |
|                      | enroll, please visit the   |       |         |
|                      | **FSAFEDS Web site** at    |       |         |
|                      | [**www.fsafeds.com**]      |       |         |
|                      | (http://www.fsafeds.com/), |       |         |
|                      | or contact SHPS by email   |       |         |
|                      | or by phone**.** SHPS      |       |         |
|                      | Benefit Counselors are     |       |         |
|                      | available from 9:00 a.m.   |       |         |
|                      | until 9:00 p.m. eastern    |       |         |
|                      | time, Monday through       |       |         |
|                      | Friday.                    |       |         |
|                      |                            |       |         |
|                      | -   E-mail:                |       |         |
|                      |     <fsafeds@shps.net>     |       |         |
|                      |                            |       |         |
|                      | -   Telephone: 877/FSAFEDS |       |         |
|                      |     (372-3337)             |       |         |
|                      |                            |       |         |
|                      | -   TTY: 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    | Here's why you should      |       |         |
| protection**         | 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   | Call 800/LTC-FEDS          |       |         |
| and to request an    | (800/582-3337) (TTY        |       |         |
| application**        | 800/843-3557)              |       |         |
|                      |                            |       |         |
|                      | or visit                   |       |         |
|                      | [www.ltcfeds.com]          |       |         |
|                      | (http://www.ltcfeds.com/). |       |         |
+----------------------+----------------------------+-------+---------+

+-----------------------------------------------------------------------+
| **Index**                                                             |
+-----------------------------------------------------------------------+
| Do not rely on this page; it is for your convenience and may not show |
| all pages where the terms appear.                                     |
|                                                                       |
| > *CDO* -- **Consumer-driven Option** HO -- **High Option**           |
+-----------------------------------------------------------------------+

**Accidental injury**

*CDO* 70

HO 39, 47

**Acupuncture**

*CDO* 63

HO 30

**Allergy**

*CDO* 58

HO 26

**Alternative treatments**

*CDO* 63

HO 30

**Ambulance**

*CDO* 69-70

HO 38, 40

**Anesthesia**

*CDO* 67-69

HO 35, 37-38

**Biopsies**

*CDO* 63, 65

HO 31, 33

**Blood and blood plasma**

*CDO* 68-69

HO 37-38

**Breast reconstruction**

*CDO* 60, 64

HO 28, 32

**Casts**

*CDO* 68-69

HO 37-38

**Catastrophic protection** 18-19

**CHAMPVA** 83

**Changes for 2004** 10

**Chemotherapy/Radiation**

*CDO* 58, 69

HO 26, 38

**Chiropractic** 11

*CDO* 62

HO 30

**Cholesterol tests**

*CDO* 50

HO 24

**Coinsurance** 16-20, 81

**Colorectal cancer screening**

*CDO* 50

HO 24

**Congenital anomalies**

*CDO* 63-64

HO 31-32

**Consumer-driven Option** 49-74, 85, 100-101

**Contraceptive devices and drugs**

*CDO* 57, 63, 73

HO 25, 32, 44

**Coordination of benefits** 80-81

**Copayment** 16, 20, 83, 85

HO 23, 28, 30, 40, 81

**Covered providers** 11

**Deductible** 16, 18, 83, 85

*CDO* 50, 52, 54

HO 81

**Definitions** 85-87

**Dental** 48

*CDO* 53, 65-66

HO 33-34, 47

**Diabetic supplies**

*CDO* 53, 73

HO 43-44

**Diagnostic services**

*CDO* 56, 69

HO 23-24, 38

**Dialysis**

*CDO* 58

HO 26

**Disease Management Program**

HO 46

**Disputed claims review** 78-79

**Durable Medical Equipment**

**(DME)** 15, 76

*CDO* 61

HO 29

**Educational classes and programs**

*CDO* 63

HO 30

**Effective date of enrollment** 89

**Emergency** 13, 21

*CDO* 70

HO 39-40

**Experimental or**

**investigational** 75, 86

**Eyeglasses**

*CDO* 53, 59

HO 27, 46

**Family planning**

*CDO* 57

HO 25

**Fecal occult blood test**

*CDO* 50

HO 24

**Flexible benefits option**

HO 46

**Foot care**

*CDO* 60

HO 28

**General exclusions** 75

**Hearing services**

*CDO* 59

HO 27, 46

**High Option** 22-47, 99, 101

**Home health services** 15, 86

*CDO* 62

HO 30

**Hospice** 18, 86

*CDO* 69

HO 38

**Hospital** 11-15, 20-21

**Inpatient**

*CDO* 53, 67-68

HO 36-37

**Outpatient**

*CDO* 69

HO 38

**Immunizations**

**Adult**

*CDO* 50

HO 24

**Children**

*CDO* 51

HO 25

**Infertility**

*CDO* 57

HO 26

**Insulin**

*CDO* 73

HO 44

**Magnetic Reasonance Imagings (MRIs)**

*CDO* 56

HO 24

**Mail order prescription drugs**

*CDO* 73

HO 43-45

**Mammograms**

*CDO* 50, 56

HO 24

**Maternity** 13

*CDO* 56-57

HO 25

**Medicaid** 84

**Medical emergency**

*CDO* 70

HO 39-40

**Medically necessary** 87

**Medically underserved areas** 11

*CDO* 63

HO 30

**Medicare** 14, 20-21, 80-83

*CDO* 73

HO 44

**Member responsibility**

*CDO* 54-55, 87, 89

**Mental health**

*CDO* 71-72

HO 41-42

**Newborn care** 13

*CDO* 56-57

HO 23, 25

**Nurse** 11, 15, 86

*CDO* 62, 68

HO 30, 37

**Nurse help line**

*CDO* 74

HO 46

**Office visits**

*CDO* 50-51, 56

HO 23

**Organic impotence** 15, 75

*CDO* 65, 73

HO 31, 33, 44

**Orthopedic devices** 15

*CDO* 60

HO 28

**Osteoporosis screening**

*CDO* 50

HO 24

**Out-of-pocket expenses** 18-19

**Overseas claims** 77

**Oxygen** 15

*CDO* 61, 68, 69

HO 29, 37, 38

**Pap test**

*CDO* 50, 56

HO 24

**Personal Care Account (PCA)**

*CDO* 52-53, 87

**Physical examination**

**Adult**

*CDO* 50

**Children**

*CDO* 51

HO 25

**Physician**

*CDO* 56-67

HO 23-35

**Positron Emission Tomography (PET)**

*CDO* 56

HO 24

**Precertification** 13-15

*CDO* 54, 72

HO 24, 36, 42, 71

**Preferred Provider Organizations (PPO)** 8

**Prescription drugs** 75, 76

*CDO* 19, 53, 73

HO 18, 37, 43-45

**Preventive care**

**Adult**

*CDO* 50, 53

HO 24

**Children**

*CDO* 51, 53

*HO* 25

**Prior approval** 15, 35, 66, 78, 79

**Privacy Practices** see notice

**Prostate Cancer Screening (PSA)**

*CDO* 50

HO 24

**Prosthetic devices**

*CDO* 60, 63-64

HO 28, 32-33

**Psychologist** 11

**Rate Information** 101

**Review and reward program**

HO 46

**Rollover**

*CDO* 53, 87

**Room and board**

*CDO* 67-68

HO 36-37

**Second surgical opinion**

*CDO* 56

HO 23

**Sigmoidoscopy**

*CDO* 50

HO 24

**Skilled nursing facility** 12

*CDO* 56, 68, 69

HO 23, 37, 38

**Smoking cessation**

*CDO* 63, 73

HO 30, 44

**Subrogation** 84

**Substance abuse** 15, 18

*CDO* 71-72

HO 41-42

**Surgery** 31-35, 63-67

**Assistant surgeon**

*CDO* 63

HO 32

**Cosmetic**

*CDO* 64, 65

HO 32, 33

**Multiple procedures**

*CDO* 64

HO 32

**Oral**

*CDO* 65-66

HO 33-34

**Reconstructive**

*CDO* 64-65

HO 32-33

**Temporary Continuation of Coverage (TCC)** 90

**Therapy (Occupational, Physical, & Speech)** 11

*CDO* 58-59

HO 27

**Transplants**

*CDO* 66-67

HO 34-35

**Treatment therapies**

*CDO* 58

HO 26

**TRICARE** 83

**Vision services**

*CDO* 53, 59

HO 27, 46

**Wellness**

HO 46

**Wheelchairs**

*CDO* 61

HO 29

**Workers\' compensation** 83

**X-rays**

*CDO* 56, 68-69

HO 24, 37-38

  -----------------------------------------------------------------------
  Notes

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

  -----------------------------------------------------------------------
  **Summary of benefits for the APWU Health Plan*\
  *High Option - 2004**

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

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

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

Below, an asterisk (\*) means the item is subject to the calendar year
deductible, \$275 (PPO) or \$500 (Non-PPO). And, after we pay, you
generally pay any difference between our allowance and the billed amount
if you use a Non-PPO physician or other health care professional.

+-------------------------------------+----------------------------+---+
| **Benefits**                        | **You Pay**                | * |
|                                     |                            | * |
|                                     |                            | P |
|                                     |                            | a |
|                                     |                            | g |
|                                     |                            | e |
|                                     |                            | * |
|                                     |                            | * |
+-------------------------------------+----------------------------+---+
| Medical services provided by        |                            |   |
| physicians:                         |                            |   |
+-------------------------------------+----------------------------+---+
| Diagnostic and treatment services   | PPO: \$18 copay per visit  | > |
| provided in the office\*            | (No deductible); 10% of    |   |
|                                     | Plan allowance             | 2 |
|                                     |                            | 3 |
|                                     | Non-PPO: 30% of our        |   |
|                                     | allowance plus amount over |   |
|                                     | our allowance              |   |
+-------------------------------------+----------------------------+---+
| > Services provided by a hospital:  |                            |   |
+-------------------------------------+----------------------------+---+
| Inpatient                           | PPO: 10% of Plan allowance | > |
|                                     |                            |   |
|                                     | Non-PPO: \$300 copay and   | 3 |
|                                     | 30% of our allowance plus  | 6 |
|                                     | amount over our allowance  |   |
+-------------------------------------+----------------------------+---+
| Outpatient\*                        | PPO: 10% of Plan allowance | > |
|                                     |                            |   |
|                                     | Non-PPO: 30% of our        | 3 |
|                                     | allowance plus amount over | 8 |
|                                     | our allowance              |   |
+-------------------------------------+----------------------------+---+
| > Emergency benefits:               |                            |   |
+-------------------------------------+----------------------------+---+
| Accidental injury                   | PPO: Nothing               | > |
|                                     |                            |   |
|                                     | Non-PPO: Any amount over   | 3 |
|                                     | our allowance              | 9 |
+-------------------------------------+----------------------------+---+
| Medical emergency\*                 | Regular benefits           | > |
|                                     |                            |   |
|                                     |                            | 4 |
|                                     |                            | 0 |
+-------------------------------------+----------------------------+---+
| Mental health and substance abuse   | In-network: Regular cost   | > |
| treatment                           | sharing. Out-of-network:   |   |
|                                     | Benefits are limited.      | 4 |
|                                     |                            | 1 |
+-------------------------------------+----------------------------+---+
| Prescription drugs:                 |                            |   |
+-------------------------------------+----------------------------+---+
| Network pharmacy                    | \$8 generic/25% brand name | > |
|                                     |                            |   |
|                                     |                            | 4 |
|                                     |                            | 3 |
+-------------------------------------+----------------------------+---+
| Network pharmacy Medicare           | \$8 generic/25% brand name |   |
+-------------------------------------+----------------------------+---+
| Non-network pharmacy                | 50% of cost                |   |
+-------------------------------------+----------------------------+---+
| Non-network pharmacy Medicare       | 50% of cost                |   |
+-------------------------------------+----------------------------+---+
| Mail order                          | \$12 generic/25% brand     |   |
|                                     | name                       |   |
+-------------------------------------+----------------------------+---+
| Mail order Medicare                 | \$12 generic/25% brand     |   |
|                                     | name                       |   |
+-------------------------------------+----------------------------+---+
| Dental Care ..                      | > Any difference between   | > |
|                                     | > our allowance and the    |   |
|                                     | > billed amount for        | 4 |
|                                     | > covered services         | 7 |
+-------------------------------------+----------------------------+---+
| Special features: Flexible benefits |                            | > |
| option, 24-hour nurse line,         |                            |   |
| Services for deaf and               |                            | 4 |
| hearing-impaired, Wellness benefit, |                            | 6 |
| Disease Management Program, Review  |                            |   |
| and reward                          |                            |   |
| program.........                    |                            |   |
| ................................... |                            |   |
+-------------------------------------+----------------------------+---+
| Protection against catastrophic     | PPO: Nothing after         | > |
| costs (your out-of-pocket maximum)  | \$4,000/Self Only or       |   |
|                                     | Family enrollment per      | 1 |
|                                     | year\                      | 8 |
|                                     | Non-PPO: Nothing after     |   |
|                                     | \$10,000/Self Only or      |   |
|                                     | Family enrollment per      |   |
|                                     | year\                      |   |
|                                     | Some costs do not count    |   |
|                                     | toward this protection     |   |
+-------------------------------------+----------------------------+---+

  -----------------------------------------------------------------------
  **Summary of benefits for the APWU Health Plan*\
  *Consumer-driven Option -- 2004**

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

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

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

Below, an asterisk (\*) means the item is subject to the Member
Responsibility, generally \$600 per Self Only and \$1,200 per Self and
Family, once your Personal Care Account has been spent. And, after we
pay, you generally pay any difference between our allowance and the
billed amount if you use an out-of-network physician or other health
care professional.

+-------------------------------------+----------------------------+---+
| **Benefits**                        | **You Pay**                | * |
|                                     |                            | * |
|                                     |                            | P |
|                                     |                            | a |
|                                     |                            | g |
|                                     |                            | e |
|                                     |                            | * |
|                                     |                            | * |
+-------------------------------------+----------------------------+---+
| In-network preventive care          | Nothing                    | > |
|                                     |                            |   |
|                                     |                            | 5 |
|                                     |                            | 0 |
+-------------------------------------+----------------------------+---+
| Personal Care Account               | Nothing up to \$1,000 for  | > |
|                                     | Self Only or \$2,000 for   |   |
| Up to \$1,000 for Self Only or      | Self and Family            | 5 |
| \$2,000 for Self and Family for     |                            | 2 |
| medical, surgical, hospital, mental |                            |   |
| health and substance abuse services |                            |   |
| and prescription drugs plus certain |                            |   |
| dental and vision care              |                            |   |
+-------------------------------------+----------------------------+---+
| Traditional Health Coverage after   |                            |   |
| Personal Care Account is exhausted  |                            |   |
+-------------------------------------+----------------------------+---+
| > Medical/Surgical services         |                            |   |
| > provided by physicians:           |                            |   |
+-------------------------------------+----------------------------+---+
| > Diagnostic and treatment services | In-network: 15% of Plan    | > |
| > provided in the office\*          | allowance                  |   |
|                                     |                            | 5 |
|                                     |                            | 6 |
+-------------------------------------+----------------------------+---+
| > Services provided by a hospital:  | Out-of-network: 40% of our |   |
|                                     | allowance plus amount      |   |
+-------------------------------------+----------------------------+---+
| > Inpatient\*                       | over our allowance         | > |
|                                     |                            |   |
|                                     |                            | 6 |
|                                     |                            | 7 |
+-------------------------------------+----------------------------+---+
| > Outpatient\*                      |                            | > |
|                                     |                            |   |
|                                     |                            | 6 |
|                                     |                            | 9 |
+-------------------------------------+----------------------------+---+
| > Accidental injury\*               | In-network: 15% of Plan    | > |
| >                                   | Allowance\                 |   |
| > Medical emergency\*               | Out-of-network: 15% of     | 7 |
|                                     | Plan Allowance put amount  | 0 |
|                                     | over our allowance         | > |
|                                     |                            | > |
|                                     |                            |   |
|                                     |                            | 7 |
|                                     |                            | 0 |
+-------------------------------------+----------------------------+---+
| > Mental health and substance abuse | In-network: Regular cost   | > |
| > treatment\*                       | sharing.\                  |   |
|                                     | Out-of-network: Benefits   | 7 |
|                                     | are limited.               | 1 |
+-------------------------------------+----------------------------+---+
| > Prescription drugs:               |                            |   |
+-------------------------------------+----------------------------+---+
| > Network pharmacy\*                | 25%/minimum \$8            | > |
|                                     |                            |   |
|                                     |                            | 7 |
|                                     |                            | 3 |
+-------------------------------------+----------------------------+---+
| > Network pharmacy Medicare\*       | 25%/minimum \$8            |   |
+-------------------------------------+----------------------------+---+
| > Mail order\*                      | 25%/minimum \$8            |   |
+-------------------------------------+----------------------------+---+
| > Mail order Medicare\*             | 25%/minimum \$8            |   |
+-------------------------------------+----------------------------+---+
| Dental Care/Vision Care (covered    | Any amount over \$400 per  | > |
| only under Personal Care Account)   | Self Only or \$800 per     |   |
| ..                                  | Family                     | 5 |
|                                     |                            | 3 |
+-------------------------------------+----------------------------+---+
| Special features: Online tools and  |                            | > |
| resources, Consumer choice          |                            |   |
| information, Services for deaf and  |                            | 7 |
| hearing-impaired,\                  |                            | 4 |
| 24-hour nurse advisory service and  |                            |   |
| Care                                |                            |   |
| support......................       |                            |   |
| ................................... |                            |   |
| ................................... |                            |   |
+-------------------------------------+----------------------------+---+
| Protection against catastrophic     | In-network: Nothing after  | > |
| costs (your out-of-pocket maximum)  | \$4,500/Self Only or       |   |
|                                     | Family enrollment per year | 1 |
|                                     |                            | 9 |
|                                     | Out-of-network: Nothing    |   |
|                                     | after \$9,000/Self Only or |   |
|                                     | Family enrollment per year |   |
|                                     |                            |   |
|                                     | Some costs do not count    |   |
|                                     | toward this protection     |   |
+-------------------------------------+----------------------------+---+

**2004 Rate Information** **for**

**APWU Health Plan**

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

**Postal rates** apply to career Postal Service employees. Most
employees should refer to the FEHB Guide for United States Postal
Service Employees, RI 70-2. Different postal rates apply and a special
FEHB guide is published for Postal Service Inspectors and Office of
Inspector General (OIG) employees (see RI 70-21N).

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.

  ------------------- ---------- -------------- -------------- -------------- -------------- -------------- -------------
                                 **Non-Postal                                                **Postal       
                                 Premium**                                                   Premium**      

                                 **Biweekly**                  **Monthly**                   **Biweekly**   

  **Type of\          **Code**   **Gov\'t\      **Your\        **Gov\'t\      **Your\        **USPS\        **Your\
  Enrollment**                   Share**        Share**        Share**        Share**        Share**        Share**

                                                                                                            

  **High Option\      **471**    **\$121.40**   **\$56.92**    **\$263.03**   **\$123.33**   **\$143.32**   **\$35.00**
  Self Only**                                                                                               

  **High Option\      **472**    **\$277.09**   **\$114.25**   **\$600.36**   **\$247.54**   **\$327.12**   **\$64.22**
  Self & Family**                                                                                           

  **Consumer-driven   **474**    **\$116.84**   **\$38.95**    **\$253.16**   **\$84.39**    **\$138.26**   **\$17.53**
  Option\                                                                                                   
  Self Only**                                                                                               

  **Consumer-driven   **475**    **\$272.09**   **\$90.70**    **\$589.54**   **\$196.51**   **\$321.98**   **\$40.81**
  Option\                                                                                                   
  Self & Family**                                                                                           
  ------------------- ---------- -------------- -------------- -------------- -------------- -------------- -------------