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## Introduction

This brochure describes the benefits of the Association Benefit Plan
under the Government Employees Health Association's contract (CS 1065)
with the United States Office of Personnel Management, as authorized by
the Federal Employees Health Benefits law. This Plan is underwritten by
Mutual of Omaha Insurance Company. The address for the Association
Benefit Plan administrative office is:

Association Benefit Plan\
PO Box 668587\
Charlotte, NC 28266-8587

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 are summarized on page 80.
Rates are shown at the end of this brochure.

## Plain Language

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

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

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

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

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

## Stop Health Care Fraud!

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 physi­cian,
    other provider, or authorized plan or OPM representative.

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

## Stop Health Care Fraud! (continued)

-   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
    1-800-634-0069 and explain the situation.

-   If we do not resolve the issue:

#  CALL -- THE HEALTH CARE FRAUD HOTLINE 202-418-3300 OR WRITE TO:

# United States Office of Personnel Management Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400 Washington, DC 20415-1100

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

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

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

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

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

## Preventing medical mistakes

An influential report from the Institute of Medicine estimates that up
to 98,000 American 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 with 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?

-   **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.** The National Patient Safety Foundation has
    information on how to ensure safer health care for you and your
    family.

-   **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.** The Leapfrog Group is active in promoting
    safe practices in hospital care.

-   **www.ahqa.org.** The American Health Quality Association represents
    organizations and health care professionals working to improve
    patient safety.

-   **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.

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

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 a** **Preferred Provider Organization (PPO):**

Our fee-for-service plan offers services through a PPO. When you reside
in the PPO network area and use our PPO providers, you will receive
covered services at reduced cost. Contact us at 1-800-634-0069 for
information concerning your PPO. You can also go to the Mutual of Omaha
Website, www.mutualofomaha.com, for PPO information. Also, when you
phone for an appointment, please verify that your physician is still a
PPO provider. Contact the Association Benefit Plan to request a PPO
directory.

PPO benefits apply only when you reside in the PPO network area and use
a PPO provider. **You must present your PPO identi­fication (ID) card
confirming your PPO participation to be eligible for PPO benefits**.
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. When you use a PPO 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 preferred providers. If they are not, they
will be paid as non-PPO providers.

The PPO Network Area consists of Washington, D.C. and selected cities
and counties in all states with the exception of Hawaii and Vermont.

If you reside in the PPO network area and no PPO provider is available,
or if you do not use a PPO provider, non-PPO benefits apply.

If you reside outside the PPO network area, Out-of-network benefits
apply.

**How we pay providers**

Our participating providers are generally reimbursed according to an
agreed-upon fee schedule and are not offered additional financial
incentives based on care provided or not provided to you. Our standard
provider agreements do not contain any contrac­tual provisions that
include incentives to restrict a provider's ability to communicate with
and advise patients of any appropriate treatment options. In addition,
the Plan has no compensation, ownership, or other influential interests
that are likely to affect pro­vider advice or treatment decisions.

We may, through a negotiated agreement with some non-PPO health care
providers, apply a discount to covered services that you receive from
these providers.

To locate a non-PPO provider from whom a discount may be available, call
the number on your identification card.

**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 by calling 1-800-634-0069, or writing to Association
Benefit Plan, PO Box 668587, Charlotte, NC 28266-8587.

## Section 2. How we change for 2004

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

**Program-wide changes**

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

> See page 74.

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

-   We added information regarding enrolling in Medicare. See page 19.

-   We revised the Medicare Primary Payer Chart. See page 63.

**Changes to this Plan**

-   The PPO catastrophic maximum for deductibles, coinsurance and copays
    has changed to \$3500 for self or any covered family member.

-   The \$10 copay for one annual routine physical examination has been
    eliminated and the exam and all associated tests will be paid at
    100% up to a maximum of \$500.

-   The coinsurance for pre-admission test performed within 7 days of
    hospital admission has changed to 10% PPO, 30% non-PPO and 15% out
    of network, subject to the deductible.

-   PPO treatment therapies have been changed to 10% coinsurance,
    subject to the deductible.

-   The lifetime maximum benefit for wigs has been changed to \$300.

-   The per confinement copay for non-PPO inpatient hospitalizations has
    been changed to \$300.

-   The coinsurance for Non-PPO outpatient surgical services and
    supplies has been changed to 30%.

-   The maximum number of days per confinement in a skilled nursing care
    facility has changed to 90 days.

-   The coinsurance for ambulance service has changed to 10% for PPO,
    25% for non-PPO and 15% out of network.

-   The accidental injury benefit has changed to 100% payment of all
    services and supplies for outpatient facility charges, outpatient
    physician charges, including office visit if used in lieu of
    emergency room, excluding x-ray, lab or DME.

-   The coinsurance for PPO mental health providers has changed to 10%
    not subject to the deductible.

-   The coinsurance for Non-PPO mental health services in an approved
    alternative care setting has changed to 25% of the Plan allowance
    and the difference between the allowance and the billed amount.

-   Non-PPO inpatient care for substance abuse benefit has changed to a
    \$300 copayment per hospital confinement, payable at 70% of covered
    charges up to a combined lifetime maximum of \$25,000.

-   The coinsurance for Non-PPO outpatient care for substance abuse has
    changed to a 25% of the Plan allowance and the difference between
    the allowance and the billed amount, up to a combined lifetime
    maximum of \$25,000.

-   Non-PPO inpatient and outpatient care for alcoholism and drug abuse
    benefit has changed to a lifetime maximum benefit of \$25,000.

-   The retail generic drug copayments have changed from \$10 to \$5;
    for formulary brand name from \$20 to \$25; and for non-formulary
    brand name from 30% or \$30 whichever is greater to 30% or \$40
    whichever is greater.

-   The mail order drug copayments have changed from \$20 to \$10 for
    generic; from \$40 to \$45 for formulary brand name; and from 30% or
    \$45 whichever is greater to 30% or \$55 whichever is greater, for
    non-formulary brand name.

-   The number of days covered in a skilled nursing facility,
    semiprivate room, board, services and supplies has changed from 30
    days to 45 days.

## Section 3. How you get care 

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

If you do not receive your card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
1-800-634- 0069.

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

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

-   **Physician**: Doctors of medicine or psychiatry (M.D.), osteopathy
    (D.O.), dental surgery (D.D.S.), medical dentistry (D.M.D.),
    podiatric medicine (D.P.M.), chiropractic (D.C.), and optometry
    (O.D.) when acting within the scope of their licenses or
    certification.

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-   **Qualified Clinical** **Psychologist**: An individual who has
    earned either a Doctoral or Masters Clinical Degree in psychology or
    an allied discipline and who is licensed or certified in the state
    where services are performed. This presumes a licensed individual
    has demonstrated to the satisfaction of state licensing officials
    that he/she, by virtue of academic and clinical experience, is
    qualified to provide psychological services in that state.

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-   **Nurse Midwife**: A person who is certified by the American College
    of Nurse Midwives or is licensed or certified as a nurse midwife in
    states requiring licensure or certification.

-   **Nurse Practitioner/Clinical Specialist**: A person who 1) has an
    active R.N. license in the United States, 2) has a baccalaureate or
    higher degree in nursing, and 3) is licensed or certified as a nurse
    practitioner or clinical nurse specialist in states requiring
    licensure or certification.

-   **Clinical** **Social Worker:** A social worker who 1) has a
    Master's or Doctoral degree in social work, 2) has at least two
    years of clinical social work practice, and 3) in states requiring
    licensure, certification or registration, is licensed, certified, or
    registered as a social worker where the services are rendered.

-   **Physician Assistant**: A person who is licensed, registered, or
    certified in the state where services are performed.

-   **Licensed Professional Counselor or Master's Level Counselor**: A
    person who is licensed, registered, or certified in the state where
    services are performed.

-   **Audiologist**: A person who is licensed, registered, or certified
    in the state where services are performed.

-   **Licensed Acupuncturist (L.A.C.)**: A person who has completed the
    required schooling and licensure to perform acupuncture in the state
    where services are performed (see definition of acupuncture
    benefits, Section 5(a)).

## Section 3. How you get care (continued)

-   **Christian Science Practitioner**: If you choose to visit a
    Christian Science practitioner instead of a physician, the charges
    are still considered allowable expenses. To qualify for benefits,
    you must make this choice annually. The benefits will then apply to
    all subsequent expenses incurred during the year. You can change
    your mind only at the time of your first claim each year. The
    practitioner you choose must be listed as such in the *Christian
    Science Journal* that is current at the time the service is
    provided. Your choice will not apply to, or prevent payment of, a
    physician's maternity charges.

**Medically underserved areas.** We cover any licensed medical
practitioner, including chiropractors, 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,
Lousiana, Maine, Mississippi, Missouri, Montana, New Mexico, North
Dakota, South Carolina, South Dakota, Texas, Utah, West Virginia, and
Wyoming.

**Covered facilities** **Hospital**

1.  An institution that is accredited as a hospital under the hospital
    accredita­tion program of the Joint Commission on Accreditation of
    Healthcare Organizations (JCAHO); or

2.  Any other institution that is operated pursuant to law, under the
    supervision of a staff of doctors and with 24-hour-a-day nursing
    service, and that is primarily engaged in providing:

    a.  General patient care and treatment of sick and injured persons
        through medical, diagnostic and major surgical facilities, all
        of which facilities 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.

3.  For inpatient and outpatient treatment of mental health and
    substance abuse, the term hospital also includes a freestanding
    residential treatment center facility approved by the JCAHO.

> In no event shall the term hospital include a convalescent nursing
> home or institution or part thereof that:

1)  is used principally as a convalescent facility, rest facility,
    nursing facility or facility for the aged;

2)  furnishes primarily domiciliary or custodial care including training
    in the routines of daily living; or

3)  is operated as a school.

> **Nursing School Administered Clinic**: A clinic that is

1)  licensed or certified in the state where the services are performed,
    and

2)  provides ambulatory care in an outpatient setting---primarily in
    rural or inner city areas where there is a shortage of physicians.
    Services billed for by these clinics are considered outpatient
    'office' services rather than facility charges.

## Section 3. How you get care (continued)

> **Skilled nursing facility:** An institution, or that part of an
> institution that provides convalescent skilled nursing care 24 hours a
> day and is classified as a skilled nursing facility under Medicare.
>
> **Birthing Center:** A licensed facility that is equipped and operated
> solely to provide prenatal care, to perform uncomplicated spontaneous
> deliveries and to provide immediate postpartum care.
>
> **Hospice**: A facility that meets all of the following:
>
> primarily provides inpatient hospice care to terminally ill persons;
>
> is certified by Medicare as such, or is licensed or accredited as such
> by the jurisdiction it is in;
>
> is supervised by a staff of M.D.s or D.O.s, at least one of whom must
> be on call at all times;
>
> provides 24-hour-a-day nursing services under the direction of an R.N.
> and has a full-time administrator; and
>
> provides an ongoing quality assurance program.

**What you must do to get covered care** It depends on the kind of care
you want to receive. You can go to any provider you want, but we must
approve some care in advance.

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

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

-   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 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 Plan begins, call our customer service department
> immediately at 1-800-634-0069.
>
> If you changed from another FEHB plan to us, your former plan will pay
> for the hospital stay until:
>
> You are discharged, not merely moved to an alternative care center; or
>
> The day your benefits from your former plan run out; or
>
> The 92^nd^ day after you become a member of this Plan, whichever\
> happens first.
>
> These provisions apply only to the benefits of the hospitalized
> person. If your plan terminates participation in the FEHB 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.

## Section 3. How you get care (continued)

######## How to Get Approval for...

> **Your hospital stay** **Precertification** is the process by
> which---prior to your hospital admission or residential treatment
> care---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 will not 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 if they have contacted us.

######### Warning We will reduce our benefits for the inpatient hospital stay or residential treatment care 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 an admission You, your representative, your physician, or your hospital must call us before the admission or care. The toll-free number is 1-800-634-0069.

> Provide the following information:

-   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 physician;

-   Name of hospital or facility; and

-   Number of planned days of hospital stay.

> We will then tell your physician and/or hospital the number of
> approved inpatient days and we will send written confirmation of our
> decision to you, your physi­cian, and the hospital.
>
> 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, your physician,
> or your hospital must telephone us within two business days following
> the day of the emergency admission, even if you have been discharged
> from 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 stay   If your hospital stay---including for
  needs to be extended**    maternity care---needs to be extended, you,
                            your representative, your physician or the
                            hospital must ask us to approve the
                            additional days.

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

##  Section 3. How you get care (continued)

+--------------------------+-------------------------------------------+
| ######## What            | If no one contacted us, we will decide    |
|  happens when you do not | whether the hospital stay was medically   |
|                          | necessary.                                |
| ######## Follow th       |                                           |
| e precertification rules |                                           |
+--------------------------+-------------------------------------------+

-   If we determine that the stay was medically necessary, we will pay
    the inpatient charges, less the \$500 penalty.

-   If we determine that it was not medically necessary for you to be an
    inpatient, 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.

> If no one contacted us for specified services such as Hospice Care,
> Skilled Nursing Facility Care, Home Health Care, we will disqualify
> higher paid benefits.
>
> 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:

-   for the part of the admission that was medically necessary, we will
    pay inpatient benefits, but

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

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

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

-   You have another group health insurance 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.

**Other services** Some other services require precertification or prior
authorization, such as:

-   Home health care (See Section 5(a))

-   Hospice care (See Section 5(c))

-   Skilled nursing facilities (See Section 5(c))

-   Psychiatric and substance abuse treatment (See Section 5(e))

-   Some prescription drugs (See Section 5(f))

## Section 4. Your costs for covered services 

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

**Copayments** A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc., when you receive services. You will
only be responsible for one copayment per day per provider.

> Example: When you see your PPO physician you pay a copayment of \$10
> per day, and when you go in a PPO hospital, you pay a copayment of
> \$100 per hospital stay.

**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 deductible.

> The calendar year deductible is \$300 per person. Under a family
> enrollment, the deductible is satisfied for all family members when
> the combined covered expenses applied to the calendar year deductible
> for family members reach \$600.
>
> Note: If you change plans during Open Season, you do not have to start
> a new deductible under your old plan between January 1 and the
> effective date of your new plan. If you change plans at another time
> during the year, you must begin a new deductible under your new plan.

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

> Example: You pay 10% coinsurance of our allowance for an X-ray.
>
> Note: If your provider routinely waives (does not require you to pay)
> your copayments, deductibles, or coinsurance, the provider is
> misstating the fee and may be violating the law. In this case, when we
> calculate our share, we will reduce the provider's fee by the amount
> waived.
>
> For example, if your physician ordinarily charges \$100 for a service
> but routinely waives your 10% coinsurance, the actual charge is \$90.
> We will pay \$81 (90% of the actual charge of \$90).

+-------------------------+--------------------------------------------+
| #                       | Our "Plan allowance" is the amount we use  |
| ####### Differences bet | to calculate our payment for               |
| ween our allowance and  |                                            |
|                         | covered services. Fee service plans arrive |
| **the bill**            | at their allowances in different           |
|                         |                                            |
|                         | ways, so their allowances vary. For more   |
|                         | information about how we                   |
|                         |                                            |
|                         | determine our Plan allowance, see the      |
|                         | definition of Plan allowance in            |
|                         |                                            |
|                         | Section 10.                                |
+-------------------------+--------------------------------------------+

> Often, the provider\'s bill is more than a fee-for-service plan\'s
> allowance. Whether or not you have to pay the difference between our
> allowance and the bill will depend on the provider you use.
>
> When you live in the Plan's PPO area, you should use a PPO provider.
> The following two examples explain how we will handle your bill when
> you go to a PPO provider and when you go to a non-PPO provider. When
> you use a PPO provider, the amount you pay is much less.

## Section 4. Your costs for covered services (continued)

> **PPO providers** agree to limit what they will bill you. Because of
> that, when you use a preferred provider, your share of covered charges
> consists only of your deductible and coinsurance or copayment. Here is
> an example about coinsurance: You see a PPO physician who charges
> \$350, but our allowance is \$300. If you have met your deductible,
> you are only responsible for your coinsurance. That is, you pay just
> 10% of our \$300 allowance (\$30). Because of the agreement, your PPO
> physician will not bill you for the \$50 difference between our
> allowance and his bill. Follow these procedures when you use a PPO
> provider in order to receive PPO benefits:
>
> Verify with us that your address of record is in a PPO area;
>
> When you phone for an appointment, verify that the physician or
> facility is still a PPO provider and;
>
> Present your PPO ID card confirming your PPO participation in order to
> receive PPO benefits.
>
> **Non-PPO providers**, on the other hand, have no agreement to limit
> what they will bill you. For instance,

-   **When you reside in the PPO network area and use a non-PPO\
    provider**, you will pay your deductible and coinsurance---**plus**
    any difference between our allowance and charges on the bill. Here
    is an example: You see a non-PPO physician who charges \$350 and our
    allowance is again \$300. Because you\'ve met your deductible, you
    are responsible for your coinsurance, so you pay **30%** of our
    \$300 allowance (\$90). 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.

-   **When you reside outside the PPO network area,** you will pay your
    deductible and coinsurance -- plus any difference between our
    allowance and charges on the bill. As in the example above, once you
    have met your deductible, you are responsible for your coinsurance.
    You will pay **15%** of our allowance (\$45) and the physician can
    bill you for the \$50 difference between our allowance and his bill.

> The following table illustrates the examples of how much you have to
> pay out-of-pocket for services from a PPO physician vs. a non-PPO
> physician when you reside in the PPO network area. The table uses our
> example of a service for which the physician charges \$350 and our
> allowance is \$300. The table shows the amount you pay if you have met
> your calendar year deductible.

+-------------------+-------------------------+------------------------+
| > **EXAMPLE**     | **PPO physician**       | **Non-PPO physician**  |
+-------------------+-------------------------+------------------------+
| Physician\'s      | \$350                   | \$350                  |
| charge            |                         |                        |
+-------------------+-------------------------+------------------------+
| Our allowance     | We set it at: \$300     | We set it at: \$300    |
+-------------------+-------------------------+------------------------+
| We pay            | 90% of our allowance:   | 70% of our allowance:  |
|                   | \$270                   | \$210                  |
+-------------------+-------------------------+------------------------+
| You owe:          | 10% of our allowance:   | 30% of our allowance:  |
|                   | \$30                    | \$90                   |
| Coinsurance       |                         |                        |
+-------------------+-------------------------+------------------------+
| +Difference up to | No: 0                   | Yes: \$50              |
| charge?           |                         |                        |
+-------------------+-------------------------+------------------------+
| ### TOTAL YOU PAY | \$30                    | \$140                  |
+-------------------+-------------------------+------------------------+

## Section 4. Your costs for covered services (continued)

  ------------------------- ---------------------------------------------
  **Your** **catastrophic   For those benefits where coinsurance or
  protection out-of-pocket  deductibles apply, we pay 100% of the Plan
  maximum for deductibles,  allowance for the rest of the calendar year
  coinsurance, and          after your expenses total:
  copayments**              

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

-   PPO providers: \$3,500---For you or any covered family member;

-   Non-PPO providers: \$7,000---For you or any covered family member;

-   Out-of-network providers: \$3,000---For you or any covered family
    member.

> Out-of-pocket expenses are:

-   Your \$300/\$600 calendar year deductible;

-   The percentage you pay for covered services after you have met your
    deduct­ibles;

-   The percentage you pay for surgery, anesthesia and extended medical
    care after an accidental injury; and

-   Your copayment for hospital stays.

> The following cannot be included in your out-of-pocket expenses:

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

-   Non-covered services and supplies;

-   Prescription drug copayments;

-   Copayments, except for hospital admission copayments;

-   Expenses for dental care including the 20% you pay for dental care
    after an accidental injury; or

-   Any amounts you pay if benefits have been reduced because of
    noncompliance with our precertification, prior authorization or
    prior approval requirements.

**When Government facilities bill us** Facilities of the Department of
Veterans Affairs, the Department of Defense, and the Indian Health
Service are entitled to seek reimbursement from us for certain services
and supplies they provide to you or a family member. They may not seek
more than their governing laws allow.

**If we overpay you** We will make diligent efforts to recover benefit
payments we made in error, but in good faith. If your claim has been
paid in error for any reason, we shall make a diligent effort to recover
an overpayment to you from you. If the overpayment was made to a
provider, we shall make a diligent effort to recover the overpayment
from the provider. We may also reduce subsequent benefit payments to you
or to a provider to offset overpayments made in error.

## Section 4. Your costs for covered services (continued)

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

**If you\....**

-   are age 65 or over, and

-   do not have Medicare Part A, Part B, or both; and

-   have this Plan as an annuitant or as a former spouse, or as a family
    member of an annuitant or former spouse; and

-   are not employed in a position that gives FEHB coverage. (Your
    employing office can tell you if this applies.)

**Then, for your inpatient hospital care,**

-   the law requires us to base our payment on an amount---the
    "equivalent Medicare amount"---set by Medicare's rules for what
    Medicare would pay, not on the actual charge;

-   you are responsible for your applicable deductibles, coinsurance, or
    copayments you owe under this Plan;

-   you are not responsible for any charges greater than the equivalent
    Medicare amount; we will show that amount on the explanation of
    benefits; and

-   the law prohibits a hospital from collecting more than the Medicare
    equivalent amount.

**And, for your physician care, the law requires us to base our payment
and your coinsurance on...**

-   an amount set by Medicare and called the "Medicare approved amount,"
    or

-   **the actual charge if it is lower than the Medicare approved
    amount**

  ----------------------------------- -----------------------------------
  If your physician...                Then you are responsible for...

  Participates with Medicare or       your deductibles, coinsurance,
  accepts Medicare assignment for the copayments;
  claim and is a member of our PPO    
  network,                            

  Participates with Medicare and is   your deductibles, coinsurance,
  not in our PPO network,             copayments, and any balance up to
                                      the Medicare approved amount;

  Does not participate with Medicare, your deductibles, coinsurance,
                                      copayments, and any balance up to
                                      115% of the Medicare approved
                                      amount.
  ----------------------------------- -----------------------------------

It is generally to your financial advantage to use a physician who
participates with Medicare. Such physicians are permitted to collect
only up to the Medicare approved amount.

Our explanation of benefits (EOB) form will tell you how much the
physician or hospital can collect from you. If your physician or
hospital tries to collect more than allowed by law, ask the physician or
hospital to reduce the charges. If you have paid more than allowed, ask
for a refund. If you need further assistance, call us.

## Section 4. Your costs for covered services (continued)

+-------------------------+--------------------------------------------+
| **When you the have the | We limit our payment to an amount that     |
| Original Medicare Plan  | supplements the benefits that Medicare     |
| (Part A, Part B, or     | would pay under Medicare A (Hospital       |
| both)**                 | insurance) and Medicare B (Medical         |
|                         | insurance), regardless of whether Medicare |
|                         | pays. Note: We pay our regular benefits    |
|                         | for emergency services to an institutional |
|                         | provider, such as a hospital, that does    |
|                         | not participate with Medicare and is not   |
|                         | reimbursed by Medicare.                    |
|                         |                                            |
|                         | 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. |
+-------------------------+--------------------------------------------+

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

-   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.

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

> If you can get premium-free Part A coverage, we advise you to enroll
> in it. Most Federal employees and annuitants are entitle 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 cost to the FEHB, which can help keep FEHB premiums down.
>
> Medicare Part B covers doctors' services and outpatient hospital care.
> Everyone is charged a premium for Medicare Part B coverage. The Social
> Security Adminis­tration can provide you with premium and benefit
> information. Review the information and decide if it makes sense for
> you to buy the Medicare Part B coverage.
>
> **Please see Section 9, *Coordinating benefits with other coverage*,
> for more information about how we coordinate benefits with Medicare.**

## Section 5. Benefits -- OVERVIEW (See page 8 for how our benefits changed this year and page 80 for a benefits summary.)

Note: This benefits section is divided into subsections. Please read the
important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claims forms,
claims filing advice, or more information about our benefits, contact us
at 1-800-634-0069.

(a) Medical services and supplies provided by physicians and other
    health care professionals start on page 21.

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

\(b\) Surgical and anesthesia services provided by physicians and other
health care professional start on page 32

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

(c) Services provided by a hospital or other facility, and ambulance
    services start on page 37.

+----------------------------------+---+---------------------------------+---+---+
| -   Inpatient hospital           | - |                                 |   |   |
|                                  |   |                                 |   |   |
|                                  |   |                                 |   |   |
|                                  |   |                                 |   |   |
|                                  | H |                                 |   |   |
|                                  | o |                                 |   |   |
|                                  | s |                                 |   |   |
|                                  | p |                                 |   |   |
|                                  | i |                                 |   |   |
|                                  | c |                                 |   |   |
|                                  | e |                                 |   |   |
|                                  |   |                                 |   |   |
|                                  |   |                                 |   |   |
|                                  |   |                                 |   |   |
|                                  |   |                                 |   |   |
|                                  | c |                                 |   |   |
|                                  | a |                                 |   |   |
|                                  | r |                                 |   |   |
|                                  | e |                                 |   |   |
+----------------------------------+---+---------------------------------+---+---+
| -   Outpatient hospital or       | - |                                 |   |   |
|     ambulatory surgical center   |   |                                 |   |   |
|                                  |   |                                 |   |   |
|                                  |   |                                 |   |   |
|                                  | A |                                 |   |   |
|                                  | m |                                 |   |   |
|                                  | b |                                 |   |   |
|                                  | u |                                 |   |   |
|                                  | l |                                 |   |   |
|                                  | a |                                 |   |   |
|                                  | n |                                 |   |   |
|                                  | c |                                 |   |   |
|                                  | e |                                 |   |   |
+----------------------------------+---+---------------------------------+---+---+
| -   Skilled nursing care         |   |                                 |   |   |
|     facility                     |   |                                 |   |   |
+----------------------------------+---+---------------------------------+---+---+

(d) Emergency services/Accidents start on page 41.

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

\(e\) Mental health and substance abuse benefits start on page 43.

\(f\) Prescription drug benefits start on page 48.

\(g\) Special features start on page 51.

+-----------------------------------------+----------------------------+
| -   Flexible benefits option            | -   Centers of excellence  |
+-----------------------------------------+----------------------------+
| -   Services overseas                   | -   Glucose monitors       |
+-----------------------------------------+----------------------------+
| -   Healthy*directions*^sm^             | -   Lifestyle prescription |
|                                         |     medications            |
+-----------------------------------------+----------------------------+

\(h\) Dental benefits start on page 53.

\(i\) Non-FEHB benefits available to Plan members start on page 54.

*SUMMARY OF BENEFITS* start on page 80.

## Section 5 (a). Medical services and supplies provided by physicians and other health care professionals

+---+---+-------------------------------------+----------------+---+---+
|   | * | **Here are some important things    |                | * |   |
|   | * | you should keep in mind about these |                | * |   |
|   | I | benefits:**                         |                | I |   |
|   | * |                                     |                | * |   |
|   | * | Please remember that all benefits   |                | * |   |
|   |   | are subject to the definitions,     |                |   |   |
|   | * | limitations, and exclusions in this |                | * |   |
|   | * | brochure and are payable only when  |                | * |   |
|   | M | we determine they are medically     |                | M |   |
|   | * | necessary.                          |                | * |   |
|   | * |                                     |                | * |   |
|   |   | The calendar year deductible is:    |                |   |   |
|   | * | \$300 per person (\$600 per         |                | * |   |
|   | * | family). The calendar year          |                | * |   |
|   | P | deductible applies to almost all    |                | P |   |
|   | * | benefits in this Section. We added  |                | * |   |
|   | * | (No Deductible) to show when the    |                | * |   |
|   |   | calendar year deductible **does     |                |   |   |
|   | * | not** apply.                        |                | * |   |
|   | * |                                     |                | * |   |
|   | O | PPO benefits apply only when you    |                | O |   |
|   | * | reside in the PPO network area and  |                | * |   |
|   | * | use a PPO provider. When no PPO     |                | * |   |
|   |   | provider is available, non-PPO      |                |   |   |
|   | * | benefits apply. Out-of-network      |                | * |   |
|   | * | benefits apply when you reside      |                | * |   |
|   | R | outside the PPO network area.       |                | R |   |
|   | * |                                     |                | * |   |
|   | * | 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 age 65 |                | T |   |
|   | * | or over. Also read Section 9 about  |                | * |   |
|   | * | coordinating benefits with other    |                | * |   |
|   |   | coverage, including with Medicare.  |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | A |                                     |                | A |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | N |                                     |                | N |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | T |                                     |                | T |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
+---+---+-------------------------------------+----------------+---+---+
| B |   |                                     | # You Pay      |   |   |
| e |   |                                     |                |   |   |
| n |   |                                     | # After        |   |   |
| e |   |                                     | the calendar y |   |   |
| f |   |                                     | ear deductible |   |   |
| i |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| D |   |                                     |                |   |   |
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| i |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
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| o |   |                                     |                |   |   |
| w |   |                                     |                |   |   |
| w |   |                                     |                |   |   |
| h |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
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| d |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
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| y |   |                                     |                |   |   |
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| d |   |                                     |                |   |   |
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| c |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| b |   |                                     |                |   |   |
| l |   |                                     |                |   |   |
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| d |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
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| s |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
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| a |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
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| y |   |                                     |                |   |   |
| . |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| 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: \$10      |   |   |
| r |   |                                     | copayment (No  |   |   |
| o |   |                                     | Deductible)    |   |   |
| f |   |                                     |                |   |   |
| e |   |                                     | Non-PPO: 30%   |   |   |
| s |   |                                     | of the Plan    |   |   |
| s |   |                                     | allowance and  |   |   |
| i |   |                                     | any difference |   |   |
| o |   |                                     | between our    |   |   |
| n |   |                                     | allowance and  |   |   |
| a |   |                                     | the billed     |   |   |
| l |   |                                     | amount         |   |   |
| s |   |                                     |                |   |   |
| e |   |                                     | O              |   |   |
| r |   |                                     | ut-of-network: |   |   |
| v |   |                                     | 15% of the     |   |   |
| i |   |                                     | Plan allowance |   |   |
| c |   |                                     | and any        |   |   |
| e |   |                                     | difference     |   |   |
| s |   |                                     | between our    |   |   |
| o |   |                                     | allowance and  |   |   |
| f |   |                                     | the billed     |   |   |
| p |   |                                     | amount         |   |   |
| h |   |                                     |                |   |   |
| y |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
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| p |   |                                     |                |   |   |
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| v |   |                                     |                |   |   |
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| d |   |                                     |                |   |   |
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| d |   |                                     |                |   |   |
| b |   |                                     |                |   |   |
| y |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| h |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| h |   |                                     |                |   |   |
| y |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| v |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| d |   |                                     |                |   |   |
| u |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| d |   |                                     |                |   |   |
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| r |   |                                     |                |   |   |
| S |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
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| 5 |   |                                     |                |   |   |
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| . |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| P |   |                                     | PPO: 10% of    |   |   |
| r |   |                                     | the Plan       |   |   |
| o |   |                                     | allowance      |   |   |
| f |   |                                     |                |   |   |
| e |   |                                     | Non-PPO: 30%   |   |   |
| s |   |                                     | of the Plan    |   |   |
| s |   |                                     | allowance and  |   |   |
| i |   |                                     | any difference |   |   |
| o |   |                                     | between our    |   |   |
| n |   |                                     | allowance and  |   |   |
| a |   |                                     | the billed     |   |   |
| l |   |                                     | amount         |   |   |
| s |   |                                     |                |   |   |
| e |   |                                     | O              |   |   |
| r |   |                                     | ut-of-network: |   |   |
| v |   |                                     | 15% of the     |   |   |
| i |   |                                     | Plan allowance |   |   |
| c |   |                                     | and any        |   |   |
| e |   |                                     | difference     |   |   |
| s |   |                                     | between our    |   |   |
| o |   |                                     | allowance and  |   |   |
| f |   |                                     | the billed     |   |   |
| p |   |                                     | amount         |   |   |
| h |   |                                     |                |   |   |
| y |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
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| n |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| k |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| l |   |                                     |                |   |   |
| l |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| d |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| u |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| g |   |                                     |                |   |   |
| f |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| l |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| y |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| A |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| h |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| m |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+

+--------------------------------------------+-------------------------+
| **Lab, X-ray and other diagnostic tests**  | ## You pay              |
+--------------------------------------------+-------------------------+
| Tests, such as:                            | PPO: 10% of the Plan    |
|                                            | allowance               |
| Blood tests                                |                         |
|                                            | Note: If your PPO       |
| Urinalysis                                 | provider uses a non-PPO |
|                                            | lab or radiologist, we  |
| Non-routine pap tests                      | will pay non-PPO        |
|                                            | benefits for any lab or |
| Pathology                                  | X-ray charges           |
|                                            |                         |
| X-rays                                     | Non-PPO: 30% of the     |
|                                            | Plan allowance and any  |
| Non-routine mammograms                     | difference between our  |
|                                            | allowance and the       |
| CAT Scans/MRI                              | billed amount           |
|                                            |                         |
| Ultrasound                                 | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
| Electrocardiogram and EEG                  | any difference between  |
|                                            | our allowance and the   |
| Sonograms                                  | billed amount           |
+--------------------------------------------+-------------------------+
| **Preventive care, adult**                 |                         |
+--------------------------------------------+-------------------------+
| Routine physical examination per person to | PPO: **Services in      |
| include a history and physical, chest      | physician's office**    |
| X-ray, urinalysis, blood tests, and EKG    | Nothing up to the \$500 |
| (electrocardiogram). Up to a maximum of    | maximum and all charges |
| \$500 per calendar year                    | in excess of the \$500  |
|                                            | maximum (No Deductible) |
| One annual cervical cancer screening (pap  |                         |
| smear) for women age 18 and older. Note:   | PPO: **Services outside |
| if you see another physician for your pap  | physician's office**    |
| smear, the office visit will be covered.   | Nothing up to the \$500 |
|                                            | maximum and all charges |
| One annual Prostate Specific Antigen (PSA) | in excess of the \$500  |
| test (prostate cancer screening) for men   | maximum (No Deductible) |
| age 40 and older.                          |                         |
|                                            | Non-PPO: 30% of the     |
| One annual fecal occult blood test         | Plan allowance and any  |
| (colorectal cancer screening) for members  | difference between our  |
| age 40 and older.                          | allowance and the       |
|                                            | billed amount and all   |
| One routine sigmoidoscopy every five years | charges in excess of    |
| starting at age 50.                        | the \$500 maximum       |
|                                            |                         |
| One routine colonoscopy every ten years    | Out-of-Network: 15% of  |
| starting at age 50.                        | the Plan allowance and  |
|                                            | any difference between  |
| One annual routine mammogram (breast       | our allowance and the   |
| cancer screening) for women age 35 and     | billed amount and all   |
| older.                                     | charges in excess of    |
|                                            | the \$500 maximum (No   |
| One non-fasting blood cholesterol test     | Deductible)             |
| every three consecutive calendar years     |                         |
|                                            |                         |
| Chlamydial screening                       |                         |
|                                            |                         |
| Note: Your physician's bill **must**       |                         |
| clearly state "Routine Physical Exam." If  |                         |
| a medical diagnosis is provided on the     |                         |
| bill, those services will be paid under    |                         |
| the medical benefit.                       |                         |
+--------------------------------------------+-------------------------+
| Routine immunizations, limited to:         | PPO: 10% of the Plan    |
|                                            | allowance               |
| Tetanus-diphtheria (Td) booster once every |                         |
| 10 years, ages 22 and over                 | Non-PPO: 25% of the     |
|                                            | Plan allowance and any  |
| Pneumococcal vaccine, annually, age 65 and | difference between our  |
| over                                       | allowance and the       |
|                                            | billed amount           |
| Influenza vaccine, annually                |                         |
|                                            | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount           |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Preventive care, children**              | **You Pay**             |
+--------------------------------------------+-------------------------+
| Childhood immunizations recommended by the | PPO: Nothing (No        |
| American Academy of Pediatrics (to age 22) | Deductible)             |
|                                            |                         |
|                                            | Non-PPO: Only the       |
|                                            | difference between the  |
|                                            | Plan allowance and the  |
|                                            | billed amount (No       |
|                                            | Deductible)             |
|                                            |                         |
|                                            | Out-of-network: Only    |
|                                            | the difference between  |
|                                            | the Plan allowance and  |
|                                            | the billed amount (No   |
|                                            | Deductible)             |
+--------------------------------------------+-------------------------+
| Well-child care charges for routine        | PPO: \$10 copayment (No |
| examinations and care (to age 2):          | Deductible)             |
|                                            |                         |
| One annual routine physical examination    | PPO: **Services outside |
| (over age 2 to age 22):                    | physician's office**    |
|                                            | Nothing (No Deductible) |
|                                            |                         |
|                                            | Non-PPO: 30% of the     |
|                                            | Plan allowance and any  |
|                                            | difference between our  |
|                                            | allowance and the       |
|                                            | billed amount.          |
|                                            |                         |
|                                            | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount. (No      |
|                                            | Deductible)             |
+--------------------------------------------+-------------------------+
| **Maternity care**                         |                         |
+--------------------------------------------+-------------------------+
| Complete maternity (obstetrical) care such | PPO: 10% of the Plan    |
| as:                                        | allowance (No           |
|                                            | Deductible)             |
| Prenatal care                              |                         |
|                                            | Non-PPO: 30% of the     |
| Amniocentesis                              | Plan allowance and any  |
|                                            | difference between our  |
| Delivery                                   | allowance and the       |
|                                            | billed amount (No       |
| Initial, routine examination of your       | Deductible)             |
| newborn infant covered under your family   |                         |
| enrollment                                 | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
| Circumcision of your newborn infant        | any difference between  |
|                                            | our allowance and the   |
| Postnatal care                             | billed amount (No       |
|                                            | Deductible)             |
| One routine sonogram                       |                         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Maternity care (continued)**             | ## You Pay              |
+--------------------------------------------+-------------------------+
| Note: Here are some things to keep in      |                         |
| mind:                                      |                         |
|                                            |                         |
| You do not have to precertify your normal  |                         |
| delivery; see page 9 for other             |                         |
| circumstances, such as extended stays for  |                         |
| you or your baby.                          |                         |
|                                            |                         |
| You may remain in the hospital up to 48    |                         |
| hours after a regular delivery and 96      |                         |
| hours after a cesarean delivery. We will   |                         |
| cover an extended stay, if medically       |                         |
| necessary but you, your representative,    |                         |
| your physician or your hospital must       |                         |
| precertify.                                |                         |
|                                            |                         |
| We cover routine nursery care of the       |                         |
| newborn child during the covered portion   |                         |
| of the mother's maternity stay. We will    |                         |
| cover other care of an infant who requires |                         |
| non-routine treatment if we cover the      |                         |
| infant under a Self and Family             |                         |
| enrollment.If your baby stays in the       |                         |
| hospital after your discharge and is       |                         |
| covered under your Self and Family         |                         |
| enrollment, you must pay a separate        |                         |
| hospital stay copayment. See Section 5(c). |                         |
|                                            |                         |
| Bassinet or nursery charges on which you   |                         |
| and your baby are confined are considered  |                         |
| your maternity expenses, not your baby's.  |                         |
|                                            |                         |
| Sonograms and other related tests that are |                         |
| not included in your routine prenatal or   |                         |
| postnatal care are covered in Lab, X-ray,  |                         |
| and other diagnostic tests, page page      |                         |
| [Error: Reference source not               |                         |
| found](#Lab_Tests).                        |                         |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| *Routine sonograms to determine fetal age, |                         |
| size or sex; or procedures, services,      |                         |
| drugs and 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.*              |                         |
+--------------------------------------------+-------------------------+
| **Family planning**                        |                         |
+--------------------------------------------+-------------------------+
| A range of voluntary family planning       | PPO: 10% of the Plan    |
| services, limited to:                      | allowance (No           |
|                                            | Deductible)             |
| Voluntary sterilization (See Section 5(b)  |                         |
| for surgical procedures)                   | Non-PPO: 30% of the     |
|                                            | Plan allowance and any  |
| Surgically implanted contraceptives        | difference between our  |
|                                            | allowance and the       |
| Fitting, inserting or removing             | billed amount (No       |
| intrauterine devices (such as diaphragms   | Deductible)             |
| IUDs)                                      |                         |
|                                            | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount (No       |
|                                            | Deductible)             |
+--------------------------------------------+-------------------------+
| Injection of contraceptive drugs (such as  | PPO: \$10 copay (No     |
| Depo-Provera)                              | Deductible)             |
|                                            |                         |
| Note: We cover FDA-approved prescription   | Non-PPO: 30% of the     |
| drugs and devices for birth con­trol in     | Plan allowance and any  |
| Section 5(f).                              | difference between our  |
|                                            | allowance and the       |
|                                            | billed amount.          |
|                                            |                         |
|                                            | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount.          |
+--------------------------------------------+-------------------------+
| *Not covered: reversal of voluntary        | *All charges*           |
| surgical sterilization, genetic            |                         |
| counseling.*                               |                         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Infertility services**                   | ## You Pay              |
+--------------------------------------------+-------------------------+
| Diagnosis and treatment of infertility     | PPO: 10% of the Plan    |
| except as shown in *Not covered*.          | allowance and charges   |
|                                            | in excess of the        |
| Initial diagnostic tests and procedures    | \$5,000 maximum         |
| done only to identify the cause of         |                         |
| infertility                                | Non-PPO: 30% of the     |
|                                            | Plan allowance and any  |
| Fertility drugs, hormone therapy and       | difference between our  |
| related services                           | allowance and the       |
|                                            | billed amount and       |
| Medical or surgical procedures done to     | charges in excess of    |
| create or enhance fertility                | the \$5,000 maximum     |
|                                            |                         |
| Note: We will pay up to \$5,000 per person | Out-of-network: 15% of  |
| per lifetime for covered infertility       | the Plan allowance and  |
| services, including prescription drugs.    | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount and       |
|                                            | charges in excess of    |
|                                            | the \$5,000 maximum     |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| Infertility services after voluntary       |                         |
| sterilization                              |                         |
|                                            |                         |
| Assisted reproductive technology (ART)     |                         |
| procedures, such as:                       |                         |
|                                            |                         |
| artificial insemination                    |                         |
|                                            |                         |
| in vitro fertilization                     |                         |
|                                            |                         |
| embryo transfer and gamete intrafallopian  |                         |
| transfer (GIFT)                            |                         |
|                                            |                         |
| intravaginal insemination (IVI)            |                         |
|                                            |                         |
| intracervical insemination (ICI)           |                         |
|                                            |                         |
| intrauterine insemination (IUI)            |                         |
|                                            |                         |
| Services and supplies related to ART       |                         |
| procedures                                 |                         |
|                                            |                         |
| Cost of donor sperm                        |                         |
|                                            |                         |
| Cost of donor egg                          |                         |
+--------------------------------------------+-------------------------+
| **Allergy care**                           |                         |
+--------------------------------------------+-------------------------+
| Allergy testing, injections and treatment  | PPO services **in       |
| (including allergy serum)                  | physician's office:**   |
|                                            | \$10 copayment (No      |
|                                            | Deductible)             |
|                                            |                         |
|                                            | PPO services **outside  |
|                                            | physician's office:**   |
|                                            | 10% of the Plan         |
|                                            | allowance               |
|                                            |                         |
|                                            | Non-PPO: 30% of the     |
|                                            | Plan allowance and any  |
|                                            | difference between our  |
|                                            | allowance and the       |
|                                            | billed amount           |
|                                            |                         |
|                                            | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount           |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Allergy care (continued)**               | ## You Pay              |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| RAST tests                                 |                         |
|                                            |                         |
| Food tests                                 |                         |
|                                            |                         |
| End Point titration techniques             |                         |
|                                            |                         |
| Sublingual allergy desensitation           |                         |
|                                            |                         |
| Hair analysis                              |                         |
+--------------------------------------------+-------------------------+
| **Treatment therapies**                    |                         |
+--------------------------------------------+-------------------------+
| Chemotherapy and radiation therapy (High   | PPO: 10% of the Plan    |
| dose chemotherapy in associ­ation with      | allowance               |
| autologous bone marrow transplants is      |                         |
| limited to those trans­plants listed in     | Non-PPO: 30% of the     |
| Section 5(b), Organ/tissue transplants.)   | Plan allowance and any  |
|                                            | difference between our  |
| Renal Dialysis                             | allowance and the       |
|                                            | billed amount           |
| Intravenous (IV)/Infusion Therapy Home IV  |                         |
| and antibiotic therapy                     | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
| Respiratory and inhalation therapies       | any difference between  |
|                                            | our allowance and the   |
| Growth hormone therapy (GHT) (We only      | billed amount           |
| cover GHT when you obtain prior approval.  |                         |
| Call 1-800-634-0069 for preauthorization.  |                         |
| We will ask you to submit information that |                         |
| establishes that the GHT is medically      |                         |
| necessary. Ask us to authorize GHT before  |                         |
| you begin treatment; other­wise, we will    |                         |
| only cover GHT services from the date you  |                         |
| submit the information. If you do not ask  |                         |
| or if we determine GHT is not medically    |                         |
| necessary, we will not cover the GHT or    |                         |
| related services and supplies. See Other   |                         |
| services under How to get approval         |                         |
| for\...in Section 3.)                      |                         |
|                                            |                         |
| Note: We cover drugs administered for the  |                         |
| therapies listed above in Section 5(f).    |                         |
+--------------------------------------------+-------------------------+
| **Physical,** **occupational, and**        |                         |
| **speech therapies**                       |                         |
+--------------------------------------------+-------------------------+
| 90 total combined outpatient physical,     | PPO: 10% of the Plan    |
| speech and occupational therapy visits per | allowance               |
| calendar year for the following:           |                         |
|                                            | Non-PPO: 30% of the     |
| Visits for the services of each of the     | Plan allowance and any  |
| following:                                 | difference between our  |
|                                            | allowance and the       |
| physicians;                                | billed amount           |
|                                            |                         |
| qualified physical therapists;             | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
| speech therapists; and                     | any difference between  |
|                                            | our allowance and the   |
| occupational therapists                    | billed amount           |
|                                            |                         |
| Note: 90 total combined visits not to      |                         |
| include inpatient physical, speech and     |                         |
| occupational therapy. Which is covered     |                         |
| under Section 5(c) hospital or facility    |                         |
| coverage.                                  |                         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Physical, occupational, and speech       | **You Pay**             |
| therapies (continued)**                    |                         |
+--------------------------------------------+-------------------------+
| Note: We only cover therapy when a         |                         |
| physician:                                 |                         |
|                                            |                         |
| orders the care;                           |                         |
|                                            |                         |
| identifies the specific professional       |                         |
| skills you require and the medical         |                         |
| necessity for skilled services; and        |                         |
|                                            |                         |
| indicates the length of time you need the  |                         |
| services.                                  |                         |
|                                            |                         |
| Note: We only cover physical and           |                         |
| occupational therapy to restore bodily     |                         |
| function when there has been a total or    |                         |
| partial loss due to illness or injury.     |                         |
|                                            |                         |
| Note: Inpatient rehabilitative services    |                         |
| are covered under Section 5(c)             |                         |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| *Long-term rehabilitative therapy*         |                         |
|                                            |                         |
| *Exercise programs*                        |                         |
+--------------------------------------------+-------------------------+
| **Hearing services (testing, treatment,    |                         |
| and supplies)**                            |                         |
+--------------------------------------------+-------------------------+
| First hearing aid and testing only when    | PPO: 10% of the Plan    |
| necessitated by accidental injury or       | allowance               |
| intra-aural surgery.                       |                         |
|                                            | Non-PPO: 25% of the     |
| Note: Services must be received within one | Plan allowance and any  |
| year of the date of the accident or        | difference between our  |
| surgery.                                   | allowance and the       |
|                                            | billed amount           |
|                                            |                         |
|                                            | Out-of-network: 15% 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, except for accidental injury or  |                         |
| intra-aural surgery.*                      |                         |
+--------------------------------------------+-------------------------+
| **Vision services (testing, treatment, and |                         |
| supplies)**                                |                         |
+--------------------------------------------+-------------------------+
| One pair of eyeglasses or contact lenses   | PPO: 10% of the Plan    |
| per incident to correct an impairment      | allowance               |
| directly caused by:                        |                         |
|                                            | Non-PPO: 25% of the     |
| Accidental ocular injury or                | Plan allowance and any  |
|                                            | difference between our  |
| Specifically ordered by the physician in   | allowance and the       |
| connection with a diagnosis of:            | billed amount           |
|                                            |                         |
| Cataract                                   | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
| Keratoconus or                             | any difference between  |
|                                            | our allowance and the   |
| Glaucoma                                   | billed amount           |
|                                            |                         |
| Note: Services must be received within one |                         |
| year of the date of accident or surgery.   |                         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Vision services (Continued)**            | ## You Pay              |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | All charges             |
|                                            |                         |
| *Eyeglasses or contact lenses and          |                         |
| examinations for them, except for          |                         |
| accidental injury and intraocular surgery* |                         |
|                                            |                         |
| *Eye exercises and orthoptics*             |                         |
|                                            |                         |
| *Radial keratotomy and other refractive    |                         |
| surgery*                                   |                         |
|                                            |                         |
| *Eye refractions*                          |                         |
+--------------------------------------------+-------------------------+
| **Foot care**                              |                         |
+--------------------------------------------+-------------------------+
| We do not provide benefits for routine     | All charges             |
| foot care, such as:                        |                         |
|                                            |                         |
| Treatment or removal of corns and          |                         |
| calluses, or trimming of toenails          |                         |
|                                            |                         |
| Orthopedic shoes, orthotics and other      |                         |
| supportive devices for the feet            |                         |
+--------------------------------------------+-------------------------+
| **Orthopedic and** **prosthetic devices**  |                         |
+--------------------------------------------+-------------------------+
| Orthopedic braces                          | PPO: 10% of the Plan    |
|                                            | allowance               |
| Artificial limbs and eyes to replace       |                         |
| natural limbs and eyes; stump hose         | Non-PPO: 25% of the     |
|                                            | Plan allowance and any  |
| Externally worn breast prostheses and      | difference between our  |
| surgical bras including necessary          | allowance and the       |
| replacements following a mastectomy        | billed amount           |
|                                            |                         |
| Internal prosthetic devices, such as       | Out-of-network: 15% of  |
| artificial joints, pacemakers, cochlear    | the Plan allowance and  |
| implants, and surgically implanted breast  | any difference between  |
| implants following mastec­tomy.             | our allowance and the   |
|                                            | billed amount           |
| Note: See Section 5(b) for coverage of the |                         |
| surgery to insert the device and Section   |                         |
| 5(c) for hospital or facility coverage.    |                         |
+--------------------------------------------+-------------------------+
| Wigs up to a \$300 maximum while covered   | Nothing up to the       |
| under this Plan, when required due to hair | lifetime maximum of     |
| loss in connection with chemotherapy or    | \$300 (No Deductible).  |
| radiation treatment                        | All charges over the    |
|                                            | \$300 lifetime maximum. |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| *Orthopedic and corrective shoes and other |                         |
| supportive devices for the feet*           |                         |
|                                            |                         |
| *Arch supports*                            |                         |
|                                            |                         |
| *Foot orthotics*                           |                         |
|                                            |                         |
| *Heel pads and heel cups*                  |                         |
|                                            |                         |
| *Corsets, trusses, elastic stockings,      |                         |
| support hose, and other supportive         |                         |
| devices*                                   |                         |
|                                            |                         |
| *Lumbosacral supports*                     |                         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Durable medical equipment (DME)**        | ## You Pay              |
+--------------------------------------------+-------------------------+
| Durable medical equipment (DME) is         | PPO: 10% of the Plan    |
| equipment and supplies that:               | allowance               |
|                                            |                         |
| Are prescribed by your attending physician | Non-PPO: 25% of the     |
| (i.e., the physician who is treating your  | Plan allowance and any  |
| illness or injury);                        | difference between our  |
|                                            | allowance and the       |
| Are medically necessary;                   | billed amount           |
|                                            |                         |
| Are primarily and customarily used only    | Out-of-network: 15% of  |
| for a medical purpose;                     | the Plan allowance and  |
|                                            | any difference between  |
| Are generally useful only to a person with | our allowance and the   |
| an illness or injury;                      | billed amount           |
|                                            |                         |
| Are designed for prolonged use; and        |                         |
|                                            |                         |
| Serve a specific therapeutic purpose in    |                         |
| the treatment of an illness or injury.     |                         |
+--------------------------------------------+-------------------------+
| We cover purchase or rental up to the      | PPO: 10% of the Plan    |
| purchase price, at our option, including   | allowance               |
| repair and adjustment, of durable medical  |                         |
| equipment. Under this benefit, we also     | Non-PPO: 25% of the     |
| cover:                                     | Plan allowance and any  |
|                                            | difference between our  |
| Oxygen;                                    | allowance and the       |
|                                            | billed amount           |
| Hospital beds;                             |                         |
|                                            | Out-of-network: 15% of  |
| Dialysis equipment;                        | the Plan allowance and  |
|                                            | any difference between  |
| Respirators;                               | our allowance and the   |
|                                            | billed amount           |
| Wheelchairs, crutches, canes, walkers,     |                         |
| casts;                                     |                         |
|                                            |                         |
| Cervical collars and traction kits; and    |                         |
|                                            |                         |
| Splints and trusses                        |                         |
+--------------------------------------------+-------------------------+
| *Not covered: Sun or heat lamps, whirlpool | *All charges*           |
| baths, heating pads, air purifiers,        |                         |
| humidifiers, air conditioners, and         |                         |
| exercise devices*                          |                         |
+--------------------------------------------+-------------------------+
| **Home health services**                   |                         |
+--------------------------------------------+-------------------------+
| For services provided on a **part-time     | PPO: Charges in excess  |
| basis** (less than an 8-hour shift):       | of \$80 per visit (No   |
|                                            | Deductible) (90 visit   |
| If **precertified**, 90 visits per         | maximum). All charges   |
| calendar year up to a maximum Plan payment | over the visit limit.   |
| of \$80 per visit when:                    |                         |
|                                            | Non-PPO: Charges in     |
| A registered nurse (R.N.) or licensed      | excess of \$80 per      |
| practical nurse (L.P.N.) provides the      | visit and any           |
| services;                                  | difference between the  |
|                                            | Plan allowance and the  |
| A licensed therapist provides physical,    | billed amount (No       |
| occupational or speech therapy;            | Deductible) (90 visit   |
|                                            | maximum). All charges   |
| The attending physician orders the care;   | over the visit limit.   |
|                                            |                         |
| The physician identifies the specific      | Out-of-network: Charges |
| professional skills required by the        | in excess of \$80 per   |
| patient and the medical necessity for      | visit and any           |
| skilled services; and                      | difference between the  |
|                                            | Plan allowance and the  |
| The physician indicates the length of time | billed amount (No       |
| the services are needed.                   | Deductible) (90 visit   |
|                                            | maximum). All charges   |
|                                            | over the visit limit.   |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Home health services (continued)**       | ## You Pay              |
+--------------------------------------------+-------------------------+
| For private duty nursing provided on a     | PPO: 10% of the Plan    |
| **full-time basis** (more than an 8-hour   | allowance               |
| shift) by a Registered Nurse (R.N.) or     |                         |
| Licensed Practical Nurse (L.P.N.) when:    | Non-PPO: 25% of the     |
|                                            | Plan allowance and any  |
| -   the care is ordered by the attending   | difference between our  |
|     physician, and                         | allowance and the       |
|                                            | billed amount           |
| -   your physician identifies the specific |                         |
|     professional nursing skills that you   | Out-of-network: 15% of  |
|     require, as well as the length of time | the Plan allowance and  |
|     needed.                                | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount           |
+--------------------------------------------+-------------------------+
| *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, rehabilitative:*              |                         |
|                                            |                         |
| *Custodial care as defined in Section 10.* |                         |
+--------------------------------------------+-------------------------+
| **Chiropractic**                           |                         |
+--------------------------------------------+-------------------------+
| No Benefits                                | All Charges             |
+--------------------------------------------+-------------------------+
| **Alternative treatments**                 |                         |
+--------------------------------------------+-------------------------+
| Acupuncture when used as an anesthetic     | PPO: 10% of the Plan    |
| agent for covered surgery                  | allowance (No           |
|                                            | Deductible)             |
|                                            |                         |
|                                            | Non-PPO: 25% of the     |
|                                            | Plan allowance and any  |
|                                            | difference between our  |
|                                            | allowance and the       |
|                                            | billed amount (No       |
|                                            | Deductible)             |
|                                            |                         |
|                                            | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount (No       |
|                                            | Deductible)             |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| *Chiropractic services*                    |                         |
|                                            |                         |
| *Chelation therapy except for acute        |                         |
| arsenic, gold, mercury, lead, or use of    |                         |
| Deferoxamine in iron poisoning*            |                         |
|                                            |                         |
| *Naturopathic services*                    |                         |
|                                            |                         |
| *Homeopathic services and medicines*       |                         |
|                                            |                         |
| (Note: Benefits of certain alternative     |                         |
| treatment providers may be covered in      |                         |
| medically underserved areas; see page      |                         |
| [Error: Reference source not               |                         |
| found](#Medically_underserv).)             |                         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Educational classes and programs**       | ## You Pay              |
+--------------------------------------------+-------------------------+
| Coverage is limited to:                    | PPO: 10% of the Plan    |
|                                            | allowance and all       |
| Smoking Cessation Up to \$100 maximum per  | charges in excess of    |
| person per calendar year                   | the \$100 maximum       |
|                                            |                         |
| Individual/Group counseling and            | Non-PPO: 25% of the     |
| over-the-counter (OTC) drugs               | Plan allowance and any  |
|                                            | difference between our  |
|                                            | allowance and the       |
|                                            | billed amount and all   |
|                                            | charges in excess of    |
|                                            | the \$100 maximum       |
|                                            |                         |
|                                            | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount and all   |
|                                            | charges in excess of    |
|                                            | the \$100 maximum       |
+--------------------------------------------+-------------------------+
| Coverage is limited to:                    | PPO: \$10 copayment (No |
|                                            | Deductible)             |
| Smoking Cessation Up to \$100 maximum per  |                         |
| person per calendar year                   | Non-PPO: 30% of the     |
|                                            | Plan allowance and any  |
| Individual/Group counseling and            | difference between our  |
| over-the-counter (OTC) drugs               | allowance and the       |
|                                            | billed amount           |
|                                            |                         |
|                                            | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount           |
+--------------------------------------------+-------------------------+
| Note: Prescription drugs are covered under |                         |
| Section 5(f).                              |                         |
+--------------------------------------------+-------------------------+

## Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals

+----+----+---------------------------------+----------------+---+---+
|    | *  | **Here are some important       |                | * |   |
|    | *I | things you should keep in mind  |                | * |   |
|    | ** | about these benefits:**         |                | I |   |
|    |    |                                 |                | * |   |
|    | *  | Please remember that all        |                | * |   |
|    | *M | benefits are subject to the     |                |   |   |
|    | ** | definitions, limitations, and   |                | * |   |
|    |    | exclusions in this brochure and |                | * |   |
|    | *  | are payable only when we        |                | M |   |
|    | *P | determine they are medically    |                | * |   |
|    | ** | necessary.                      |                | * |   |
|    |    |                                 |                |   |   |
|    | *  | The calendar year deductible    |                | * |   |
|    | *O | does not apply for these        |                | * |   |
|    | ** | benefits; however, we added     |                | P |   |
|    |    | ---(No Deductible) - to show    |                | * |   |
|    | *  | that the calendar year          |                | * |   |
|    | *R | deductible does not apply.      |                |   |   |
|    | ** |                                 |                | * |   |
|    |    | PPO benefits apply only when    |                | * |   |
|    | *  | you reside in the PPO network   |                | O |   |
|    | *T | area and use a PPO provider.    |                | * |   |
|    | ** | When no PPO provider is         |                | * |   |
|    |    | available, non-PPO benefits     |                |   |   |
|    | *  | apply. Out-of-network benefits  |                | * |   |
|    | *A | apply when you reside outside   |                | * |   |
|    | ** | the PPO network area.           |                | R |   |
|    |    |                                 |                | * |   |
|    | *  | Be sure to read Section 4,      |                | * |   |
|    | *N | *Your costs for covered         |                |   |   |
|    | ** | services* for valuable          |                | * |   |
|    |    | information about how cost      |                | * |   |
|    | *  | sharing works, with special     |                | T |   |
|    | *T | sections for members who are    |                | * |   |
|    | ** | age 65 or over. Also read       |                | * |   |
|    |    | Section 9 about coordinating    |                |   |   |
|    |    | benefits with other coverage,   |                | * |   |
|    |    | including with Medicare.        |                | * |   |
|    |    |                                 |                | A |   |
|    |    | 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     |                | N |   |
|    |    | facility (i.e., hospital,       |                | * |   |
|    |    | surgical center, etc.).         |                | * |   |
|    |    |                                 |                |   |   |
|    |    | **YOU MUST GET PRECERTIFICATION |                | * |   |
|    |    | OF SOME SURGICAL PROCEDURES.    |                | * |   |
|    |    | Please refer to the             |                | T |   |
|    |    | precertification information    |                | * |   |
|    |    | shown in Section 3 to be sure   |                | * |   |
|    |    | which services require          |                |   |   |
|    |    | precertification.**             |                |   |   |
+----+----+---------------------------------+----------------+---+---+
| ## |    |                                 | **You pay**    |   |   |
|  B |    |                                 |                |   |   |
| en |    |                                 | **After the    |   |   |
| ef |    |                                 | calendar year  |   |   |
| it |    |                                 | deductible**   |   |   |
|  D |    |                                 |                |   |   |
| es |    |                                 |                |   |   |
| cr |    |                                 |                |   |   |
| ip |    |                                 |                |   |   |
| ti |    |                                 |                |   |   |
| on |    |                                 |                |   |   |
+----+----+---------------------------------+----------------+---+---+
| N  |    |                                 |                |   |   |
| ot |    |                                 |                |   |   |
| e: |    |                                 |                |   |   |
| We |    |                                 |                |   |   |
| a  |    |                                 |                |   |   |
| dd |    |                                 |                |   |   |
| ed |    |                                 |                |   |   |
|  - |    |                                 |                |   |   |
| (  |    |                                 |                |   |   |
| No |    |                                 |                |   |   |
| D  |    |                                 |                |   |   |
| ed |    |                                 |                |   |   |
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| bl |    |                                 |                |   |   |
| e) |    |                                 |                |   |   |
|  - |    |                                 |                |   |   |
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| ow |    |                                 |                |   |   |
| wh |    |                                 |                |   |   |
| en |    |                                 |                |   |   |
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| ar |    |                                 |                |   |   |
| de |    |                                 |                |   |   |
| du |    |                                 |                |   |   |
| ct |    |                                 |                |   |   |
| ib |    |                                 |                |   |   |
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| ** |    |                                 |                |   |   |
| do |    |                                 |                |   |   |
| es |    |                                 |                |   |   |
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| ot |    |                                 |                |   |   |
| ** |    |                                 |                |   |   |
| a  |    |                                 |                |   |   |
| pp |    |                                 |                |   |   |
| ly |    |                                 |                |   |   |
+----+----+---------------------------------+----------------+---+---+
| ** |    |                                 |                |   |   |
| Su |    |                                 |                |   |   |
| rg |    |                                 |                |   |   |
| ic |    |                                 |                |   |   |
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| ed |    |                                 |                |   |   |
| ur |    |                                 |                |   |   |
| es |    |                                 |                |   |   |
| ** |    |                                 |                |   |   |
+----+----+---------------------------------+----------------+---+---+
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| 2) |    |                                 |                |   |   |
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| de |    |                                 |                |   |   |
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| ce |    |                                 |                |   |   |
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| ra |    |                                 |                |   |   |
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| in |    |                                 |                |   |   |
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| n. |    |                                 |                |   |   |
+----+----+---------------------------------+----------------+---+---+

+--------------------------------------------+-------------------------+
| **Surgical procedures (continued)**        | ## You pay              |
+--------------------------------------------+-------------------------+
| Voluntary sterilization (e.g., tubal       | PPO: 10% of the Plan    |
| ligation, vasectomy)                       | allowance (No           |
|                                            | Deductible)             |
| Surgically implanted contraceptives, and   |                         |
| intrauterine devices (IUDs)                | Non-PPO: 30% of the     |
|                                            | Plan allowance and any  |
| Treatment of burns                         | difference between our  |
|                                            | allowance and the       |
| Surgical treatment of bunions or spurs     | billed amount (No       |
|                                            | Deductible)             |
| Assistant surgeons - we cover up to 20% of |                         |
| our allowance for the surgeon's charge     | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
| Note: For related services, see applicable | any difference between  |
| benefits section (i.e., for\               | our allowance and the   |
| inpatient hospital benefits, see Section   | billed amount (No       |
| 5(c)).                                     | Deductible)             |
+--------------------------------------------+-------------------------+
| When multiple or bilateral surgical        | PPO: 10% of the Plan    |
| procedures performed during the same       | allowance for the\      |
| operative session add time or complexity   | primary procedure and   |
| to patient care, our\                      | 10% of one-half of the  |
| benefits are:                              | Plan allowance for the  |
|                                            | secondary\              |
| For the primary procedure:                 | procedure(s) (No        |
|                                            | Deductible)             |
| PPO: 90% of the Plan allowance or (No      |                         |
| Deductible)                                | Non-PPO: 30% of the     |
|                                            | Plan allowance for the  |
| Non-PPO: 70% of the Plan allowance or (No  | primary procedure and   |
| Deductible)                                | 30% of one-half of the  |
|                                            | Plan allowance for the  |
| Out-of-network: 85% of the Plan allowance  | secondary\              |
| (No Deductible)                            | procedure(s); and any   |
|                                            | difference between our\ |
| For the secondary procedure(s):            | payment and the billed  |
|                                            | amount (No Deductible)  |
| PPO: 90% of one-half of the Plan allowance |                         |
| or (No Deductible)                         | Out-of-network: 15% of  |
|                                            | the Plan allowance for  |
| Non-PPO: 70% of one-half of the Plan       | the primary procedure   |
| allowance (No Deductible)                  | and 15% of\             |
|                                            | one-half of the Plan    |
| Out-of-network: 85% of one-half of the     | allowance for the\      |
| Plan allowance (No Deductible)             | secondary procedure(s); |
|                                            | and any difference      |
| Note: Multiple or bilateral surgical       | between our payment and |
| procedures performed through the same      | the billed amount (No   |
| incision are "incidental" to the primary   | Deductible)             |
| surgery. That is, the procedure would not  |                         |
| add time or complexity to patient care. We | Note: For certain       |
| do not pay extra for incidental            | surgical procedures, we |
| procedures.                                | may apply a value of    |
|                                            | less than 50% of        |
|                                            | subsequent procedures.  |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| *Services of a standby surgeon, except     |                         |
| during angioplasty or other high risk      |                         |
| procedures when we determine standbys are  |                         |
| medically\                                 |                         |
| necessary*                                 |                         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Reconstructive surgery**                 | **You Pay**             |
+--------------------------------------------+-------------------------+
| Surgery to correct a functional defect     | PPO: 10% of the Plan    |
|                                            | allowance (No           |
| Surgery to correct a condition caused by   | Deductible)             |
| injury or illness if:                      |                         |
|                                            | Non-PPO: 30% of the     |
| the condition produced a major effect on   | Plan allowance and any  |
| the member's\                              | difference between our  |
| appearance and                             | allowance and the       |
|                                            | billed amount (No       |
| the condition can reasonably be expected   | Deductible)             |
| to be corrected by such surgery.           |                         |
|                                            | Out-of-network: 15% of  |
| Surgery to correct a condition that        | the Plan allowance and  |
| existed at or from birth and is a          | any difference between  |
| significant deviation from the common form | our allowance and the   |
| or norm. Examples of congenital anomalies  | billed amount (No       |
| are: protruding ear deformities; cleft     | Deductible)             |
| lip; cleft palate; birthmarks; and webbed  |                         |
| fingers and toes.                          |                         |
|                                            |                         |
| All stages of breast reconstruction        |                         |
| surgery following a mastectomy, such as:   |                         |
|                                            |                         |
| surgery to produce a symmetrical           |                         |
| appearance of breasts;                     |                         |
|                                            |                         |
| treatment of any physical complications,   |                         |
| such as lymphedemas;                       |                         |
|                                            |                         |
| breast prostheses; and surgical bras and   |                         |
| replacements (see\                         |                         |
| Prosthetic devices for coverage)           |                         |
+--------------------------------------------+-------------------------+
| Note: Internal breast prostheses are       |                         |
| covered under Section 5(a).                |                         |
|                                            |                         |
| Note: If you need a mastectomy, you may    |                         |
| choose to have the procedure performed on  |                         |
| an inpatient basis and remain in the       |                         |
| hospital up to 48 hours after the          |                         |
| procedure.                                 |                         |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| *Cosmetic surgery -- any surgical          |                         |
| procedure (or any portion of a\            |                         |
| procedure) performed primarily to improve  |                         |
| physical appearance through change in      |                         |
| bodily form, except repair of accidental   |                         |
| injury*                                    |                         |
|                                            |                         |
| *Surgeries related to sex transformation   |                         |
| or sexual dysfunction*                     |                         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Oral and maxillofacial surgery**         | ## You Pay              |
+--------------------------------------------+-------------------------+
| Oral surgical procedures, limited to:      | PPO: 10% of the Plan    |
|                                            | allowance (No           |
| Reduction of fractures of the jaws or      | Deductible)             |
| facial bones                               |                         |
|                                            | Non-PPO: 30% of the     |
| Surgical correction of cleft lip, cleft    | Plan allowance and any  |
| palate or severe functional\               | difference between our  |
| malocclusion                               | allowance and the       |
|                                            | billed amount (No       |
| Removal of stones from salivary ducts      | Deductible)             |
|                                            |                         |
| Excision of leukoplakia or malignancies    | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
| Excision of cysts and incision of          | any difference between  |
| abscesses when done as\                    | our allowance and the   |
| independent procedures                     | billed amount (No       |
|                                            | Deductible)             |
| Surgical correction of temporomandibular   |                         |
| joint (TMJ) dysfunction                    |                         |
|                                            |                         |
| Surgical removal of impacted teeth,        |                         |
| including anesthesia charges               |                         |
|                                            |                         |
| Other surgical procedures that do not      |                         |
| involve the teeth or their\                |                         |
| supporting structures                      |                         |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| *Oral implants and transplants*            |                         |
|                                            |                         |
| *Procedures that involve the teeth or      |                         |
| their supporting structures (such as the   |                         |
| periodontal membrane, gingiva, and         |                         |
| alveolar bone)*                            |                         |
|                                            |                         |
| *Pre- and post-operative examinations in   |                         |
| preparation for surgical removal of        |                         |
| impacted teeth*                            |                         |
+--------------------------------------------+-------------------------+
| **Organ/tissue** **transplants**           |                         |
+--------------------------------------------+-------------------------+
| Limited to the following transplants       | PPO: 10% of the Plan    |
|                                            | allowance (No           |
| Cornea                                     | Deductible)             |
|                                            |                         |
| Heart                                      | Non-PPO: 30% of the     |
|                                            | Plan allowance and any  |
| Kidney                                     | difference between our  |
|                                            | allowance and the       |
| Pancreas                                   | billed amount (No       |
|                                            | Deductible)             |
| Kidney/Pancreas                            |                         |
|                                            | Out-of-network: 15% of  |
| Heart/Lung                                 | the Plan allowance and  |
|                                            | any difference between  |
| Liver                                      | our allowance and the   |
|                                            | billed amount (No       |
| Lung: Single---only for the following      | Deductible)             |
| end-stage pulmonary diseases: pulmonary    |                         |
| fibrosis, primary pulmonary hypertension,  |                         |
| or emphysema; Double---only for patients   |                         |
| with cystic fibrosis                       |                         |
|                                            |                         |
| Intestinal transplants (small intestine)   |                         |
| and the small intestine with the liver or  |                         |
| small intestine with multiple organs such  |                         |
| as the liver, stomach and pancreas for     |                         |
| irreversible intestinal failure            |                         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Organ/tissue transplants (continued)**   | ## You Pay              |
+--------------------------------------------+-------------------------+
| Bone marrow and stem cell support as       | PPO: 10% of the Plan    |
| follows:                                   | allowance (No           |
|                                            | Deductible)             |
| Allogeneic bone marrow transplants         |                         |
|                                            | Non-PPO: 30% of the     |
| Autologous bone marrow transplants         | Plan allowance and any  |
| (autologous stem support) and autologous   | difference between our  |
| peripheral stem cell support for           | allowance and the       |
|                                            | billed amount (No       |
| Acute lymphocytic or non-lymphocytic       | Deductible)             |
| leukemia;                                  |                         |
|                                            | Out-of-network: 15% of  |
| Advanced Hodgkin's and non-Hodgkin's       | the Plan allowance and  |
| lymphoma;                                  | any difference between  |
|                                            | our allowance and the   |
| Advanced neuroblastoma;                    | billed amount (No       |
|                                            | Deductible)             |
| Testicular, mediastinal, retroperitoneal   |                         |
| and ovarian germ cell tumors;              |                         |
|                                            |                         |
| Breast cancer;                             |                         |
|                                            |                         |
| Multiple myeloma; and                      |                         |
|                                            |                         |
| Epithelial ovarian cancer                  |                         |
|                                            |                         |
| Note: We cover related medical and         |                         |
| hospital expenses of the donor when we     |                         |
| cover the recipient.                       |                         |
|                                            |                         |
| Note: We have special arrangements with    |                         |
| facilities to provide services for tissue  |                         |
| and organ transplants---our Medical        |                         |
| Specialty Network. The network was         |                         |
| designed to give you an opportunity to     |                         |
| access providers that demonstrate high     |                         |
| quality medical care for transplant        |                         |
| patients. Your physician can coordinate    |                         |
| arrangements by calling us at              |                         |
| 1-800-634-0069.                            |                         |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| *Donor screening tests and donor search    |                         |
| expenses, except those performed for the   |                         |
| actual donor*                              |                         |
|                                            |                         |
| *Transplants not listed as covered*        |                         |
|                                            |                         |
| *Implants of artificial organs*            |                         |
+--------------------------------------------+-------------------------+
| **Anesthesia**                             |                         |
+--------------------------------------------+-------------------------+
| Professional services provided in:         | PPO: 10% of the Plan    |
|                                            | allowance (No           |
| Hospital (inpatient)                       | Deductible)             |
|                                            |                         |
| Hospital outpatient department             | Non-PPO: 25% of the     |
|                                            | Plan allowance and any  |
| Skilled nursing facility                   | difference between our  |
|                                            | allowance and the       |
| Ambulatory surgical center                 | billed amount (No       |
|                                            | Deductible)             |
| Office                                     |                         |
|                                            | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount (No       |
|                                            | Deductible)             |
+--------------------------------------------+-------------------------+

## Section 5 (c). Services provided by a hospital or other facility, and ambulance services 

+---+---+-------------------------------------+---------------+---+---+
|   | * | **Here are some important things    |               | * |   |
|   | * | you should keep in mind about these |               | * |   |
|   | I | benefits:**                         |               | I |   |
|   | * |                                     |               | * |   |
|   | * | Please remember that all benefits   |               | * |   |
|   |   | are subject to the definitions,     |               |   |   |
|   | * | limitations, and exclusions in this |               | * |   |
|   | * | brochure and are payable only when  |               | * |   |
|   | M | we determine they are medically     |               | M |   |
|   | * | necessary.                          |               | * |   |
|   | * |                                     |               | * |   |
|   |   | The calendar year deductible does   |               |   |   |
|   | * | not apply for these benefits;       |               | * |   |
|   | * | however, we added ---(No            |               | * |   |
|   | P | Deductible) - to show that the      |               | P |   |
|   | * | calendar year deductible does not   |               | * |   |
|   | * | apply.                              |               | * |   |
|   |   |                                     |               |   |   |
|   | * | PPO benefits apply only when you    |               | * |   |
|   | * | reside in the PPO network area and  |               | * |   |
|   | O | use a PPO provider. When no PPO     |               | O |   |
|   | * | provider is available, non-PPO      |               | * |   |
|   | * | benefits apply. Out-of-network      |               | * |   |
|   |   | benefits apply when you reside      |               |   |   |
|   | * | outside the PPO network area.       |               | * |   |
|   | * |                                     |               | * |   |
|   | R | Be sure to read Section 4, *Your    |               | R |   |
|   | * | 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 9 about  |               | * |   |
|   | T | coordinating benefits with other    |               | T |   |
|   | * | coverage, including with Medicare.  |               | * |   |
|   | * |                                     |               | * |   |
|   |   | The amounts listed below are for    |               |   |   |
|   | * | the charges billed by a physician   |               | * |   |
|   | * | or other health care professional   |               | * |   |
|   | A | for your surgical care. Look in     |               | A |   |
|   | * | Section 5(c) for charges associated |               | * |   |
|   | * | with the facility (i.e., hospital,  |               | * |   |
|   |   | surgical center, etc.).             |               |   |   |
|   | * |                                     |               | * |   |
|   | * | **YOU MUST GET PRECERTIFICATION OF  |               | * |   |
|   | N | SOME SURGICAL PROCEDURES. Please    |               | N |   |
|   | * | refer to the precertification       |               | * |   |
|   | * | information shown in Section 3 to   |               | * |   |
|   |   | be sure which services require      |               |   |   |
|   | * | precertification.**                 |               | * |   |
|   | * |                                     |               | * |   |
|   | T |                                     |               | T |   |
|   | * |                                     |               | * |   |
|   | * |                                     |               | * |   |
+---+---+-------------------------------------+---------------+---+---+
| # |   |                                     | **You Pay**   |   |   |
| # |   |                                     |               |   |   |
| # |   |                                     |               |   |   |
|   |   |                                     |               |   |   |
| B |   |                                     |               |   |   |
| e |   |                                     |               |   |   |
| n |   |                                     |               |   |   |
| e |   |                                     |               |   |   |
| f |   |                                     |               |   |   |
| i |   |                                     |               |   |   |
| t |   |                                     |               |   |   |
|   |   |                                     |               |   |   |
| D |   |                                     |               |   |   |
| e |   |                                     |               |   |   |
| s |   |                                     |               |   |   |
| c |   |                                     |               |   |   |
| r |   |                                     |               |   |   |
| i |   |                                     |               |   |   |
| p |   |                                     |               |   |   |
| t |   |                                     |               |   |   |
| i |   |                                     |               |   |   |
| o |   |                                     |               |   |   |
| n |   |                                     |               |   |   |
+---+---+-------------------------------------+---------------+---+---+
| * |   |                                     |               |   |   |
| * |   |                                     |               |   |   |
| N |   |                                     |               |   |   |
| o |   |                                     |               |   |   |
| t |   |                                     |               |   |   |
| e |   |                                     |               |   |   |
| : |   |                                     |               |   |   |
| W |   |                                     |               |   |   |
| e |   |                                     |               |   |   |
| a |   |                                     |               |   |   |
| d |   |                                     |               |   |   |
| d |   |                                     |               |   |   |
| e |   |                                     |               |   |   |
| d |   |                                     |               |   |   |
|   |   |                                     |               |   |   |
| - |   |                                     |               |   |   |
| ( |   |                                     |               |   |   |
| N |   |                                     |               |   |   |
| o |   |                                     |               |   |   |
| D |   |                                     |               |   |   |
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| d |   |                                     |               |   |   |
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| e |   |                                     |               |   |   |
| ) |   |                                     |               |   |   |
|   |   |                                     |               |   |   |
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| t |   |                                     |               |   |   |
| o |   |                                     |               |   |   |
| s |   |                                     |               |   |   |
| h |   |                                     |               |   |   |
| o |   |                                     |               |   |   |
| w |   |                                     |               |   |   |
| w |   |                                     |               |   |   |
| h |   |                                     |               |   |   |
| e |   |                                     |               |   |   |
| n |   |                                     |               |   |   |
| t |   |                                     |               |   |   |
| h |   |                                     |               |   |   |
| e |   |                                     |               |   |   |
| c |   |                                     |               |   |   |
| a |   |                                     |               |   |   |
| l |   |                                     |               |   |   |
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| n |   |                                     |               |   |   |
| d |   |                                     |               |   |   |
| a |   |                                     |               |   |   |
| r |   |                                     |               |   |   |
| y |   |                                     |               |   |   |
| e |   |                                     |               |   |   |
| a |   |                                     |               |   |   |
| r |   |                                     |               |   |   |
| d |   |                                     |               |   |   |
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| d |   |                                     |               |   |   |
| u |   |                                     |               |   |   |
| c |   |                                     |               |   |   |
| t |   |                                     |               |   |   |
| i |   |                                     |               |   |   |
| b |   |                                     |               |   |   |
| l |   |                                     |               |   |   |
| e |   |                                     |               |   |   |
| d |   |                                     |               |   |   |
| o |   |                                     |               |   |   |
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| s |   |                                     |               |   |   |
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| y |   |                                     |               |   |   |
| * |   |                                     |               |   |   |
| * |   |                                     |               |   |   |
+---+---+-------------------------------------+---------------+---+---+
| * |   |                                     |               |   |   |
| * |   |                                     |               |   |   |
| I |   |                                     |               |   |   |
| n |   |                                     |               |   |   |
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+---+---+-------------------------------------+---------------+---+---+
| R |   |                                     | PPO: \$100    |   |   |
| o |   |                                     | copayment per |   |   |
| o |   |                                     | hospital stay |   |   |
| m |   |                                     | (No           |   |   |
| a |   |                                     | Deductible)   |   |   |
| n |   |                                     |               |   |   |
| d |   |                                     | Non-PPO:      |   |   |
| b |   |                                     | \$300         |   |   |
| o |   |                                     | copayment per |   |   |
| a |   |                                     | hospital stay |   |   |
| r |   |                                     | and 30% of    |   |   |
| d |   |                                     | the covered   |   |   |
| , |   |                                     | charges (No   |   |   |
| s |   |                                     | Deduct- ible) |   |   |
| u |   |                                     |               |   |   |
| c |   |                                     | Ou            |   |   |
| h |   |                                     | t-of-network: |   |   |
| a |   |                                     | \$200 per     |   |   |
| s |   |                                     | hospital stay |   |   |
|   |   |                                     | (No           |   |   |
| s |   |                                     | Deductible)   |   |   |
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| t |   |                                     |               |   |   |
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| l |   |                                     |               |   |   |
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| . |   |                                     |               |   |   |
+---+---+-------------------------------------+---------------+---+---+

+--------------------------------------------+-------------------------+
| **Inpatient hospital (Continued)**         | ## You Pay              |
+--------------------------------------------+-------------------------+
| Operating, recovery, maternity, and other  | PPO: \$100 copayment    |
| treatment rooms                            | per hospital stay (No   |
|                                            | Deductible)             |
| Rehabilitative services                    |                         |
|                                            | Non-PPO: \$300          |
| Prescribed drugs and medicines             | copayment per hospital  |
|                                            | stay and 30% of the     |
| Diagnostic laboratory tests and X-rays     | covered charges (No     |
|                                            | Deduct- ible)           |
| Blood or blood plasma, if not donated or   |                         |
| replaced                                   | Out-of-network: \$200   |
|                                            | per hospital stay (No   |
| Dressings, splints, casts, and sterile     | Deductible)             |
| tray services                              |                         |
|                                            |                         |
| Medical supplies and equipment, including  |                         |
| oxygen                                     |                         |
|                                            |                         |
| Anesthetics                                |                         |
|                                            |                         |
| Note: Take-home drugs are covered under    |                         |
| Section 5(f).                              |                         |
|                                            |                         |
| Note: Take-home medical supplies,          |                         |
| appliances, medical equipment, and any     |                         |
| covered items billed by a hospital are     |                         |
| covered under Section 5(a).                |                         |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| *Any part of a hospital admission that is  |                         |
| not medically necessary (see definition in |                         |
| Section 10) such as when you do not need   |                         |
| the acute hospital inpatient (overnight)   |                         |
| setting but could receive care in some     |                         |
| other setting without adversely affecting  |                         |
| your condition or the quality of the       |                         |
| medical care.*                             |                         |
|                                            |                         |
| *Note: In this event, we pay benefits for  |                         |
| services and supplies, excluding room and  |                         |
| board and in-patient physician care, at    |                         |
| the level of benefits that would have been |                         |
| covered if provided in another approved    |                         |
| setting.*                                  |                         |
|                                            |                         |
| *Inpatient hospital services and supplies  |                         |
| for surgery that we do not cover*          |                         |
|                                            |                         |
| *Custodial care (see definition) even when |                         |
| provided by a hospital*                    |                         |
|                                            |                         |
| *Non-covered facilities, such as nursing   |                         |
| homes, rest homes, places for the aged,    |                         |
| convalescent homes or any place that is    |                         |
| not a hospital, skilled nursing facility,  |                         |
| or hospice*                                |                         |
|                                            |                         |
| *Personal comfort items, such as radio,    |                         |
| television, telephone, beauty and barber   |                         |
| services*                                  |                         |
|                                            |                         |
| *Private nursing care*                     |                         |
|                                            |                         |
| *Long term rehabilitative therapy*         |                         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Outpatient hospital or ambulatory**      | ## You Pay              |
| **surgical center**                        |                         |
+--------------------------------------------+-------------------------+
| Operating, recovery, and other treatment   | PPO: 10% of the Plan    |
| rooms                                      | allowance               |
|                                            |                         |
| Prescribed drugs and medicines for use in  | Non-PPO: 30% of the     |
| the facility                               | Plan allowance and any  |
|                                            | difference between our  |
| X-ray, laboratory and pathology services,  | allowance and the       |
| and machine diagnostic tests               | billed amount           |
|                                            |                         |
| Administration of blood, blood plasma, and | Out-of-network: 15% of  |
| other biologicals                          | the Plan allowance and  |
|                                            | any difference between  |
| Blood and blood plasma, if not donated or  | our allowance and the   |
| replaced                                   | billed amount           |
|                                            |                         |
| Dressings, casts, and sterile tray         |                         |
| services                                   |                         |
|                                            |                         |
| Medical supplies, including oxygen         |                         |
|                                            |                         |
| Anesthetics and anesthesia service         |                         |
|                                            |                         |
| Outpatient facility room charges           |                         |
|                                            |                         |
| Note: Take-home drugs are covered under    |                         |
| Section 5(f).                              |                         |
|                                            |                         |
| Note: Take-home medical supplies,          |                         |
| appliances, medical equipment and any      |                         |
| covered items billed by a hospital are     |                         |
| covered under Section 5(a).                |                         |
|                                            |                         |
| Note: We cover hospital services related   |                         |
| to dental procedures (even though the      |                         |
| dental procedure itself may not be         |                         |
| covered) only when a nondental physical    |                         |
| impairment exists that makes               |                         |
| hospitalization neces sary to safeguard    |                         |
| your health.                               |                         |
+--------------------------------------------+-------------------------+
| **Skilled nursing care facility benefits** |                         |
+--------------------------------------------+-------------------------+
| If **precertified**, we cover semiprivate  | PPO: Charges in excess  |
| room, board, services and supplies in a    | of 90-day maximum (No   |
| Skilled Nursing Facility (SNF) for up to   | Deductible)             |
| 90 days when:                              |                         |
|                                            | Non-PPO: Charges in     |
| hospital stay is medically necessary and   | excess of 90-day        |
|                                            | maximum and the         |
| when the hospital stay is under the        | difference between the  |
| supervision of a physician                 | Plan allowance and the  |
|                                            | billed amount (No       |
|                                            | Deduct ible)            |
|                                            |                         |
|                                            | Out-of-network: Charges |
|                                            | in excess of 90-day     |
|                                            | maximum and the         |
|                                            | difference between the  |
|                                            | Plan allowance and the  |
|                                            | billed amount (No       |
|                                            | Deductible)             |
+--------------------------------------------+-------------------------+
| If **not precertified**, we cover          | PPO: 20% and charges in |
| semiprivate room, board, services and      | excess of the 45-day    |
| supplies for up to 45 days subject to the  | maximum (No Deductible) |
| above conditions                           |                         |
|                                            | Non-PPO: 20% of the     |
| Note; Precertified and Nonprecertified     | Plan allowance and any  |
| days are combined. Day limit not to exceed | difference between our  |
| 90 days per calendar year.                 | allow ance and the      |
|                                            | billed amount for 45    |
|                                            | days, then all          |
|                                            | additional charges (No  |
|                                            | Deduct ible)            |
|                                            |                         |
|                                            | Out-of-network: 20% of  |
|                                            | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount for 45    |
|                                            | days, then all          |
|                                            | additional charges (No  |
|                                            | Deductible)             |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| *Custodial care*                           |                         |
+--------------------------------------------+-------------------------+

+--------------------------------------------+-------------------------+
| **Hospice care**                           | ## You Pay              |
+--------------------------------------------+-------------------------+
| Hospice is a coordinated inpatient and     | PPO: Charges in excess  |
| outpatient program of maintenance and      | of \$7500 maximum (No   |
| supportive care for the terminally ill     | Deductible)             |
| provided by a medically supervised team    |                         |
| under the direction of a Plan-approved     | Non-PPO: Charges in     |
| independent hospice administration.        | excess of \$7500        |
|                                            | maximum and the         |
| If **precertified**, we pay \$7500 for     | difference between the  |
| inpatient or outpatient hospice care       | Plan allowance and the  |
|                                            | billed amount (No       |
|                                            | Deductible)             |
|                                            |                         |
|                                            | Out-of-network: Charges |
|                                            | in excess of \$7500     |
|                                            | maximum and the         |
|                                            | difference between the  |
|                                            | Plan allowance and the  |
|                                            | billed amount (No       |
|                                            | Deductible)             |
+--------------------------------------------+-------------------------+
| **If not precertified**, we pay \$4500 for | PPO: Charges in excess  |
| inpatient or outpatient hospice care       | of \$4500 maximum (No   |
|                                            | Deductible)             |
| Note: One hospice program is covered per   |                         |
| lifetime. This benefit does not apply to   | Non-PPO: Charges in     |
| services covered under any other           | excess of \$4500        |
| provisions of the Plan.                    | maximum and the         |
|                                            | difference between the  |
|                                            | Plan allowance and the  |
|                                            | billed amount (No       |
|                                            | Deductible)             |
|                                            |                         |
|                                            | Out-of-network: Charges |
|                                            | in excess of \$4500     |
|                                            | maximum and the         |
|                                            | difference between the  |
|                                            | Plan allowance and the  |
|                                            | billed amount (No       |
|                                            | Deductible)             |
+--------------------------------------------+-------------------------+
| **Ambulance**                              |                         |
+--------------------------------------------+-------------------------+
| Professional ambulance service (including  | PPO: 10% of Plan        |
| air ambulance when medically necessary) to | allowance               |
| or from the nearest hospital equipped to   |                         |
| handle your condition.                     | Non-PPO: 25% of Plan    |
|                                            | allowance and any       |
| Transportation by professional ambulance,  | difference between our  |
| railroad or commercial air line on a       | allowance and the       |
| regularly scheduled flight to the nearest  | billed amount           |
| hospital equipped to furnish special and   |                         |
| unique treatment when medically            | Out-of-network: 15% of  |
| appropriate                                | Plan allowance and any  |
|                                            | difference between our  |
|                                            | allowance and the       |
|                                            | billed amount           |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| *Ambulance transport for you or your       |                         |
| family's convenience.*                     |                         |
+--------------------------------------------+-------------------------+

##  Section 5 (d). Emergency services/accidents

+---+---+-------------------------------------+------------------+---+---+
|   | * | **Here are some important things    |                  | * |   |
|   | * | you should keep in mind about these |                  | * |   |
|   | I | benefits:**                         |                  | I |   |
|   | * |                                     |                  | * |   |
|   | * | Please remember that all benefits   |                  | * |   |
|   |   | are subject to the definitions,     |                  |   |   |
|   | * | limitations, and exclusions in this |                  | * |   |
|   | * | brochure and are payable only when  |                  | * |   |
|   | M | we determine they are medically     |                  | M |   |
|   | * | necessary.                          |                  | * |   |
|   | * |                                     |                  | * |   |
|   |   | The calendar year deductible does   |                  |   |   |
|   | * | not apply for these benefits;       |                  | * |   |
|   | * | however, we added ---(No            |                  | * |   |
|   | P | Deductible) - to show that the      |                  | P |   |
|   | * | calendar year deductible does not   |                  | * |   |
|   | * | apply.                              |                  | * |   |
|   |   |                                     |                  |   |   |
|   | * | PPO benefits apply only when you    |                  | * |   |
|   | * | reside in the PPO network area and  |                  | * |   |
|   | O | use a PPO provider. When no PPO     |                  | O |   |
|   | * | provider is available, non-PPO      |                  | * |   |
|   | * | benefits apply. Out-of-network      |                  | * |   |
|   |   | benefits apply when you reside      |                  |   |   |
|   | * | outside the PPO network area.       |                  | * |   |
|   | * |                                     |                  | * |   |
|   | R | Be sure to read Section 4, *Your    |                  | R |   |
|   | * | 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 9 about  |                  | * |   |
|   | T | coordinating benefits with other    |                  | T |   |
|   | * | coverage, including with Medicare.  |                  | * |   |
|   | * |                                     |                  | * |   |
|   |   | The amounts listed below are for    |                  |   |   |
|   | * | the charges billed by a physician   |                  | * |   |
|   | * | or other health care professional   |                  | * |   |
|   | A | for your surgical care. Look in     |                  | A |   |
|   | * | Section 5(c) for charges associated |                  | * |   |
|   | * | with the facility (i.e., hospital,  |                  | * |   |
|   |   | surgical center, etc.).             |                  |   |   |
|   | * |                                     |                  | * |   |
|   | * | **YOU MUST GET PRECERTIFICATION OF  |                  | * |   |
|   | N | SOME SURGICAL PROCEDURES. Please    |                  | N |   |
|   | * | refer to the precertification       |                  | * |   |
|   | * | information shown in Section 3 to   |                  | * |   |
|   |   | be sure which services require      |                  |   |   |
|   | * | precertification.**                 |                  | * |   |
|   | * |                                     |                  | * |   |
|   | T |                                     |                  | T |   |
|   | * |                                     |                  | * |   |
|   | * |                                     |                  | * |   |
+---+---+-------------------------------------+------------------+---+---+
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| ) |   |                                     |                  |   |   |
| . |   |                                     |                  |   |   |
+---+---+-------------------------------------+------------------+---+---+
| # |   |                                     | **You Pay**      |   |   |
| # |   |                                     |                  |   |   |
| # |   |                                     |                  |   |   |
|   |   |                                     |                  |   |   |
| B |   |                                     |                  |   |   |
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+---+---+-------------------------------------+------------------+---+---+
| * |   |                                     |                  |   |   |
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| d |   |                                     |                  |   |   |
| u |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| b |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| 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 |   |                                     |                  |   |   |
| * |   |                                     |                  |   |   |
| * |   |                                     |                  |   |   |
+---+---+-------------------------------------+------------------+---+---+
| W |   |                                     | PPO: Nothing (No |   |   |
| e |   |                                     | Deductible).     |   |   |
| p |   |                                     |                  |   |   |
| a |   |                                     | Non-PPO: Only    |   |   |
| y |   |                                     | the difference   |   |   |
| 1 |   |                                     | between our      |   |   |
| 0 |   |                                     | allowance and    |   |   |
| 0 |   |                                     | the billed       |   |   |
| % |   |                                     | amount (No       |   |   |
| o |   |                                     | Deductible).     |   |   |
| f |   |                                     |                  |   |   |
| t |   |                                     | Out-of-network:  |   |   |
| h |   |                                     | Only the         |   |   |
| e |   |                                     | difference       |   |   |
| p |   |                                     | between our      |   |   |
| l |   |                                     | allowance and    |   |   |
| a |   |                                     | the billed       |   |   |
| n |   |                                     | amount (No       |   |   |
| a |   |                                     | Deductible).     |   |   |
| l |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| w |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| f |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| h |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| f |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| w |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| g |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| y |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| u |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| v |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| s |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| s |   |                                     |                  |   |   |
| u |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| f |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| d |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| j |   |                                     |                  |   |   |
| u |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| y |   |                                     |                  |   |   |
| : |   |                                     |                  |   |   |
|   |   |                                     |                  |   |   |
| E |   |                                     |                  |   |   |
| m |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| g |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| y |   |                                     |                  |   |   |
| R |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| m |   |                                     |                  |   |   |
| ( |   |                                     |                  |   |   |
| E |   |                                     |                  |   |   |
| R |   |                                     |                  |   |   |
| ) |   |                                     |                  |   |   |
| f |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| y |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| h |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| g |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| E |   |                                     |                  |   |   |
| R |   |                                     |                  |   |   |
| p |   |                                     |                  |   |   |
| h |   |                                     |                  |   |   |
| y |   |                                     |                  |   |   |
| s |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| ' |   |                                     |                  |   |   |
| s |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| h |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| g |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
|   |   |                                     |                  |   |   |
| E |   |                                     |                  |   |   |
| R |   |                                     |                  |   |   |
| p |   |                                     |                  |   |   |
| h |   |                                     |                  |   |   |
| y |   |                                     |                  |   |   |
| s |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| ' |   |                                     |                  |   |   |
| s |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| h |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| g |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| f |   |                                     |                  |   |   |
| f |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| v |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| s |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
|   |   |                                     |                  |   |   |
| N |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| : |   |                                     |                  |   |   |
| W |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| p |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| y |   |                                     |                  |   |   |
| f |   |                                     |                  |   |   |
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| r |   |                                     |                  |   |   |
| s |   |                                     |                  |   |   |
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| r |   |                                     |                  |   |   |
| v |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
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| s |   |                                     |                  |   |   |
| p |   |                                     |                  |   |   |
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| r |   |                                     |                  |   |   |
| f |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| m |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| d |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| u |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| s |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| d |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| h |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| E |   |                                     |                  |   |   |
| R |   |                                     |                  |   |   |
| f |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| y |   |                                     |                  |   |   |
| u |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| d |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| h |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| p |   |                                     |                  |   |   |
| p |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| p |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| P |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| b |   |                                     |                  |   |   |
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| n |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| f |   |                                     |                  |   |   |
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| t |   |                                     |                  |   |   |
| . |   |                                     |                  |   |   |
|   |   |                                     |                  |   |   |
| N |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
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| r |   |                                     |                  |   |   |
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| n |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
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| R |   |                                     |                  |   |   |
| , |   |                                     |                  |   |   |
| b |   |                                     |                  |   |   |
| u |   |                                     |                  |   |   |
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| d |   |                                     |                  |   |   |
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| - |   |                                     |                  |   |   |
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| s |   |                                     |                  |   |   |
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| S |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| c |   |                                     |                  |   |   |
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| n |   |                                     |                  |   |   |
| 5 |   |                                     |                  |   |   |
| ( |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| ) |   |                                     |                  |   |   |
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| . |   |                                     |                  |   |   |
|   |   |                                     |                  |   |   |
| N |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
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| p |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
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| H |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| s |   |                                     |                  |   |   |
| p |   |                                     |                  |   |   |
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| t |   |                                     |                  |   |   |
| a |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
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| n |   |                                     |                  |   |   |
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| 5 |   |                                     |                  |   |   |
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| ) |   |                                     |                  |   |   |
| . |   |                                     |                  |   |   |
+---+---+-------------------------------------+------------------+---+---+

+--------------------------------------------+-------------------------+
| **Medical emergency**                      |                         |
+--------------------------------------------+-------------------------+
| Regular Plan benefits apply when you       | PPO services **in       |
| receive care because of a non- accidental  | physician's office:**   |
| medical emergency. See Section 5(a).       | \$10 copayment (No      |
|                                            | Deductible)             |
|                                            |                         |
|                                            | PPO services **outside  |
|                                            | physician's office:**   |
|                                            | 10% of the Plan         |
|                                            | allowance               |
|                                            |                         |
|                                            | Non-PPO: 30% of Plan    |
|                                            | allowance and any       |
|                                            | difference between our  |
|                                            | allowance and the       |
|                                            | billed amount           |
|                                            |                         |
|                                            | Out-of-network: 15% of  |
|                                            | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount.          |
+--------------------------------------------+-------------------------+
| **Ambulance**                              |                         |
+--------------------------------------------+-------------------------+
| Professional ambulance service (including  | PPO: 10% of the Plan    |
| air ambulance when medically necessary) to | allowance               |
| or from the nearest hospital equipped to   |                         |
| handle your condition.                     | Non-PPO: 25% of the     |
|                                            | Plan allowance and any  |
| Transportation by professional ambulance,  | difference between our  |
| railroad or commercial airline on a        | allowance and the       |
| regularly scheduled flight to the nearest  | billed amount           |
| hospital equipped to furnish special and   |                         |
| unique treatment when medically            | Out-of-network: 15% of  |
| appropriate                                | the Plan allowance and  |
|                                            | any difference between  |
|                                            | our allowance and the   |
|                                            | billed amount           |
+--------------------------------------------+-------------------------+
| *Not covered:*                             | *All charges*           |
|                                            |                         |
| Ambulance transport for you or your        |                         |
| family's convenience.                      |                         |
+--------------------------------------------+-------------------------+

## Section 5(e). Mental health and substance abuse benefits

+---+---+-------------------------------------+------------------+---+---+
|   | * | If you reside in the PPO Network    |                  | * |   |
|   | * | Area, you may choose to get PPO or  |                  | * |   |
|   | I | Non-PPO care. If you reside outside |                  | I |   |
|   | * | the network area, you will receive  |                  | * |   |
|   | * | out-of-network care. PPO members    |                  | * |   |
|   |   | who choose PPO care must get our    |                  |   |   |
|   | * | approval for services and follow a  |                  | * |   |
|   | * | treatment plan we approve.          |                  | * |   |
|   | M | Cost-sharing and limitations for    |                  | M |   |
|   | * | PPO or out-of-network mental health |                  | * |   |
|   | * | and substance abuse benefits will   |                  | * |   |
|   |   | be no greater than for similar      |                  |   |   |
|   | * | benefits for other illnesses and    |                  | * |   |
|   | * | conditions                          |                  | * |   |
|   | P |                                     |                  | P |   |
|   | * | **Here are some important things to |                  | * |   |
|   | * | keep in mind about these            |                  | * |   |
|   |   | benefits:**                         |                  |   |   |
|   | * |                                     |                  | * |   |
|   | * | All benefits are subject to the     |                  | * |   |
|   | O | definitions, limitations, and       |                  | O |   |
|   | * | exclusions in this brochure and are |                  | * |   |
|   | * | payable only when we determine they |                  | * |   |
|   |   | are medically necessary.            |                  |   |   |
|   | * |                                     |                  | * |   |
|   | * | The calendar year deductible is     |                  | * |   |
|   | R | \$300 per person (\$600 per family) |                  | R |   |
|   | * | and applies to almost all benefits  |                  | * |   |
|   | * | in this Section. We added - (No     |                  | * |   |
|   |   | Deductible) - to show when the      |                  |   |   |
|   | * | calendar year deductible **does not |                  | * |   |
|   | * | apply**.                            |                  | * |   |
|   | T |                                     |                  | T |   |
|   | * | PPO benefits apply only when you    |                  | * |   |
|   | * | reside in the PPO network area and  |                  | * |   |
|   |   | use a PPO provider. When no PPO     |                  |   |   |
|   | * | provider is available, non-PPO      |                  | * |   |
|   | * | benefits apply. Out-of-network      |                  | * |   |
|   | A | benefits apply when you reside      |                  | A |   |
|   | * | outside the PPO network area.       |                  | * |   |
|   | * |                                     |                  | * |   |
|   |   | Be sure to read Section 4, *Your    |                  |   |   |
|   | * | costs for covered services*, for    |                  | * |   |
|   | * | valuable information about how cost |                  | * |   |
|   | N | sharing works. Also read Section 9  |                  | N |   |
|   | * | about coordinating benefits with    |                  | * |   |
|   | * | other coverage, including with      |                  | * |   |
|   |   | Medicare.                           |                  |   |   |
|   | * |                                     |                  | * |   |
|   | * | **PPO MEMBERS WHO CHOOSE PPO CARE   |                  | * |   |
|   | T | MUST GET PREAUTHORIZA­TION OF THESE  |                  | T |   |
|   | * | SERVICES. BENEFITS MAY BE REDUCED   |                  | * |   |
|   | * | IF YOU FAIL TO GET PRECERTIFICATION |                  | * |   |
|   |   | OF THESE SERVICES.** See the        |                  |   |   |
|   |   | instructions after the benefits     |                  |   |   |
|   |   | descriptions below.                 |                  |   |   |
|   |   |                                     |                  |   |   |
|   |   | PPO mental health and substance     |                  |   |   |
|   |   | abuse benefits are listed below,    |                  |   |   |
|   |   | then Non-PPO and Out-of-network     |                  |   |   |
|   |   | benefits begin on page [Error:      |                  |   |   |
|   |   | Reference source not                |                  |   |   |
|   |   | found](#NonPPO_and_Outofnet).       |                  |   |   |
+---+---+-------------------------------------+------------------+---+---+
| # |   |                                     | **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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| : |   |                                     |                  |   |   |
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| d |   |                                     |                  |   |   |
| d |   |                                     |                  |   |   |
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|   |   |                                     |                  |   |   |
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| ) |   |                                     |                  |   |   |
|   |   |                                     |                  |   |   |
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| w |   |                                     |                  |   |   |
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| d |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
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| p |   |                                     |                  |   |   |
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| y |   |                                     |                  |   |   |
| * |   |                                     |                  |   |   |
| * |   |                                     |                  |   |   |
+---+---+-------------------------------------+------------------+---+---+
| * |   |                                     |                  |   |   |
| * |   |                                     |                  |   |   |
| P |   |                                     |                  |   |   |
| P |   |                                     |                  |   |   |
| O |   |                                     |                  |   |   |
| N |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| w |   |                                     |                  |   |   |
| o |   |                                     |                  |   |   |
| r |   |                                     |                  |   |   |
| k |   |                                     |                  |   |   |
| b |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
| e |   |                                     |                  |   |   |
| f |   |                                     |                  |   |   |
| i |   |                                     |                  |   |   |
| t |   |                                     |                  |   |   |
| s |   |                                     |                  |   |   |
| * |   |                                     |                  |   |   |
| * |   |                                     |                  |   |   |
+---+---+-------------------------------------+------------------+---+---+
| A |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| l |   |                                     |                  |   |   |
| d |   |                                     |                  |   |   |
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| a |   |                                     |                  |   |   |
| g |   |                                     |                  |   |   |
| n |   |                                     |                  |   |   |
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| c |   |                                     |                  |   |   |
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| . |   |                                     |                  |   |   |
+---+---+-------------------------------------+------------------+---+---+

+--------------------------------------------+-------------------------+
| ## *                                       |                         |
| *PPO Network benefits (continued)**You Pay |                         |
+--------------------------------------------+-------------------------+
| Professional services provided by a        |                         |
| physician                                  |                         |
|                                            |                         |
| Other professional services (i.e.,         |                         |
| psychologists, clinical social workers,    |                         |
| licensed counselors), inpatient            |                         |
| professional services, and outpatient      |                         |
| hospital services                          |                         |
|                                            |                         |
| Services in approved alternative care      |                         |
| settings, such as partial hospitalization  |                         |
| or facility-based intensive outpatient     |                         |
| treatment (See definitions, Section 10).   |                         |
|                                            |                         |
| Diagnostic tests (including psychological  |                         |
| testing)PPO: 10% of the Plan allowance (No |                         |
| Deductible)                                |                         |
+--------------------------------------------+-------------------------+
| Medical management                         |                         |
|                                            |                         |
| Note: No preauthorization is required.PPO: |                         |
| \$10 copayment (No Deductible)             |                         |
+--------------------------------------------+-------------------------+
| Inpatient hospital charges (to include     |                         |
| residential treatment centers) and other   |                         |
| hospital services and supplies.PPO: \$100  |                         |
| copayment per hospital stay (No            |                         |
| Deductible)                                |                         |
+--------------------------------------------+-------------------------+
| *Not covered:*                             |                         |
|                                            |                         |
| *Services we have not approved.*           |                         |
|                                            |                         |
| *All charges for chemical aversion         |                         |
| therapy, conditioned reflex treat­ments,    |                         |
| narcotherapy or any similar aversion       |                         |
| treatments and all related charges         |                         |
| (including room and board)*                |                         |
|                                            |                         |
| *Any provider not specifically listed as   |                         |
| covered*                                   |                         |
|                                            |                         |
| *Counseling or therapy for marital,        |                         |
| educational or behavioral problems, or     |                         |
| related to mental retardation or learning  |                         |
| disabilities*                              |                         |
|                                            |                         |
| *Community-based programs such as          |                         |
| self-help groups or 12 step program*       |                         |
|                                            |                         |
| *Services by pastoral (except in medically |                         |
| underserved areas), marital, or            |                         |
| drug/alcohol counselorsAll charges*        |                         |
+--------------------------------------------+-------------------------+
| Note: OPM will base its review of disputes |                         |
| about treatment plans on the treatment     |                         |
| plan's clinical appropriateness. OPM will  |                         |
| generally not order us to pay or provide   |                         |
| one clinically appropriate treatment plan  |                         |
| in favor of another.                       |                         |
+--------------------------------------------+-------------------------+

+-------------------------------------------+--------------------------+
| ## **                                     |                          |
| PPO Network benefits (continued)**You Pay |                          |
+-------------------------------------------+--------------------------+
| **Preauthorization and                    |                          |
| Precertification**To be eligible to       |                          |
| receive these enhanced mental health and  |                          |
| substance abuse benefits, you must obtain |                          |
| a treatment plan and follow all of our    |                          |
| network authorization processes. These    |                          |
| include:                                  |                          |
|                                           |                          |
| Outpatient mental health and substance    |                          |
| abuse benefits will be reduced by 50% if  |                          |
| services are not preauthorized within two |                          |
| business days of the initial visit.       |                          |
|                                           |                          |
| Preauthorization and concurrent review    |                          |
| are required for all levels of care       |                          |
| whether in-or out-of-network.             |                          |
|                                           |                          |
| The medical necessity of your inpatient   |                          |
| services (to include residential          |                          |
| treatment care) must be precertified for  |                          |
| you to receive full Plan benefits.        |                          |
| Otherwise, the benefits payable will be   |                          |
| reduced by \$500. Emergency admissions    |                          |
| must be reported within two business days |                          |
| following the day of admission even if    |                          |
| you have been discharged.                 |                          |
|                                           |                          |
| You, your representative, your physician, |                          |
| or your hospital must call Mutual of      |                          |
| Omaha's Care Review Unit prior to         |                          |
| admission. The toll-free number is        |                          |
|                                           |                          |
| 1-800-634-0069.                           |                          |
|                                           |                          |
| You must provide the following            |                          |
| information: enrollee's name and Plan     |                          |
| identification number; patient's name,    |                          |
| birth date and phone number; reason for   |                          |
| hospitalization, proposed treatment; name |                          |
| of hospital or facility; name and number  |                          |
| of admitting physician; and number of     |                          |
| planned days of hospital stay.            |                          |
+-------------------------------------------+--------------------------+
| **Network limitation**We will reduce your |                          |
| benefits if you do not follow all of our  |                          |
| preauthorization process and your         |                          |
| treatment plan.                           |                          |
+-------------------------------------------+--------------------------+
| **Non-PPO and Out-of-network benefits**   |                          |
+-------------------------------------------+--------------------------+
| **Mental Health**                         |                          |
|                                           |                          |
| Professional services by physicians,      |                          |
| psychologists, clinical social workers or |                          |
| licensed counselors, and inpatient        |                          |
| professional services                     |                          |
|                                           |                          |
| **Non-PPO**: 50% of the Plan allowance    |                          |
| and any difference between our allowance  |                          |
| and the billed amount and **all charges   |                          |
| in excess of 50 visit maximum per         |                          |
| calendar year**                           |                          |
|                                           |                          |
| **Out-of-network**: 15% of the Plan       |                          |
| allowance and the difference between our  |                          |
| allowance and the billed amount           |                          |
+-------------------------------------------+--------------------------+

+-------------------------------------------+--------------------------+
| **Non-PPO and Out-of-network benefits     | ## You Pay               |
| (continued)**                             |                          |
+-------------------------------------------+--------------------------+
| Diagnostic testing (including             |                          |
| psychological testing)                    |                          |
|                                           |                          |
| Medical management**Non-PPO**: 25% of the |                          |
| Plan allowance and the difference between |                          |
| our allowance and the billed amount       |                          |
|                                           |                          |
| **Out-of-network**: 15% of the Plan       |                          |
| allowance and the difference between our  |                          |
| Plan and the billed amount                |                          |
+-------------------------------------------+--------------------------+
| Outpatient hospital charges**Non-PPO**:   |                          |
| 50% of the Plan allowance and the         |                          |
| difference between our allowance and the  |                          |
| billed amount                             |                          |
|                                           |                          |
| **Out-of-network**: 15% of the Plan       |                          |
| allowance and the difference between our  |                          |
| Plan and the billed amount                |                          |
+-------------------------------------------+--------------------------+
| Inpatient hospital charges (including     |                          |
| residential treatment centers) and other  |                          |
| hospital services and                     |                          |
| supplies.**Non-PPO**: \$300 copayment per |                          |
| hospital stay and 30% of the covered      |                          |
| charges (No Deductible)                   |                          |
|                                           |                          |
| **Out-of-network**: \$200 copayment per   |                          |
| hospital stay (No Deductible)             |                          |
+-------------------------------------------+--------------------------+
| Services in approved alternative care     |                          |
| settings, such as partial hospitalization |                          |
| or facility-based intensive outpatient    |                          |
| treatment (See definitions, Section       |                          |
| 10)**Non-PPO**: 25% of the Plan allowance |                          |
| and any difference between our allowance  |                          |
| and the billed amount                     |                          |
|                                           |                          |
| **Out-of-network**: 15% of the Plan       |                          |
| allowance and any difference between our  |                          |
| allowance and the billed amount           |                          |
+-------------------------------------------+--------------------------+
| **Substance Abuse**                       |                          |
|                                           |                          |
| Inpatient care includes room and board    |                          |
| and ancillary charges for hospital stays  |                          |
| in a treatment facility for               |                          |
| rehabilitative treatment of alcoholism or |                          |
| substance abuse**Non-PPO**: \$300         |                          |
| copayment per hospital stay and 30% of    |                          |
| the covered charges **up to the combined  |                          |
| lifetime maximum of \$25,000** (No        |                          |
| Deductible) and all charges in excess of  |                          |
| the combined lifetime maximim.            |                          |
|                                           |                          |
| **Out-of-network**: \$200 copayment per   |                          |
| hospital stay (No Deductible)             |                          |
+-------------------------------------------+--------------------------+
| Outpatient benefits (including            |                          |
| aftercare)**Non-PPO**: 25% of the Plan    |                          |
| allowance and the difference between our  |                          |
| allowance and the billed amount **up to   |                          |
| the combined lifetime maximum of          |                          |
| \$25,000** and all charges in excess of   |                          |
| the combined lifetime maximum.            |                          |
|                                           |                          |
| **Out-of-network**: 15% of the Plan       |                          |
| allowance and the difference between our  |                          |
| allowance and the billed amount           |                          |
+-------------------------------------------+--------------------------+
| Services in approved alternative care     |                          |
| settings, such as partial hospitalization |                          |
| or facility-based intensive outpatient    |                          |
| treatment (See definitions, Section       |                          |
| 10.)**Non-PPO**: 25% of the Plan          |                          |
| allowance and any difference between our  |                          |
| allowance and the billed amount           |                          |
|                                           |                          |
| **Out-of-network**: 15% of the Plan       |                          |
| allowance and any difference between our  |                          |
| allowance and the billed amount           |                          |
+-------------------------------------------+--------------------------+

+----------------+--------------------------+--------------------------+
| ## **          |                          |                          |
| Non-PPO and Ou |                          |                          |
| t-of-network b |                          |                          |
| enefits (conti |                          |                          |
| nued)**You Pay |                          |                          |
+----------------+--------------------------+--------------------------+
| *Not covered   |                          |                          |
| under mental   |                          |                          |
| health and     |                          |                          |
| substance      |                          |                          |
| abuse:*        |                          |                          |
|                |                          |                          |
| *Services we   |                          |                          |
| have not       |                          |                          |
| approved*      |                          |                          |
|                |                          |                          |
| *All charges   |                          |                          |
| for chemical   |                          |                          |
| aversion       |                          |                          |
| therapy,       |                          |                          |
| conditioned    |                          |                          |
| reflex         |                          |                          |
| treatments,    |                          |                          |
| narcotherapy   |                          |                          |
| or any similar |                          |                          |
| aversion       |                          |                          |
| treatments and |                          |                          |
| all related    |                          |                          |
| charges        |                          |                          |
| (including     |                          |                          |
| room and       |                          |                          |
| board)*        |                          |                          |
|                |                          |                          |
| *Any provider  |                          |                          |
| not            |                          |                          |
| specifically   |                          |                          |
| listed as      |                          |                          |
| covered*       |                          |                          |
|                |                          |                          |
| *Counseling or |                          |                          |
| therapy for    |                          |                          |
| marital,       |                          |                          |
| educational or |                          |                          |
| behavioral     |                          |                          |
| problems, or   |                          |                          |
| related to     |                          |                          |
| mental         |                          |                          |
| retardation or |                          |                          |
| learning       |                          |                          |
| disabilities*  |                          |                          |
|                |                          |                          |
| *C             |                          |                          |
| ommunity-based |                          |                          |
| programs such  |                          |                          |
| as self-help   |                          |                          |
| groups or 12   |                          |                          |
| step program*  |                          |                          |
|                |                          |                          |
| *Services by   |                          |                          |
| pastoral       |                          |                          |
| (except in     |                          |                          |
| medically      |                          |                          |
| underserved    |                          |                          |
| areas),        |                          |                          |
| marital, or    |                          |                          |
| drug/alcohol   |                          |                          |
| counselorsAll  |                          |                          |
| charges*       |                          |                          |
+----------------+--------------------------+--------------------------+
| **Lifetime     |                          |                          |
| ma             |                          |                          |
| ximum**Non-PPO |                          |                          |
| inpatient or   |                          |                          |
| outpatient     |                          |                          |
| care for the   |                          |                          |
| treatment of   |                          |                          |
| alcoholism and |                          |                          |
| drug abuse is  |                          |                          |
| limited to a   |                          |                          |
| lifetime       |                          |                          |
| maximum of     |                          |                          |
| \$25,000.      |                          |                          |
| Withdrawal     |                          |                          |
| from a         |                          |                          |
| treatment      |                          |                          |
| program prior  |                          |                          |
| to completion  |                          |                          |
| constitutes    |                          |                          |
| use of one     |                          |                          |
| program.       |                          |                          |
+----------------+--------------------------+--------------------------+
| **Pr           |                          |                          |
| eauthorization |                          |                          |
| and            |                          |                          |
| Precer         |                          |                          |
| tification**Pr |                          |                          |
| ecertification |                          |                          |
| of treatment   |                          |                          |
| programs is    |                          |                          |
| not required.  |                          |                          |
| The medical    |                          |                          |
| necessity of   |                          |                          |
| your admission |                          |                          |
| to a hospital  |                          |                          |
| or other       |                          |                          |
| covered        |                          |                          |
| facility must  |                          |                          |
| be             |                          |                          |
| precertified   |                          |                          |
| for you to     |                          |                          |
| receive these  |                          |                          |
| benefits.      |                          |                          |
| Emergency      |                          |                          |
| admissions     |                          |                          |
| must be        |                          |                          |
| reported       |                          |                          |
| within two     |                          |                          |
| business days  |                          |                          |
| following the  |                          |                          |
| day of         |                          |                          |
| admission even |                          |                          |
| if you have    |                          |                          |
| been           |                          |                          |
| discharged.    |                          |                          |
| Otherwise, the |                          |                          |
| benefits       |                          |                          |
| payable will   |                          |                          |
| be reduced by  |                          |                          |
| \$500. See     |                          |                          |
| Section 3 for  |                          |                          |
| details.       |                          |                          |
| Pr             |                          |                          |
| ecertification |                          |                          |
| is not         |                          |                          |
| required for   |                          |                          |
| overseas care. |                          |                          |
+----------------+--------------------------+--------------------------+
| See these      |                          |                          |
| sections of    |                          |                          |
| the brochure   |                          |                          |
| for more       |                          |                          |
| valuable       |                          |                          |
| information    |                          |                          |
| about these    |                          |                          |
| benefits:      |                          |                          |
|                |                          |                          |
| Section 3,     |                          |                          |
| *How you get   |                          |                          |
| care*, for     |                          |                          |
| information    |                          |                          |
| about          |                          |                          |
| catastrophic   |                          |                          |
| protection for |                          |                          |
| these benefits |                          |                          |
|                |                          |                          |
| Section 7,     |                          |                          |
| *Filing a      |                          |                          |
| claim for      |                          |                          |
| covered        |                          |                          |
| services*, for |                          |                          |
| information    |                          |                          |
| about          |                          |                          |
| submitting     |                          |                          |
| non-PPO and    |                          |                          |
| Out-of-network |                          |                          |
| claims         |                          |                          |
+----------------+--------------------------+--------------------------+

## Section 5 (f). Prescription drug benefits

+---+---+--------------------------------------------------------+---+---+
|   | * | Here are some important things to keep in mind about   | * |   |
|   | * | these benefits:                                        | * |   |
|   | I |                                                        | I |   |
|   | * | We cover prescribed drugs and medications, as          | * |   |
|   | * | described below.                                       | * |   |
|   |   |                                                        |   |   |
|   | * | All benefits are subject to the definitions,           | * |   |
|   | * | limitations and exclusions in this brochure and are    | * |   |
|   | M | payable only when we determine they are medically      | M |   |
|   | * | necessary.                                             | * |   |
|   | * |                                                        | * |   |
|   |   | Certain drugs require prior authorization or may be    |   |   |
|   | * | subject to quantity limits. If your prescription is    | * |   |
|   | * | for a drug requiring prior authorization, additional   | * |   |
|   | P | information from your physician will be needed before  | P |   |
|   | * | the medication is dispensed. Your physician may call   | * |   |
|   | * | 1-800-634-0069 to begin the review process.            | * |   |
|   |   |                                                        |   |   |
|   | * | The calendar year deductible does not apply to almost  | * |   |
|   | * | all benefits in this Section. We added - (No           | * |   |
|   | O | Deductible) - to show when the calendar year           | O |   |
|   | * | 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   | * |   |
|   | R | are age 65 or over. Also read Section 9 about          | R |   |
|   | * | coordinating benefits with other coverage, including   | * |   |
|   | * | with Medicare.                                         | * |   |
|   |   |                                                        |   |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   | T |                                                        | T |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   |   |                                                        |   |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   | A |                                                        | A |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   |   |                                                        |   |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   | N |                                                        | N |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   |   |                                                        |   |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
|   | T |                                                        | T |   |
|   | * |                                                        | * |   |
|   | * |                                                        | * |   |
+---+---+--------------------------------------------------------+---+---+

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

**Who can write your prescription**. A licensed physician or dentist
must write the prescription.

**Where you can obtain them**. You may fill the prescription at a
network pharmacy or by mail. To locate a network pharmacy in your area,
call 1-800-752-0598 or you may also visit Mutual of Omaha's Website at
www.mutualofomaha.com. We will send you information on the mail order
drug program. To use the program: 1) complete the initial mail order
form; 2) enclose your prescription and copayment; 3) mail your order to
Express Scripts, Inc., PO Box 27226, Albuquerque, NM 87125-9908; 4)
allow two to three weeks for delivery. You will receive forms for
refills and future prescription orders each time you receive drugs or
supplies under this program. If you have questions about the mail order
program, call 1-800-752-0598.

**We use a formulary.** A formulary is a list of selected FDA-approved
commonly prescribed medications from which your physician or dentist may
choose to prescribe. The formulary is designed to inform you and your
physician about quality medications that, when prescribed in place of
other nonformulary medications, can help contain the increasing cost of
prescription drug coverage without sacrificing quality. To find out if
your medication is on the formulary, call Express Scripts, Inc., at
1-800-752-0598 or visit Mutual of Omaha's Website at
www.mutualofomaha.com. If you are prescribed a drug not on the
formulary, you will pay a higher copayment. A request for a non
formulary appeal may be submitted in writing through the Disputed Claims
Process as described in Section 8.

**Why use generic drugs?** Generic drugs are lower-priced drugs that are
the therapeutic equivalent to more expensive brand-name drugs. They must
contain the same active ingredients and must be equivalent in strength
and dosage to the original brand-name product. Generics cost less than
the equivalent brand-name product. The U.S. 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.

**Some drugs require prior authorization.** Prior Authorization
Requirements (PAR) are applied to encourage appropriate use of
medications that are most likely to have certain risk factors. These
requirements apply to drugs that may be used in amounts that exceed
dosage or length of treatment recommendations or that may be more costly
than medications that are proven to be clinically and therapeutically
similar. If your prescription is identified as a drug requiring PAR,
your physician should call Customer Service at 1-800-634-0069.

**These are the dispensing limitations.** When you obtain prescription
drugs from a pharmacy using your Prescription Drug Card, you may obtain
up to a 30-day supply of covered drugs. If purchasing more than a 30-day
supply on the same day, any expense exceeding that supply limit will not
be covered through the pharmacy arrangement. You may purchase your
covered prescription drugs and supplies by presenting your prescription
drug card and your prescription to a participating provider.
Prescription refills will be covered when no more than 50% of the 30-day
supply remains based on your physician's prescription.

## Section 5 (f) Prescription drug benefits (continued)

If your physician or dentist prescribes a medication that will be taken
over an extended period of time, you should request two prescriptions,
one for immediate use with a participating retail pharmacy and the other
for up to a 90-day supply from the Mail Order Program. Express Scripts,
Inc., will fill your prescription. All drugs and supplies covered by the
Plan are available under this program except fertility drugs. If you
have questions about a particular drug or a prescription, and to request
your first order forms, call 1-800-752-0598. If a generic equivalent to
the prescribed drug is available, Express Scripts will dispense the
generic equivalent instead of the brand name unless you or your
physician specifies that the brand name is required

+-----------------------------------+-----------------------------------+
| Benefit Description               | You Pay                           |
+-----------------------------------+-----------------------------------+
| Note: We added - (No              |                                   |
| Deductible) - to show when the    |                                   |
| calendar year deductible does not |                                   |
| apply                             |                                   |
+-----------------------------------+-----------------------------------+
| **Covered medications and         |                                   |
| supplies**                        |                                   |
+-----------------------------------+-----------------------------------+
| You may purchase the following    | **Network Retail:**               |
| medications and supplies          |                                   |
| prescribed by a physician from    | \$5 generic (No Deductible)       |
| either a pharmacy or by mail:     |                                   |
|                                   | \$25 formulary brand name (No     |
| Drugs, vitamins and minerals that | Deductible)                       |
| by Federal law of the United      |                                   |
| States require a doctor's         | 30% nonformulary brand name or    |
| prescription for their purchase   | \$40, whichever is greater (No    |
|                                   | Deductible)                       |
| Insulin and diabetic supplies     |                                   |
|                                   | **Network Retail when Medicare    |
| Note: Members with diabetes that  | Part B is primary:**              |
| have Medicare B as their primary  |                                   |
| insurer, must obtain their        | \$3 generic (No Deductible)       |
| testing supplies through a        |                                   |
| Diabetic supplier that coordiates | \$20 formulary brand name (No     |
| benefits with Medicare. Please    | Deductible)                       |
| call the number on the back of    |                                   |
| your insurance card for           | 30% nonformulary brand name or    |
| assistance in identifying a       | \$35, whichever is greater (No    |
| supplier.                         | Deductible)                       |
|                                   |                                   |
| FDA-approved drugs and devices    | **Network Mail Order:**           |
| requiring a physician's           |                                   |
| prescrip­tion for the purpose of   | \$10 generic (No Deductible)      |
| birth control                     |                                   |
|                                   | \$45 formulary brand name (No     |
| Needles and syringes for the      | Deductible)                       |
| administration of covered         |                                   |
| medications                       | 30% nonformulary brand name or    |
|                                   | \$55, whichever is greater (No    |
| Here are some things to keep in   | Deductible)                       |
| mind about our prescription drug  |                                   |
| program:                          | **Network Mail Order when         |
|                                   | Medicare Part B is primary:**     |
| A generic equivalent will be      |                                   |
| dispensed if it is available,     | \$8 generic (No Deductible)       |
| unless your physician             |                                   |
| specifically requires a name      | \$23 formulary brand name (No     |
| brand. Your physician must        | Deductible)                       |
| specify "dispense as written" if  |                                   |
| a brand name drug is required.    | 30% nonformulary brand name or    |
|                                   | \$38, whichever is greater (No    |
| When purchasing drugs at a        | Deductible)                       |
| pharmacy, you must use your       |                                   |
| Prescrip­tion Drug Card. Please    | **Note: If there is no generic    |
| call us to request additional     | equivalent available, you will    |
| prescription drug cards for       | still have to pay the brand name  |
| family members.                   | copay.**                          |
|                                   |                                   |
| We have an open formulary. If     |                                   |
| your physician believes a name    |                                   |
| brand product is necessary or     |                                   |
| there is no generic available,    |                                   |
| your physician may prescribe a    |                                   |
| name brand drug from a formulary  |                                   |
| list. To order a prescription     |                                   |
| drug brochure, call Customer      |                                   |
| Service at 1-800-752-0598.        |                                   |
|                                   |                                   |
| Compound prescription drugs are   |                                   |
| covered as nonformulary brand     |                                   |
| name drugs.                       |                                   |
+-----------------------------------+-----------------------------------+

+-----------------------------------+-----------------------------------+
| **Covered medications and         | ## You Pay                        |
| supplies (continued)**            |                                   |
+-----------------------------------+-----------------------------------+
| If you reside outside of the      | 20%                               |
| United States and do not order    |                                   |
| prescription drugs through the    |                                   |
| Mail Order Prescription Drug      |                                   |
| Program:                          |                                   |
|                                   |                                   |
| If you are provided drugs         |                                   |
| directly by a physician or        |                                   |
| covered facility (not a           |                                   |
| pharmacy), including FDA-approved |                                   |
| drugs and devices requiring a     |                                   |
| physician's prescription for the  |                                   |
| purpose of birth control:         |                                   |
|                                   |                                   |
| If you do not use your            |                                   |
| prescription drug card to         |                                   |
| purchase needles and syringes for |                                   |
| the administration of covered     |                                   |
| medications or diabetic supplies: |                                   |
|                                   |                                   |
| If you purchase colostomy or      |                                   |
| ostomy supplies:                  |                                   |
+-----------------------------------+-----------------------------------+
| *Not covered:*                    | *All charges*                     |
|                                   |                                   |
| *Drugs and supplies for cosmetic  |                                   |
| purposes*                         |                                   |
|                                   |                                   |
| *Nutritional supplements and      |                                   |
| vitamins (including prenatal)     |                                   |
| that do not require a             |                                   |
| prescription*                     |                                   |
|                                   |                                   |
| *Medication that does not require |                                   |
| a prescription under Federal law  |                                   |
| even if your physician prescribes |                                   |
| it or a prescription is required  |                                   |
| under your State law*             |                                   |
|                                   |                                   |
| *Medical supplies such as         |                                   |
| dressings and antiseptics*        |                                   |
|                                   |                                   |
| *Medication for which there is a  |                                   |
| non-prescription equivalent       |                                   |
| available*                        |                                   |
|                                   |                                   |
| *Prescriptions received from      |                                   |
| non-participating pharmacies      |                                   |
| unless overseas or through a      |                                   |
| covered physician or facility.*   |                                   |
|                                   |                                   |
| *Call 1-800-752- 0598 to locate a |                                   |
| participating pharmacy.*          |                                   |
|                                   |                                   |
| *Drug copayments*                 |                                   |
|                                   |                                   |
| *Fertility drugs are covered only |                                   |
| under "Infertility services"*     |                                   |
+-----------------------------------+-----------------------------------+

##  Section 5 (g). Special Features

+------------------------+---------------------------------------------+
| **Special features**   | **Description**                             |
+------------------------+---------------------------------------------+
| **Flexible Benefits    | Under the flexible benefits option, we      |
| Option**               | determine the most effective way to provide |
|                        | services.                                   |
|                        |                                             |
|                        | We may identify medically appropriate       |
|                        | alternatives to traditional care and        |
|                        | coordinate other benefits as a less costly  |
|                        | alternative benefit.                        |
|                        |                                             |
|                        | Alternative benefits are subject to our     |
|                        | ongoing review.                             |
|                        |                                             |
|                        | By approving an alternative benefit, we     |
|                        | cannot guarantee you will get it in the     |
|                        | future.                                     |
|                        |                                             |
|                        | The decision to offer an alternative        |
|                        | benefit is solely ours, and we may withdraw |
|                        | it at any time and resume regular contract  |
|                        | benefits.                                   |
|                        |                                             |
|                        | Our decision to offer or withdraw           |
|                        | alternative benefits is not subject to OPM  |
|                        | review under the disputed claims process.   |
+------------------------+---------------------------------------------+
| **Healthy Pregnancy    | You have access to Mutual of Omaha's        |
| Program**              | Healthy Pregnancy Program, which provides   |
|                        | educational material and support to         |
|                        | pregnant women. Contact Customer Service at |
|                        | 1-800-634-0069 for more information.        |
+------------------------+---------------------------------------------+
| **Centers of           | Mutual of Omaha has special arrangements    |
| Excellence**           | with facilities to provide services for     |
|                        | tissue and organ transplants \-- its        |
|                        | Medical Specialty Network. The network was  |
|                        | designed to give you an opportunity to      |
|                        | access providers that demonstrate high      |
|                        | quality medical care for transplant         |
|                        | patients. For additional information        |
|                        | regarding our transplant network, please    |
|                        | call 1-800-634-0069.                        |
+------------------------+---------------------------------------------+
| **Services Overseas**  | Our overseas customers receive the same     |
|                        | out-of-network benefits and prompt customer |
|                        | service as their stateside counterparts.    |
|                        | There is no additional claims processing    |
|                        | time for foreign claims.                    |
+------------------------+---------------------------------------------+
| **Healt                | Healthy*directions*^sm^ a disease           |
| hy*directions*^sm\ ^** | management program for members and covered  |
|                        | dependents with asthma, diabetes, or heart  |
|                        | failure (HF). Your health is important to   |
|                        | us! If you or your covered dependent has    |
|                        | asthma, diabetes or heart failure (HF), you |
|                        | will be contacted to voluntarily            |
|                        | participate. If you would like to contact   |
|                        | us for more information about this program, |
|                        | please call 1-800-228-0286.                 |
+------------------------+---------------------------------------------+
| **Glucose Monitors**   | If you are diagnosed with diabetes, you may |
|                        | receive a free glucose monitor. The monitor |
|                        | is a small device that diabetics use to     |
|                        | check and monitor their blood sugar.        |
|                        | Monitoring and controlling blood sugars is  |
|                        | essential for managing diabetes and         |
|                        | preventing unnecessary complications.       |
|                        |                                             |
|                        | To obtain a glucose monitor, call           |
|                        | 1-800-634-0069.                             |
+------------------------+---------------------------------------------+

+------------------------+---------------------------------------------+
| **Special features     | **Description**                             |
| (continued)**          |                                             |
+------------------------+---------------------------------------------+
| **Lifestyle            | Many lifestyle prescription drugs are       |
| Prescription           | available at a discounted rate through      |
| Medications**          | participating pharmacies and the Plan's     |
|                        | mail order program. You are responsible for |
|                        | the entire cost of the drugs; however, they |
|                        | are available to you at our preferred       |
|                        | contracted rate. The following lifestyle    |
|                        | prescription drugs are covered under this   |
|                        | benefit:                                    |
|                        |                                             |
|                        | **Cosmetic**: Renova, Vaniqua, Propecia     |
|                        |                                             |
|                        | **Infertility**: A.P.L., Chorex-5,          |
|                        | Chorex-10, Chronon 10, Clomid, Clomiphene,  |
|                        | Crinone gel, Fertinex, Follistem, Gonal-F,  |
|                        | Gonic, HCG, Humegon, Pergonal, Pregnyl,     |
|                        | Profasi, Repronex, Serophone                |
|                        |                                             |
|                        | **Obesity**: Adipost, Didrex, Ionamin,      |
|                        | Merida, Phendimetrazine, Phenter mine,      |
|                        | Sanorex, Tenuate, Xenical                   |
|                        |                                             |
|                        | **Sexual Dysfunction:** Caverject, Edex,    |
|                        | Muse, Viagra                                |
|                        |                                             |
|                        | This list is subject to change and may be   |
|                        | subject to medical necessity review if they |
|                        | are covered under another benefit provision |
|                        | (i.e., Infertility).                        |
|                        |                                             |
|                        | If you have a question on drug coverage,    |
|                        | call 1-800-634-0069.                        |
+------------------------+---------------------------------------------+

##  Section 5 (h). Dental benefits

+---+---+-------------+----------------------+-------+-------+----+---+
|   | * | **Here are  |                      |       |       | *  |   |
|   | * | some        |                      |       |       | *I |   |
|   | I | important   |                      |       |       | ** |   |
|   | * | things to   |                      |       |       |    |   |
|   | * | keep in     |                      |       |       | *  |   |
|   |   | mind about  |                      |       |       | *M |   |
|   | * | these       |                      |       |       | ** |   |
|   | * | benefits:** |                      |       |       |    |   |
|   | M |             |                      |       |       | *  |   |
|   | * | Please      |                      |       |       | *P |   |
|   | * | remember    |                      |       |       | ** |   |
|   |   | that all    |                      |       |       |    |   |
|   | * | benefits    |                      |       |       | *  |   |
|   | * | are subject |                      |       |       | *O |   |
|   | P | to the      |                      |       |       | ** |   |
|   | * | d           |                      |       |       |    |   |
|   | * | efinitions, |                      |       |       | *  |   |
|   |   | l           |                      |       |       | *R |   |
|   | * | imitations, |                      |       |       | ** |   |
|   | * | and         |                      |       |       |    |   |
|   | O | exclusions  |                      |       |       | *  |   |
|   | * | in this     |                      |       |       | *T |   |
|   | * | brochure    |                      |       |       | ** |   |
|   |   | and are     |                      |       |       |    |   |
|   | * | payable     |                      |       |       | *  |   |
|   | * | only when   |                      |       |       | *A |   |
|   | R | we          |                      |       |       | ** |   |
|   | * | determine   |                      |       |       |    |   |
|   | * | they are    |                      |       |       | *  |   |
|   |   | medically   |                      |       |       | *N |   |
|   | * | necessary.  |                      |       |       | ** |   |
|   | * |             |                      |       |       |    |   |
|   | T | The         |                      |       |       | *  |   |
|   | * | calendar    |                      |       |       | *T |   |
|   | * | year        |                      |       |       | ** |   |
|   |   | deductible  |                      |       |       |    |   |
|   | * | does not    |                      |       |       |    |   |
|   | * | apply to    |                      |       |       |    |   |
|   | A | the         |                      |       |       |    |   |
|   | * | benefits in |                      |       |       |    |   |
|   | * | this        |                      |       |       |    |   |
|   |   | Section. We |                      |       |       |    |   |
|   | * | added - (No |                      |       |       |    |   |
|   | * | De          |                      |       |       |    |   |
|   | N | ductible) - |                      |       |       |    |   |
|   | * | to show     |                      |       |       |    |   |
|   | * | that the    |                      |       |       |    |   |
|   |   | calendar    |                      |       |       |    |   |
|   | * | year        |                      |       |       |    |   |
|   | * | deductible  |                      |       |       |    |   |
|   | T | 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 9   |                      |       |       |    |   |
|   |   | about       |                      |       |       |    |   |
|   |   | c           |                      |       |       |    |   |
|   |   | oordinating |                      |       |       |    |   |
|   |   | benefits    |                      |       |       |    |   |
|   |   | with other  |                      |       |       |    |   |
|   |   | coverage,   |                      |       |       |    |   |
|   |   | including   |                      |       |       |    |   |
|   |   | with        |                      |       |       |    |   |
|   |   | Medicare.   |                      |       |       |    |   |
|   |   |             |                      |       |       |    |   |
|   |   | Note: Even  |                      |       |       |    |   |
|   |   | when the    |                      |       |       |    |   |
|   |   | dental      |                      |       |       |    |   |
|   |   | procedure   |                      |       |       |    |   |
|   |   | itself may  |                      |       |       |    |   |
|   |   | not be      |                      |       |       |    |   |
|   |   | covered, we |                      |       |       |    |   |
|   |   | cover       |                      |       |       |    |   |
|   |   | hosp        |                      |       |       |    |   |
|   |   | italization |                      |       |       |    |   |
|   |   | for dental  |                      |       |       |    |   |
|   |   | procedures  |                      |       |       |    |   |
|   |   | when a      |                      |       |       |    |   |
|   |   | non-dental  |                      |       |       |    |   |
|   |   | physical    |                      |       |       |    |   |
|   |   | impairment  |                      |       |       |    |   |
|   |   | exists      |                      |       |       |    |   |
|   |   | which makes |                      |       |       |    |   |
|   |   | hosp        |                      |       |       |    |   |
|   |   | italization |                      |       |       |    |   |
|   |   | necessary   |                      |       |       |    |   |
|   |   | to          |                      |       |       |    |   |
|   |   | safeguard   |                      |       |       |    |   |
|   |   | the health  |                      |       |       |    |   |
|   |   | of the      |                      |       |       |    |   |
|   |   | patient.    |                      |       |       |    |   |
|   |   | See Section |                      |       |       |    |   |
|   |   | 5(c) for    |                      |       |       |    |   |
|   |   | outpatient  |                      |       |       |    |   |
|   |   | hospital    |                      |       |       |    |   |
|   |   | benefits.   |                      |       |       |    |   |
+---+---+-------------+----------------------+-------+-------+----+---+
| # |   |             |                      | **You |       |    |   |
| # |   |             |                      | Pay** |       |    |   |
| # |   |             |                      |       |       |    |   |
| # |   |             |                      |       |       |    |   |
|   |   |             |                      |       |       |    |   |
| A |   |             |                      |       |       |    |   |
| c |   |             |                      |       |       |    |   |
| c |   |             |                      |       |       |    |   |
| i |   |             |                      |       |       |    |   |
| d |   |             |                      |       |       |    |   |
| e |   |             |                      |       |       |    |   |
| n |   |             |                      |       |       |    |   |
| t |   |             |                      |       |       |    |   |
| a |   |             |                      |       |       |    |   |
| l |   |             |                      |       |       |    |   |
|   |   |             |                      |       |       |    |   |
| i |   |             |                      |       |       |    |   |
| n |   |             |                      |       |       |    |   |
| j |   |             |                      |       |       |    |   |
| u |   |             |                      |       |       |    |   |
| r |   |             |                      |       |       |    |   |
| y |   |             |                      |       |       |    |   |
|   |   |             |                      |       |       |    |   |
| b |   |             |                      |       |       |    |   |
| e |   |             |                      |       |       |    |   |
| n |   |             |                      |       |       |    |   |
| e |   |             |                      |       |       |    |   |
| f |   |             |                      |       |       |    |   |
| i |   |             |                      |       |       |    |   |
| t |   |             |                      |       |       |    |   |
+---+---+-------------+----------------------+-------+-------+----+---+
| W |   |             |                      | 20%   |       |    |   |
| e |   |             |                      | of    |       |    |   |
| c |   |             |                      | the   |       |    |   |
| o |   |             |                      | Plan  |       |    |   |
| v |   |             |                      | allo  |       |    |   |
| e |   |             |                      | wance |       |    |   |
| r |   |             |                      | and   |       |    |   |
| o |   |             |                      | any   |       |    |   |
| u |   |             |                      | diffe |       |    |   |
| t |   |             |                      | rence |       |    |   |
| p |   |             |                      | be    |       |    |   |
| a |   |             |                      | tween |       |    |   |
| t |   |             |                      | our   |       |    |   |
| i |   |             |                      | allo  |       |    |   |
| e |   |             |                      | wance |       |    |   |
| n |   |             |                      | and   |       |    |   |
| t |   |             |                      | the   |       |    |   |
| r |   |             |                      | b     |       |    |   |
| e |   |             |                      | illed |       |    |   |
| s |   |             |                      | a     |       |    |   |
| t |   |             |                      | mount |       |    |   |
| o |   |             |                      | (No   |       |    |   |
| r |   |             |                      | D     |       |    |   |
| a |   |             |                      | educt |       |    |   |
| t |   |             |                      | ible) |       |    |   |
| i |   |             |                      |       |       |    |   |
| v |   |             |                      |       |       |    |   |
| e |   |             |                      |       |       |    |   |
| s |   |             |                      |       |       |    |   |
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| a |   |             |                      |       |       |    |   |
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| p |   |             |                      |       |       |    |   |
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| m |   |             |                      |       |       |    |   |
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| ( |   |             |                      |       |       |    |   |
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|   |   |             |                      |       |       |    |   |
| T |   |             |                      |       |       |    |   |
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| c |   |             |                      |       |       |    |   |
| a |   |             |                      |       |       |    |   |
| l |   |             |                      |       |       |    |   |
| r |   |             |                      |       |       |    |   |
| e |   |             |                      |       |       |    |   |
| m |   |             |                      |       |       |    |   |
| o |   |             |                      |       |       |    |   |
| v |   |             |                      |       |       |    |   |
| a |   |             |                      |       |       |    |   |
| l |   |             |                      |       |       |    |   |
| o |   |             |                      |       |       |    |   |
| f |   |             |                      |       |       |    |   |
| i |   |             |                      |       |       |    |   |
| m |   |             |                      |       |       |    |   |
| p |   |             |                      |       |       |    |   |
| a |   |             |                      |       |       |    |   |
| c |   |             |                      |       |       |    |   |
| t |   |             |                      |       |       |    |   |
| e |   |             |                      |       |       |    |   |
| d |   |             |                      |       |       |    |   |
| t |   |             |                      |       |       |    |   |
| e |   |             |                      |       |       |    |   |
| e |   |             |                      |       |       |    |   |
| t |   |             |                      |       |       |    |   |
| h |   |             |                      |       |       |    |   |
| i |   |             |                      |       |       |    |   |
| s |   |             |                      |       |       |    |   |
| c |   |             |                      |       |       |    |   |
| o |   |             |                      |       |       |    |   |
| v |   |             |                      |       |       |    |   |
| e |   |             |                      |       |       |    |   |
| r |   |             |                      |       |       |    |   |
| e |   |             |                      |       |       |    |   |
| d |   |             |                      |       |       |    |   |
| i |   |             |                      |       |       |    |   |
| n |   |             |                      |       |       |    |   |
| S |   |             |                      |       |       |    |   |
| e |   |             |                      |       |       |    |   |
| c |   |             |                      |       |       |    |   |
| t |   |             |                      |       |       |    |   |
| i |   |             |                      |       |       |    |   |
| o |   |             |                      |       |       |    |   |
| n |   |             |                      |       |       |    |   |
| 5 |   |             |                      |       |       |    |   |
| ( |   |             |                      |       |       |    |   |
| b |   |             |                      |       |       |    |   |
| ) |   |             |                      |       |       |    |   |
| . |   |             |                      |       |       |    |   |
| * |   |             |                      |       |       |    |   |
+---+---+-------------+----------------------+-------+-------+----+---+

##  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.

**Supplemental Dental**

**CAREINGTON International Corporation** provides the following dental
benefits to you:

20,000 credentialed providers **nationwide**

**Up to 70% savings on most dental procedures, including routine exams,
dentures, root canals and crowns**

**Up to a 20% reduction of the usual and customary fee for specialties,
such as Orthodontics for children and adults, Endodontics, Oral Surgery,
Pedodontics, Periodontics and Prothodontics**

**Cosmetic dentistry such as bleaching, bonding and implants**

**NO** deductibles, **NO** claim forms and **NO** pre-existing
conditions.

**Supplemental Vision Care**

**EyeMed** provides the following vision care benefits to you:

18,000 credentialed Optometrists, Ophthalmologists, Opticians
**nationwide**, including LensCrafters

Up to 45% off all eyewear

Scheduled discounts off eye exams, lenses and lens options

15% discount on contact lenses and LASIK and PRK procedures

**Supplemental Complementary and Alternative Medicine**

**American WholeHealth, Inc.** provides Complementary and Alternative
Medicine (CAM), defined as any approach or ther­apy that is not
traditionally used in the practice of western medicine.

Save up to 30% for services provided a comprehensive network of
practitioners including

Acupuncturists Chiropractors Dieticians

Exercise specialists Holistic health practitioners Herbal consultants

Massage therapists

Save up to 30% on these popular programs

Yoga Meditation Biofeedback

Reflexology Nutrition Tai Chi

A careful screening process ensures participating practitioners meet
standards.

Save up to 30% on vitamins and nutritional supplements.

Save an additional 15% off online orders and \$5 off catalog orders over
\$25.

##  Section 5 (i) Non-FEHB benefits available to Plan members (continued)

####### Supplemental Hearing Services

**Miracle-Ear**, a leader in research and technology, provides savings
from over 1,000 hearing professionals nationwide. These savings include:

15% discount off the retail price on Miracle-Ear brand hearing aids and
hearing aid repair charges on any brand

No charge for initial comprehensive hearing test

No charge for an annual check and cleansing of hearing aid on any brand

No charge for video otoscope examination where available

State of the art audiometric evaluations

#### Long Term Care Insurance

When you or a family member requires assistance with normal daily
activities due to aging or a disabling accident or\
illness, you may require long term care assistance. These situations can
quickly deplete your family's lifetime savings. Mutual of Omaha's Long
Term Care insurance guards against this circumstance.

It provides:

Very competitive premiums based on your age at the time of enrollment

Inflation protection

Coverage for you, your spouse, parents and parents-in-law, under the age
of 80

Coverage in a nursing care or assisted living facility or in your own
home

Return of premium option if you never need coverage or need it only for
a short time

Option to increase your benefits every five years

For additional information or enrollment in any of these programs,
please call 1-800-769-6953.

**NON-FEHB Benefits are not part of the FEHB contract**.

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

The exclusions in this section apply to all benefits. **Although we may
list a specific service as a benefit, we will not cover it unless we
determine it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury, or condition.** The fact that one of our
covered providers has prescribed, recommended, or approved a service or
supply does not make it medically necessary or eligible for coverage
under this plan.

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;

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

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

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

Charges you or the Plan has no legal obligation to pay, such as excess
charges for an annuitant 65 years or older who is not covered by
Medicare Part A and/or Part B, physician charges exceeding the amount
specified by the Department of Health and Human Services when benefits
are payable under Medicare (limiting charge), or State premium taxes
however applied;

Services, drugs, or supplies for which you would not be charged if you
had no health insurance coverage;

Services, drugs or supplies related to weight control or any treatment
of obesity except surgery for morbid obesity as described in Section
5(b);

Services and supplies furnished or billed by a noncovered facility;
however, medically necessary prescription drugs are covered; and

Services, drugs or supplies you receive from immediate relatives or
household members, such as a spouse, parent, child, brother or sister by
blood, marriage, or adoption.

Listed below are examples of some of our exclusions:

Acupuncture, except when used as an anesthetic agent for covered
services;

Biofeedback, conjoint therapy, hypnotherapy, milieu therapy, and
interpretation/preparation of reports;

Charges for completion of reports or forms;

Charges for interest on unpaid balances;

Charges for missed or cancelled appointments;

Charges for telephone consultations, conferences, or treatment,
mailings, faxes, emails or any other communication to or from a hospital
or covered provider;

Chiropractic services, unless in a medically underserved area;

Custodial care;

Mutually exclusive procedures. These are procedures that are not
typically provided to you on the same date of service;

Non-medical services such as social services, recreational, educational,
visual and nutritional counseling;

Non-surgical treatment of temporomandibular joint (TMJ) dysfunction
including dental appliances, study models, splints and other devices;

Services, drugs or supplies not specifically listed as covered; and

Treatment for learning disabilities and mental retardation.

Note: Exclusions that are primarily identified with a specific benefit
category may also apply to other categories.

## Section 7. Filing a claim for covered services

**How to claim benefits** To obtain claim forms or other claims filing
advice or answers about our benefits, contact us at 1-800-634-0069.

> 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 1-800-634-0069.
>
> When you must file a claim---such as 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.
> Itemized bills and receipts should be sent to Association Benefit
> Plan, PO Box 668587, Charlotte, NC 28266-8587.

-   Name of patient and relationship to enrollee;

-   Plan identification number of the enrollee;

-   Name and address 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.

> You should use the Plan's standard claim form to file dental claims.
> Attach the dentist's itemized bill. The bill must include the name of
> the patient, dates of service, itemized charges and the dentist's tax
> ID number.
>
> 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
    or licensed practical nurse and must include nursing notes.

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

**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.

## Section 7. Filing a claim for covered services (continued)

**Deadline for filing your claim** Send us all of the documents for your
claim as soon as possible. You must submit the claim within 90 days
after you incur the expense, but in no event later then 2 years from the
date you incure the expense. We can extend this deadline if you were
prevented from filing your claim timely by administrative operations of
Government or legal incapacity, provided you file the claim as soon as
reasonably possible. Once we pay benefits, there is a three-year
limitation on the reissuance of uncashed checks.

**Foreign claims** For covered services you receive in hospitals outside
the United States and Puerto Rico and performed by physicians outside
the United States, you must send a completed claim form and the itemized
bills.

> Foreign claims for prescription drugs and supplies that are not
> ordered through the Mail Order Prescription Drug Program must include
> receipts that include the prescription number, name of drug or supply,
> prescribing physician's name, date, and charge.
>
> Claims for foreign services should include an English translation.
>
> Charges should be converted to U.S. dollars using the exchange rate
> applicable at the time the expense was incurred.

  ---------------------- ------------------------------------------------
  **When we need more    Annually you may be asked to verify other health
  information**          care coverage. We may delay processing or deny
                         your claim if you do not respond.

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

## Section 8. The disputed claims process

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

+----+-----------------------------------------------------------------+
| ** | **Description**                                                 |
| St |                                                                 |
| ep |                                                                 |
| ** |                                                                 |
+----+-----------------------------------------------------------------+
| *  | Ask us in writing to reconsider our initial decision. You must: |
| *1 |                                                                 |
| ** | Write to us within 6 months from the date of our decision; and  |
|    |                                                                 |
|    | Send your request to us at: Association Benefit Plan, PO Box    |
|    | 668587, Charlotte, NC 28266- 8587*;* and                        |
|    |                                                                 |
|    | Include a statement about why you believe our initial decision  |
|    | was wrong, based on specific benefit provisions in this         |
|    | brochure; and                                                   |
|    |                                                                 |
|    | Include copies of documents that support your claim, such as    |
|    | physicians\' letters, operative reports, bills, medical         |
|    | records, and explanation of benefits (EOB) forms.               |
+----+-----------------------------------------------------------------+
| *  | We have 30 days from the date we receive your request to:       |
| *2 |                                                                 |
| ** | Pay the claim (or arrange for the health care provider to give  |
|    | you the care); or                                               |
|    |                                                                 |
|    | Write to you and, if applicable, maintain our denial \-- go to  |
|    | step 4; or                                                      |
|    |                                                                 |
|    | Ask you or your provider for more information. If we ask your   |
|    | provider, we will send you a copy of our request \-- go to step |
|    | 3.                                                              |
+----+-----------------------------------------------------------------+
| *  | You or your provider must send the information so that we       |
| *3 | receive it within 60 days of our request. We will then decide   |
| ** | within 30 more days.                                            |
|    |                                                                 |
|    | If we do not receive the information within 60 days, we will    |
|    | decide within 30 days of the date the information was due. We   |
|    | will base our decision on the information we already have.      |
|    |                                                                 |
|    | We will write to you with our decision.                         |
+----+-----------------------------------------------------------------+
| *  | If you do not agree with our decision, you may ask OPM to       |
| *4 | review it.                                                      |
| ** |                                                                 |
|    | You must write to OPM within:                                   |
|    |                                                                 |
|    | 90 days after the date of our letter upholding our initial      |
|    | decision; or                                                    |
|    |                                                                 |
|    | 120 days after you first wrote to us \-- if we did not answer   |
|    | that request in some way within 30 days; or                     |
|    |                                                                 |
|    | 120 days after we asked for additional information.             |
|    |                                                                 |
|    | Write to OPM at: United States Office of Personnel Management,  |
|    | Insurance Services 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.            |
+----+-----------------------------------------------------------------+

**Section 8. The disputed claims process (continued)**

+----+-----------------------------------------------------------------+
|    | Note: If you want OPM to review more than one claim, you must   |
|    | clearly identify which documents apply to which claim.          |
|    |                                                                 |
|    | Note: You are the only person who has a right to file a         |
|    | disputed claim with OPM. Parties acting as your representative, |
|    | such as medical providers, must include a copy of your specific |
|    | written consent with the review request.                        |
|    |                                                                 |
|    | Note: The above deadlines may be extended if you show that you  |
|    | were unable to meet the deadline because of reasons beyond your |
|    | control.                                                        |
+----+-----------------------------------------------------------------+
| *  | OPM will review your disputed claim request and will use the    |
| *5 | information it collects from you and us to decide whether our   |
| ** | decision is correct. OPM will send you a final decision within  |
|    | 60 days. There are no other administrative appeals.             |
|    |                                                                 |
|    | If you do not agree with OPM's decision, your only recourse is  |
|    | to sue. If you decide to sue, you must file the suit against    |
|    | OPM in Federal court by December 31 of the third year after the |
|    | year in which you received the disputed services, drugs, or     |
|    | supplies or from the year in which you were denied              |
|    | 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 its disputed claim decision. This            |
|    | information will become part of the court record.               |
|    |                                                                 |
|    | You may not sue until you have completed the disputed claims    |
|    | process. Further, Federal law governs your lawsuit, benefits,   |
|    | and payment of benefits. The Federal court will base its review |
|    | on the record that was before OPM when OPM decided to uphold or |
|    | overturn our decision. You may recover only the amount of       |
|    | benefits in dispute.                                            |
+----+-----------------------------------------------------------------+

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

We haven\'t responded yet to your initial request for care or
preauthorization/prior approval, then call us at 1-800-634-0069 and we
will expedite our review; or

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

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

You may call OPM\'s Health Insurance Group 2 at 1-202-606-3818 between 8
a.m. and 5 p.m. eastern time.

## Section 9. Coordinating benefits with other coverage

+----------------------+-----------------------------------------------+
| **When you have      | You must tell us if you or a covered family   |
| other health         | member has coverage under another group       |
| coverage**           | health plan or has automobile insurance that  |
|                      | pays health care expenses without regard to   |
|                      | fault. This is called "double coverage."      |
|                      |                                               |
|                      | When you have double coverage, one plan       |
|                      | normally pays its benefits in full as the     |
|                      | primary payer and the other plan pays a       |
|                      | reduced benefit as the secondary payer. We,   |
|                      | like other insurers, determine which coverage |
|                      | is primary according to the National          |
|                      | Association of Insurance Commissioners\'      |
|                      | guidelines.                                   |
|                      |                                               |
|                      | When we are the primary payer, we will pay    |
|                      | the benefits described in this brochure.      |
|                      |                                               |
|                      | When we are the secondary payer, we will      |
|                      | determine our allowance. After the primary    |
|                      | plan pays, we will pay what is left of our    |
|                      | allowance, up to our regular benefit. We will |
|                      | not pay more than our allowance.              |
+----------------------+-----------------------------------------------+

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

-   People 65 years of age and older.

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

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

> Medicare has two parts:

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

-   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 Plan (Part A | Medicare) is available everywhere in the     |
| and Part B)**         | United States. It is the way everyone used   |
|                       | to get Medicare benefits and is the way most |
|                       | people get their Medicare Part A and Part B  |
|                       | benefits now. You may go to any doctor,      |
|                       | specialist, or hospital that accepts         |
|                       | Medicare. The Original Medicare Plan pays    |
|                       | its share and you pay your share. Some       |
|                       | things are not covered under Original        |
|                       | Medicare, like prescription drugs.           |
|                       |                                              |
|                       | When you are enrolled in Original Medicare,  |
|                       | along with this Plan, you still need to      |
|                       | follow the rules in this brochure for us to  |
|                       | cover your care.                             |
+-----------------------+----------------------------------------------+

##  Section 9. Coordinating benefits with other coverage (continued)

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

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

-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In most cases, your claims will be coordinated
    automatically and we will then provide secondary benefits for
    covered charges. You will not need to do anything. To find out if
    you need to do something to file your claims, call us at

-   1-800-634-0069.

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

-   If you are enrolled in Medicare Part B, we will waive copayments and
    coinsur­ance for medical services and supplies provided by physicians
    and other health care professionals. We will also waive deductibles
    and coinsurance for extended dental treatment for accidental dental
    injuries.

-   If you are enrolled in Medicare Part A, we will waive hospital
    copayments and coinsurance.

## Section 9. Coordinating benefits with other coverage (continued)

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.

![](media/image7.png){width="7.122222222222222in" height="7.45in"}

\*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

## Section 9. Coordinating benefits with other coverage (continued)

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

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

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

**TRICARE and CHAMPVA** TRICARE is the health care program for eligible
dependents of military persons, and the 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.

## Section 9. Coordinating benefits with other coverage (continued)

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

-   you need because of a workplace-related illness or injury that the
    Office of Workers' Compensation Programs (OWCP) or a similar Federal
    or State agency determines they must provide; or

-   OWCP or a similar agency pays for through a third party injury
    settlement or other similar proceeding that is based on a claim you
    filed under OWCP or similar laws.

> Once OWCP or similar agency pays its maximum benefits for your
> treatment, we will cover your care.

**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 |
| Government\             | a local, State, or Federal\                |
| agencies are            | Government agency directly or indirectly   |
| responsible for\        | pays for them.                             |
| your care**             |                                            |
+-------------------------+--------------------------------------------+
| **When others are       | When you receive money to compensate you   |
| responsible\            | for medical or hospital care for injuries  |
| for injuries**          | or illness caused by another person, you   |
|                         | must reimburse us for any expenses we      |
|                         | paid. However, we will cover the cost of   |
|                         | treatment that exceeds the amount you      |
|                         | received in the settlement.                |
|                         |                                            |
|                         | If you do not seek damages you must agree  |
|                         | to let us try. This is called\             |
|                         | subrogation. If you need more information, |
|                         | contact us for our subrogation procedures. |
+-------------------------+--------------------------------------------+

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

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

**Assignment** Your authorization for the Plan to issue payment of
benefits directly to the provider. We reserve the right to pay the
member 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 15.

**Hospital stay** An admission (or series of admissions separated by
less than 60 days) to a hospital as an inpatient for any one illness or
injury. There is a new hospital stay when an admission is:

1)  for a cause entirely unrelated to the cause for the previous
    admission;

2)  for an enrolled employee who returns to work for at least one day
    before the next admission; or

3)  for a dependent or annuitant when hospital stays are separated by at
    least 60 days.

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

**Copayment** A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc., when you receive covered services.
See page 15

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

**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 provided safely and
reasonably by a person who is not medically skilled, or are designed
mainly to help the patient with daily living activities. These
activities include but are not limited to:

1)  personal care such as help in: walking; getting in or out of bed;
    bathing; eating by spoon, tube or gastrostomy; exercising; dressing;

2)  homemaking, such as preparing meals or special diets;

3)  moving the patient;

4)  acting as a companion or sitter;

## Section 10. Definitions (continued)

5)  supervising medication that can usually be self administered; or

6)  treatment services such as recording temperature, pulse, and\
    respirations, or administration and monitoring of feeding systems.

7)  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 15

**Effective date** The date the benefits described in this brochure are
effective:

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

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

3)  for new enrollees during the calendar year, but not during Open
    Season, the effective date of enrollment as determined by your
    employing office or retirement system.

**Expense** The cost incurred for a covered service or supply ordered or
prescribed by a covered provider. You can incur an expense on the date
the service or supply is received. Expense does not include any charge:

1.  for a service or supply that is not medically necessary; or

2.  **that is in excess of the Plan's allowance for the service or
    supply.**

+-------------------------+--------------------------------------------+
| **Experimental or**     | A drug, device, or biological product is   |
|                         | experimental or investigational if it      |
| **investigational       | cannot lawfully be marketed without        |
| services**              | 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 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                                  |
+-------------------------+--------------------------------------------+

**Section 10. Definitions (continued)**

**Group health coverage** Health care coverage that you are eligible for
because of employment, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical or
other health care service or supplies, or that pays a specific amount
for each day or period hospitalization.

**Home health care agency** A public or private agency or organization
appropriately licensed, qualified and operated under the law of the
state in which it is located.

**Home health care plan** A written plan, approved in writing by a
physician, for continued care and treatment for a Plan member who is
under the care of a physician and who would need a continued stay in a
hospital or skilled nursing facility with the home health care.

**Hospice care program A coordinated program of home and inpatient pain
control and supportive care for the terminally-ill patient and the
patient's family. Care is provided by a medically supervised team under
the direction of an independent hospice administration that we
approve.**

  -------------------------- --------------------------------------------
  **Intensive Outpatient     A program that offers time limited services
  Program (IOP)**            that are coordinated, structured, and
                             intensively therapeutic. Such programs are
                             designed to treat a variety of individuals
                             with moderate to marked impairment in at
                             least one area of daily life resulting from
                             psychiatric or addictive disorders. At a
                             minimum, IOPs offer three to four hours of
                             active treatment per day at least two to
                             three days per week.

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

**Long term rehabilitation therapy** Physical, speech, and occupational
therapy which can be expected to last longer than a two-month period in
order to achieve a significant improvement in your condition.

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

1)  are appropriate to diagnose or treat your condition, illness or
    injury;

2)  are consistent with standards of good medical practice in the United
    States;

3)  are not primarily for the personal comfort of the patient, the\
    family, or the provider;

4)  are not a part of or associated with the scholastic education or
    vocational training of the patient; and

5)  in the case of inpatient care, cannot be provided safely on an\
    outpatient basis.

6)  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.

**Section 10. Definitions of terms we use in this brochure (continued)**

+-------------------------+--------------------------------------------+
| **Mental                | Conditions and diseases listed in the most |
| conditions/substance    | recent edition of the International        |
| abuse**                 | Classification of Diseases (ICD) as        |
|                         | psychoses, neurotic disorders, or          |
| #######                 | personality disorders; other nonpsychotic  |
|                         | mental disorders listed in the ICD to be   |
|                         | determined by the Plan; or disorders       |
|                         | listed in the ICD requiring treatment for  |
|                         | abuse of or dependence upon substances     |
|                         | such as alcohol, narcotics, or             |
|                         | hallucinogens.                             |
+-------------------------+--------------------------------------------+

**Partial hospitalization** A time-limited, ambulatory, active treatment
program that offers therapeutically intensive, coordinated, and
structured clinical services with a stable therapeutic environment. It
provides 20 hours of scheduled programming, extended over a minimum of
five days per week, by a licensed or JCAHO accredited facility.

**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:

> Twice a year the Healthcare Charges Database (HCD) compiles actual
> claims received in each Zip Code area throughout the United States.
> HCD guides are applied at the 90^th^ percentile to surgery, physician
> services, therapy, X-ray and lab expenses.
>
> We generally do not reduce overseas claims to a Plan allowance.
> However, we reserve the right to request information that will enable
> us to determine an allowance on charges that we deem to be excessive.
>
> PPO providers accept the plan allowance as payment in full.
>
> For more information, see Section 4, Differences between our allowance
> and the bill.

**Prosthetic device** An artificial substitute for a missing functional
body part (such as an arm or leg) because the body part is permanently
damaged, is absent or is malfunctioning.

**Routine physical examination** A complete evaluation, including a
comprehensive history and physical examination, without symptoms or
illness.

**Routine testing/screening** Healthcare services you receive from a
covered provider without any apparent signs or symptoms of an illness,
injury or disease.

**Sound natural tooth** A tooth that is whole or properly restored and
is without impairment, periodontal, or other conditions and is not in
need of the treatment provided for any other reason other than an
accidental injury.

###### Us/We Us and we refer to the Association Benefit Plan

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

## Section 11. FEHB facts

**Coverage Information**

+----------------------+---+------------------------------------------+---+
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|                      | . |                                          |   |
+----------------------+---+------------------------------------------+---+
| **Where you can get  | S |                                          |   |
| infor­mation about    | e |                                          |   |
| enrolling in the     | e |                                          |   |
| FEHB Program**       | w |                                          |   |
|                      | w |                                          |   |
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+----------------------+---+------------------------------------------+---+
|                      |   | -   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 for you    | Family coverage is for you, your spouse, and  |
| and your family**    | your unmarried dependent children under age   |
|                      | 22, including any foster children or          |
|                      | stepchildren your employing or retirement     |
|                      | office authorizes coverage for. Under certain |
|                      | circumstances, you may also continue coverage |
|                      | for a disabled child 22 years of age or older |
|                      | who is incapable of self-support.             |
|                      |                                               |
|                      | If you have a Self Only enrollment, you may   |
|                      | change to a Self and Family enrollment if you |
|                      | marry, give birth, or add a child to your     |
|                      | family. You may change your enrollment 31     |
|                      | days before to 60 days after that event. The  |
|                      | Self and Family enrollment begins on the      |
|                      | first day of the pay period in which the      |
|                      | child is born or becomes an eligible family   |
|                      | member. When you change to Self and Family    |
|                      | because you marry, the change is effective on |
|                      | the first day of the pay period that begins   |
|                      | after your employing office receives your     |
|                      | enrollment form; benefits will not be         |
|                      | available to your spouse until you marry.     |
|                      |                                               |
|                      | Your employing or retirement office will      |
|                      | **not** notify you when a family member is no |
|                      | longer eligible to receive health benefits,   |
|                      | nor will we. Please tell us immediately when  |
|                      | you add or remove family members from your    |
|                      | coverage for any reason, including divorce,   |
|                      | or when your child under age 22 marries or    |
|                      | turns 22.                                     |
+----------------------+-----------------------------------------------+

##  

## Section 11. FEHB facts (continue)

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

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

> If this law applies to you, you must enroll in 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 in
> Self and Family coverage in the Blue Cross and Blue Shield Service
> Benefit Plan's Basic option;
>
> 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 does not serve the area in which your
> children live, unless you provide documentation that you have coverage
> for the children. If the court/administrative order is still in effect
> when you retire, and you have at least one child still eligible for
> FEHB coverage, you must continue your FEHB coverage into retirement
> (if eligible) and cannot cancel your coverage, change to Self Only, or
> change to a plan that doesn't serve the area in which your children
> live as long as the court/administrative order is in effect. Contact
> your employing office for further information.

## Section 11. FEHB facts (continued)

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

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

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

**When you lose benefits**

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

```{=html}
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```
-   **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 coverage** If you are divorced from a Federal
    employee or annuitant, you may not continue to get benefits under
    your former spouse's enrollment. This is the case even when the
    court has ordered your former spouse to 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 former spouse's employing or retirement office to get RI 70-5,
    the *Guide to Federal Employees Health Benefits Plans for Temporary
    Continuation of Coverage and Former Spouse Enrollees*, or other
    information about your coverage choices. You can also download the
    guide from OPM's Website, [www.opm.gov/insure]{.underline}.

+----------------------------+-----------------------------------------+
| **Temporary Continuation   | If you leave Federal service, or if you |
| of Coverage (TCC)**        | lose coverage because you no longer     |
|                            | qualify as a family member, you may be  |
|                            | eligible for Temporary Continuation of  |
|                            | Coverage (TCC). For example, you can    |
|                            | receive TCC if you are not able to      |
|                            | continue your FEHB enrollment after you |
|                            | retire, if you lose your 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.                             |
+----------------------------+-----------------------------------------+

**Section 11. FEHB facts (continued)**

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

+----------------------------+-----------------------------------------+
| **Converting to\           | You may convert to a non-FEHB           |
| individual coverage**      | individual policy if:                   |
|                            |                                         |
|                            | Your coverage under TCC or the spouse   |
|                            | equity law ends. If you canceled your   |
|                            | coverage or did not pay your premium,   |
|                            | you cannot convert;                     |
|                            |                                         |
|                            | You decided not to receive coverage     |
|                            | under TCC or the spouse equity law; or  |
|                            |                                         |
|                            | You are not eligible for coverage under |
|                            | TCC or the spouse equity law.           |
|                            |                                         |
|                            | If you leave Federal service, your      |
|                            | employing office will notify you of     |
|                            | your right to convert. You must apply   |
|                            | in writing to us within 31 days after   |
|                            | you receive this notice. However, if    |
|                            | you are a family member who is losing   |
|                            | coverage, the employing or retirement   |
|                            | office will **not** notify you. You     |
|                            | must apply in writing to us within 31   |
|                            | days after you are no longer eligible   |
|                            | for coverage.                           |
|                            |                                         |
|                            | Your benefits and rates will differ     |
|                            | from those under the FEHB Program;      |
|                            | however, you will not have to answer    |
|                            | questions about your health, and we     |
|                            | will not impose a waiting period or     |
|                            | limit your coverage due to pre-existing |
|                            | conditions.                             |
+----------------------------+-----------------------------------------+
| **Getting a Certificate\   | The Health Insurance Portability and    |
| of Group Health Plan       | Accountability Act of 1996 (HIPAA) is a |
| Coverage**                 | Federal law that offers limited Federal |
|                            | protections for health coverage         |
|                            | availability and continuity to people   |
|                            | who lose employer group coverage. If    |
|                            | you leave the FEHB Program, we will     |
|                            | give you a Certificate of Group Health  |
|                            | Plan Coverage that indicates how long   |
|                            | you have been enrolled with us. You can |
|                            | use this certificate when getting       |
|                            | health insurance or other health care   |
|                            | coverage. Your new plan must reduce or  |
|                            | eliminate waiting periods, limitations, |
|                            | or exclusions for health related        |
|                            | conditions based on the information in  |
|                            | the certificate, as long as you enroll  |
|                            | within 63 days of losing coverage under |
|                            | this Plan. If you have been enrolled    |
|                            | with us for less than 12 months, but    |
|                            | were previously enrolled in other FEHB  |
|                            | plans, you may also request a           |
|                            | certificate from those plans.           |
|                            |                                         |
|                            | For more information, get OPM pamphlet  |
|                            | RI 79-27, Temporary Continuation of     |
|                            | Coverage (TCC) under the FEHB Program.  |
|                            | See also the FEHB Web site              |
|                            | ([w                                     |
|                            | ww.opm.gov/insure/health]{.underline}); |
|                            | refer to the "TCC and HIPAA" frequently |
|                            | asked questions. These highlight HIPAA  |
|                            | rules, such as the requirement that     |
|                            | Federal employees must exhaust any TCC  |
|                            | eligibility as one condition for        |
|                            | guaranteed access to individual health  |
|                            | coverage under HIPAA, and have          |
|                            | information about Federal and State     |
|                            | agencies you can contact for more       |
|                            | information.                            |
+----------------------------+-----------------------------------------+

**Two new Federal Programs complement FEHB benefits**

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

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

**What is an FSA** It is a tax-favored benefit that allows you to set
aside pre-tax money from your paychecks to pay for a variety of eligible
expenses. *By using an FSA, you can reduce your taxes while paying for
services your 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 Flexible     | Covers eligible health care expenses    |
| Spending Account (HCFSA)** | not reimbursed by this Plan, or any     |
|                            | other medical, dental, or vision care   |
|                            | plan you or your dependents may have.   |
|                            |                                         |
|                            | 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 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 Flexible  | Covers eligible dependent care expenses |
| Spending Account (DCFSA)** | incurred so you can work, or if you are |
|                            | married, so you and your spouse can     |
|                            | work, or your spouse can look for work  |
|                            | or attend school full-time.             |
|                            |                                         |
|                            | Eligible dependents for this account    |
|                            | include anyone you claim on your        |
|                            | Federal income tax return as a          |
|                            | qualified IRS dependent and/or with     |
|                            | whom you jointly file your Federal      |
|                            | income tax return.                      |
|                            |                                         |
|                            | The maximum that can be allotted for    |
|                            | the DCFSA is \$5000 annually. The       |
|                            | minimum amount is \$250 annually.       |
|                            | ***Note:*** The IRS limits              |
|                            | contributions to a Dependent Care FSA.  |
|                            | For single taxpayers and taxpayers      |
|                            | filing a joint return, the maximum is   |
|                            | \$5,000 per year. For taxpayers who     |
|                            | file their taxes separately with a      |
|                            | spouse, the maximum is \$2,500 per      |
|                            | year. The limit includes any child care |
|                            | subsidy you may receive.                |
+----------------------------+-----------------------------------------+
| **Enroll during Open       | You **must make an election** to enroll |
| Season**                   | in an FSA during the FEHB Open Season.  |
|                            | Even if you enrolled during the initial |
|                            | Open Season for 2003, you must make a   |
|                            | new election to continue to participate |
|                            | in 2004. Enrollment is easy!            |
|                            |                                         |
|                            | Enroll online anytime during Open       |
|                            | Season (November 10 through December 8, |
|                            | 2003) at **www.fsafeds.com.**           |
+----------------------------+-----------------------------------------+

## Two new Federal Programs complement FEHB benefits (continued)

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

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

**Who is eligible to enroll?** If you are a Federal employee eligible
for FEHB - even if your 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 a FSA Program established for all Executive Branch
> employees and Legislative Branch employees who employers signed on.
> Under IRS law, FSAs are not available to annuitants. In addition, the
> U.S. Postal Service and the Judicial Branch, among others, are Federal
> agencies that have their own plans with slightly different rules, but
> the advantages of having an FSA are the same no matter what agency you
> work for.

+----------------------------+-----------------------------------------+
| **How much should I        | Plan carefully when deciding how much   |
| contribute to my FSA?**    | to contribute to an FSA. Because of the |
|                            | tax benefits of an FSA, the IRS places  |
|                            | strict guidelines on them. You need to  |
|                            | estimate how much you want to allocate  |
|                            | to an FSA because current IRS           |
|                            | regulations require you forfeit any     |
|                            | funds remaining in your account(s) at   |
|                            | the end of the FSA plan year. This is   |
|                            | referred to as the "use-it-or-lose-it"  |
|                            | rule. You will have until April 29,     |
|                            | 2004 to submit claim 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 will help you plan your |
|                            | FSA allocations and provide an estimate |
|                            | of your tax savings based on your       |
|                            | individual situation.                   |
+----------------------------+-----------------------------------------+

**What can my HCFSA pay for?** Every FEHB health plan includes cost
sharing features, such as deductibles you must meet before the Plan
provides benefits, coinsurance or copayments that you pay when you and
the Plan share costs, and medical services and supplies that are not
covered by the Plan and for which you must pay. These out-of-pocket
costs are summarized on page 16 and detailed throughout this brochure.
Your HCFSA will reimburse you for such costs when they are for tax
deductible medical care for you and your dependents that is NOT covered
by this FEHB Plan or any other coverage that you have.

## Two new Federal Programs complement FEHB benefits (continued)

> Typical out-of-pocket expenses include:

-   your \$300/\$600 calendar year deductible

-   your office visit copays

-   your prescription copays

-   your inpatient hospital deductible

-   your non-covered dental procedures

-   your non-covered vision procedures

> The IRS governs expenses reimbursable by a HCFSA. See Publication 502
> for a comprehensive list of tax-deductible medical expenses. **Note:
> While you will see insurance premiums listed in Publication 502, they
> are NOT a reimbursable expense for FSA purposes.** Publication 502 can
> be found on the IRS Web site at
> http://www.irs.gov/pub/irs-pdf/p502.pdf. If you do not see your
> service or expense listed in Publication 502, please call a FSAFEDS
> Benefit Counselor at
>
> 1-877-FSAFEDS (372-3337), who will be able to answer your specific
> questions.

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

> ![](media/image8.png){width="3.734722222222222in"
> height="1.6756944444444444in"}
>
> **Note:** This example is intended to demonstrate a typical tax
> savings based on 27% Federal and 7.65% FICA taxes. Actual savings will
> vary based upon in which retirement system you are enrolled (CSRS or
> FERS), as well as your individual tax situation. In this example, the
> individual received \$2,000 in services for \$1,424, a discount of
> almost 36%! You may also wish to consult a tax professional for more
> information on the tax implications of an FSA.
>
> **Tax credits and deductions** You cannot claim expenses on your
> Federal income tax return if you receive reimbursements for them from
> your HCFSA or DCFSA. Below are some guidelines that may help you
> decide whether to participate in FSAFEDS.

## Two new Federal Programs complement FEHB benefits (continued)

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

  --------------------------- -------------------------------------------
  **Does it cost me anything  Probably not. While there is an
  to participate in           administrative fee of \$4.00 per month for
  FSAFEDS?**                  an HCFSA and 1.5% of the annual election
                              for a DCFSA, most agencies have elected to
                              pay these fees out of their share of
                              employment tax savings. To be sure, check
                              the FSAFEDS.com Web site or call
                              1-877-FSAFEDS (372-3337). Also, remember
                              that participating in FSAFEDS can cost you
                              money if you don't spend your entire
                              account balance by the end of the plan year
                              and wind up forfeiting your end of year
                              account balance, per the IRS
                              "use-it-or-lose-it" rule.

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

> **Contact us** To find out more or to enroll, please visit FSAFEDS Web
> site at **www.fsafeds.com**, or contact SHPS by email or by phone.
> SHPS Benefit Counselors are available from 9:00 a.m. until 9:00 p.m.
> eastern time, Monday through Friday.
>
> E-mail: fsafeds@shps.net
>
> Telephone: 1-877-FSAFEDS (372-3337)
>
> TTY: 1-800-952-0450 (for hearing impaired individuals that would like
> to utilize a text messaging service.

## Two new Federal Programs complement FEHB benefits (continued)

  ----------------------------- -----------------------------------------
  **The Federal Long Term Care  
  Insurance Program**           

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

-   **FEHB plans do not cover the cost of long term care**. Also called
    "custodial care," long term care is help you receive when you need
    assistance performing activities of daily living \-- such as bathing
    or dressing yourself. This need can strike anyone at an 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 that 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 any 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 or questions about your health.
    However, if you are a new or newly eligible employee, you (and you
    spouse, if applicable) have a limited opportu­nity to apply using the
    abbreviated underwriting application, which asks fewer questions. If
    you marry, you new spouse will also have a limited opportunity to
    apply using the abbreviated underwriting. Qualified relatives are
    also eligi­ble to apply with full underwriting.

+---------------------------+------------------------------------------+
| #####                     | Call 1-800-LTC-FEDS (1-800-582-3337)     |
| ## To find out more and t | (TTY 1-800-843-3557) or visit            |
| o request an application  | www.ltcfeds.com.                         |
+---------------------------+------------------------------------------+

#######