Blue HMO^SM^

http://www.anthem.[com]{.underline}![](media/image1.wmf){width="1.3756944444444446in"
height="0.1986111111111111in"}

**2004**

**A Health Maintenance Organization**![](media/image2.png){width="1.4in"
height="1.301388888888889in"}

**Serving:** **Most** **of Ohio**

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

**geographic service area to enroll. See page 8 for requirements.**

![](media/image3.png)

This Plan has excellent accreditation from NCQA.

See the *2004 Guide* for more information on accreditation.

**Enrollment codes for this Plan:**

**R51 Self Only**

**R52 Self and Family**

![](media/image4.png){width="1.1965277777777779in"
height="0.8930555555555556in"}

![](media/image5.png){width="2.792361111111111in"
height="1.2208333333333334in"} **RI 73-031**

![](media/image6.png){width="4.722222222222222in"
height="1.1381944444444445in"}

Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

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

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height="0.8402777777777778in"}
![](media/image9.png){width="1.0395833333333333in"
height="0.8173611111111111in"}

# Notice of the Office of Personnel Management's Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

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

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

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

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  Table of Contents
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Introduction 4

Plain Language 4

Stop Health Care Fraud! 5

Preventing Medical Mistakes 6

Section 1. Facts about this HMO plan 7

How we pay providers 7

Your Rights 7

Service Area 8

Section 2. How we change for 2004 9

Program-wide changes 9

Changes to this Plan 9

Section 3. How you get care 10

Identification cards 10

Where you get covered care 10

-   Plan providers 10

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-   Plan facilities 10

> What you must do to get covered care 11

-   Primary care 11

-   Specialty care 12

-   Hospital care 12

> Circumstances beyond our control 13
>
> Services requiring our prior approval 13

Section 4. Your costs for covered services 14

-   Copayments 14

-   Deductible 14

-   Coinsurance 14

> Your catastrophic protection out-of-pocket maximum 14

Section 5. Benefits 15

Overview 15

> \(a\) Medical services and supplies provided by physicians and other
> health care professionals 16
>
> \(b\) Surgical and anesthesia services provided by physicians and
> other health care professionals 24
>
> \(c\) Services provided by a hospital or other facility, and ambulance
> services 28
>
> \(d\) Emergency services/accidents 30
>
> \(e\) Mental health and substance abuse benefits 32
>
> \(f\) Prescription drug benefits 34
>
> \(g\) Special features 37

-   Flexible benefits option

-   24 hour nurse line

-   Centers of Excellence for transplants/heart surgery

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  Table of Contents *(Continued)*
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-   Reciprocity benefit

-   Discount programs

> \(h\) Dental benefits 39

Section 6. General exclusions \-- things we don\'t cover 42

Section 7. Filing a claim for covered services 43

Section 8. The disputed claims process 44

Section 9. Coordinating benefits with other coverage 46

When you have other health coverage 46

-   What is Medicare 46

-   Should I enroll in Medicare? 46

-   Medicare + Choice 49

-   TRICARE and CHAMPVA 49

-   Workers\' Compensation 49

-   Medicaid 49

-   When other Government agencies are responsible for your care 50

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-   When others are responsible for injuries 50

Section 10. Definitions of terms we use in this brochure 51

Section 11. FEHB facts 53

Coverage information

-   No pre-existing condition limitation 53

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-   Where you can get information about enrolling in the FEHB Program 53

-   Types of coverage available for you and your family 53

-   Children\'s Equity Act 53

-   When benefits and premiums start 54

-   When you retire 54

When you lose benefits 54

-   When FEHB coverage ends 54

-   Spouse equity coverage 54

-   Temporary Continuation of Coverage (TCC) 55

-   Converting to individual coverage 55

-   Getting a Certificate of Group Health Plan Coverage 55

Two new Federal Programs complement FEHB benefits 56

> The Federal Flexible Spending Account Program \-- *FSAFEDS* 56

The Federal Long Term Care Insurance Program 59

Index 60

Summary of benefits 61

Rates Back cover

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  Introduction

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This brochure describes the benefits of **Blue** **HMO^SM^**, under our
contract (CS 1659) with the United States Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. This
Plan is underwritten by Community Insurance Company, dba Anthem Blue
Cross and Blue Shield\*. The address for **Blue HMO** is:

Anthem Blue Cross and Blue Shield

Blue HMO, Mail No. CE2-014

1351 William Howard Taft Road

Cincinnati, Ohio 45206-1775

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

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

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and changes summarized on page 9.
Rates are shown at the end of this brochure.

\*An independent licensee of the Blue Cross and Blue Shield Association.
Anthem Blue Cross and Blue Shield is the trade name of Community
Insurance Company. Registered marks Blue Cross and Blue Shield
Association.

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  Plain Language

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

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

-   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}](http://www.opm.gov/reitre) or
e-mail OPM at <fehbwebcomments@opm.gov>. You may also write to OPM at
the United States Office of Personnel Management, Insurance Services
Program, Program Planning & Evaluation Group, 1900 E Street, NW,
Washington, DC 20415-3650.

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  Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at 800/848-9276
    and explain the situation.

-   If we do not resolve the issue:

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

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

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

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-   If you have any questions about the eligibility of a dependent,
    check with your personnel office if you are employed, you're 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 (TCC).

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

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  Preventing Medical Mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

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

    Want more information on patient safety?

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

-   www.npsf.org. The National Patient Safety Foundation has information
    on how to ensure safer healthcare 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 healthcare 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 healthcare delivery system.

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

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

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

When you receive services from Plan providers, you will not have to
submit claim forms or pay bills. You only pay the copayments,
coinsurance, and deductibles described in this brochure. When you
receive emergency services from non-Plan providers, you may have to
submit claim forms.

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

How we pay providers

We contract with individual physicians, medical groups, and hospitals to
provide the benefits in this brochure. These Plan providers accept a
negotiated payment from us, and you will only be responsible for your
copayments or coinsurance.

**Your Rights**

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

-   Disenrollment rates for 2002

-   Compliance with State and Federal licensing or certification
    requirements and the dates met. If noncompliant, the reason for
    noncompliance.

-   Accreditations by recognized accrediting agencies and the dates
    received

-   Whether the carrier meets State, Federal and accreditation
    requirements for fiscal solvency, confidentially and transfer of
    medical record

-   Years in existence

-   Profit status

-   Medical Records

-   Transitional Care

    If you want more information about us, call 800/228-4375, or write
    to Mail No. CE2-014, 1351 William Howard Taft Road, Cincinnati, Ohio
    45206-1775. You may also contact us by fax at 513/872-3929 or visit
    our website at [www.anthem.com](http://www.anthem.com/).

    The Plan has a Confidentiality Policy. This policy sets forth
    guidelines regarding a member's right to access and amend
    information in the Plan's possession. The Policy specifically
    addresses when a release, signed by a member, is required before
    information may be disclosed by the Plan to parties such as a
    member's provider, spouse, or other family members. Through the
    contract under which the Plan is administering your benefits, the
    Plan is not required to obtain your consent to the release of any
    information or records concerning claims for routine uses as may be
    reasonably necessary for the administration of your benefits. Please
    refer to our website [www.anthem.com](http://www.anthem.com/),
    *Frequently Asked Questions,* for further details.

    **Service Area**

# To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is: {#to-enroll-in-this-plan-you-must-live-in-or-work-in-our-service-area.-this-is-where-our-providers-practice.-our-service-area-is .unnumbered}

**Cincinnati Area:** In ***Ohio** \--* Adams, Brown, Butler, Clermont,
Clinton, Hamilton, Highland and Warren Counties

**Cleveland Area:** In ***Ohio* --** Ashtabula, Cuyahoga, Geauga, Lake,
Lorain, Medina, and Summit Counties

**Dayton Area:** In ***Ohio* \--** Butler, Champaign, Clark, Clinton,
Darke, Greene, Logan, Miami, Montgomery, Preble, Shelby and Warren
counties, and ZIP codes 43128 and 43142 in Fayette County

**Akron-Canton Area**: In ***Ohio* \--** Ashland, Carroll, Harrison,
Holmes, Medina, Portage, Stark, Summit, Tuscarawas, and Wayne Counties

**Warren-Youngstown Area**: In ***Ohio* --** Belmont, Columbiana,
Jefferson, Mahoning, and Trumbull Counties

**Columbus Area:** In ***Ohio*** \-- Athens, Coshocton, Crawford,
Delaware, Fairfield, Franklin, Guernsey, Hocking, Knox, Licking,
Madison, Marion, Morrow, Muskingham, Perry, Pickaway, Pike, Richland,
Ross, Scioto, Union and Washington Counties

**Toledo-Defiance Area:** In ***Ohio*** \-- Allen, Auglaize, Defiance,
Erie, Fulton, Hancock, Hardin, Henry, Huron, Lucas, Mercer, Ottawa,
Paulding, Putnam, Sandusky, Seneca, Williams, Wood, Wyandot and Van Wert
Counties

Ordinarily, you must receive care from providers who contract with us.
If you receive care outside our service area, we will pay only for
emergency or urgent care benefits. We will not pay for any other health
care services out of our service area unless the services have prior
plan approval.

If you or a covered family member move outside of our service area, you
can enroll in another plan. If your dependents live out of the area (for
example, if your child goes to college in another state), you should
consider enrolling in a fee-for-service Plan, or refer to Section 5(g)
*Special Features* on page 37 and 38 for details regarding our
reciprocity benefits. If you or a family member move, you do not have to
wait until Open Season to change plans. Contact your employing or
retirement office.

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

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

**Program-wide changes**

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Program - FSAFEDS and the Federal Long Term Care Insurance Program.
    See page 56.

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

-   We added information regarding enrolling in Medicare. See page 46.

-   We revised the Medicare Primary Payer Chart. See page 48.

    **Changes to this Plan**

-   Your share of the non-Postal premium will increase by 31.4% for Self
    Only or 27.9% for Self and Family.

-   Speech Therapy is covered for up to 60 visits per calendar year.
    Previously, Speech Therapy was covered for up to 20 visits per
    calendar year.

-   Our prior approval is required for certain prescription drugs such
    as for growth hormone therapy and medication to treat sexual
    dysfunction. Previously, they were not listed as requiring prior
    approval.

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

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

If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
800/228-4375 or write to us at Blue HMO, 1351 William Howard Taft Road,
CE2-014, Cincinnati, OH 45206. You may also request replacement cards
through our website at [www.anthem.com]{.underline}.

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

**Plan providers** Plan providers are physicians and other health care
professionals in our service area that we contract with to provide
covered services to our members. We credential Plan providers according
to national standards.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website at
[www.anthem.com]{.underline}.

**Plan facilities** Plan facilities are hospitals and other facilities
in our service area that we contract with to provide covered services to
our members. We list these in the provider directory, which we update
periodically. The list is also on our website at
[www.anthem.com]{.underline}.

> It depends on the type of care you need. First, you and each family
> member must choose a primary care physician (PCP). This decision is
> important since your primary care physician provides or arranges for
> most of your health care.

**How you choose a PCP**

> 1\. Ask family and friends about their doctors. While you're at it,
> ask health care practitioners you respect, too. Personal
> recommendations can mean a lot.
>
> 2\. After you choose a PCP, make an appointment to get to know your
> PCP and help your PCP get to know you. At your first appointment, talk
> to your PCP about:

-   What are your office hours?

-   Who will handle my care when you aren't available?

> 3\. Pay attention. Does the physician explain things so you can
> understand? Are you comfortable talking with him or her? Is the tone
> of the conversation friendly and respectful? Is the physician
> listening carefully to you?

**How you change your PCP**

You are encouraged to develop a long-term relationship with one
Physician, but you may change your PCP if you feel it is necessary, or
if your PCP leaves this Plan. Select your new Physician from the Plan's
Provider Directory, and then contact us to make the change. If you need
help selecting your PCP, call us. You can only change your PCP once in a
30-day period.

**Timing a Physician change**

-   If you notify us before the 15^th^ of the month, your new PCP choice
    is effective the first day of the following month

-   If you notify us on or after the 15^th^ of the month, your new PCP
    choice is effective on the first day of the second month

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-   **Primary care** Your primary care physician can be a family
    practitioner, internist or pediatrician. Your primary care physician
    will provide most of your health care, or give you a referral to see
    a specialist.

**Specialty care** Your primary care physician will refer you to a
specialist when necessary; however, we do not require referrals from
your PCP for participating specialty care providers. If specialists or
consultants are required beyond those participating with us, your
primary care doctor will make arrangements for appropriate referrals.
There are certain services that may require prior approval by us; see
Section 3, page 13. It is always a good idea for you to talk with your
PCP before receiving care from any specialty care provider.

Here are other things you should know about specialty care:

-   If you need to see a specialist frequently because of a chronic,
    complex, or serious medical condition, your primary care physician
    will work with you and the Plan to develop a treatment plan.

-   

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

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

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

```{=html}
<!-- -->
```
-   Terminate our contract with your specialist for other than cause; or

-   Drop out of the Federal Employees Health Benefits (FEHB) Program and
    you enroll in another FEHB Plan; or

-   Reduce our service area and you enroll in another FEHB Plan,

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

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

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

If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 800/228-4375. If you are
new to the FEHB Program, we will arrange for you to receive care.

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

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

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

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

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

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

+------------------------+---------------------------------------------+
| **Services requiring   | Your primary care physician has authority   |
| our prior approval**   | to refer you for most services. For certain |
|                        | services, however, your physician must      |
|                        | obtain approval from us. Before giving      |
|                        | approval, we consider if the service is     |
|                        | covered, medically necessary, and follows   |
|                        | generally accepted medical practice. We     |
|                        | call this review and approval process       |
|                        | precertification.                           |
|                        |                                             |
|                        | Your physician must obtain precertification |
|                        | for services such as, but not limited to:   |
|                        |                                             |
|                        | -   All inpatient admissions (except        |
|                        |     maternity)                              |
|                        |                                             |
|                        | -   Outpatient surgeries such as but not    |
|                        |     limited to: Plastic/Reconstructive &    |
|                        |     Uvulopalatopharyngoplasty (UPPP)        |
|                        |                                             |
|                        | -   Durable Medical Equipment -- Motorized  |
|                        |     Wheelchairs and Hospital/Rocking/Air    |
|                        |     Beds                                    |
|                        |                                             |
|                        | -   Prosthetics -- Electronic or Externally |
|                        |     Powered Prosthetics and custom made     |
|                        |     orthotics and braces                    |
|                        |                                             |
|                        | ```{=html}                                  |
|                        | <!-- -->                                    |
|                        | ```                                         |
|                        | -   Newborn admissions that extend beyond   |
|                        |     the mother\'s discharge                 |
|                        |                                             |
|                        | -   Positron Emission Tomography (PET) &    |
|                        |     Single Photon Emission Computed         |
|                        |     Tomography (SPECT) scans                |
|                        |                                             |
|                        | -   Home health services                    |
|                        |                                             |
|                        | -   Surgical treatment of morbid obesity    |
|                        |                                             |
|                        | -   Certain prescription drugs, such as     |
|                        |     Growth Hormones, Viagra, etc.           |
|                        |                                             |
|                        | > Precertification is a procedure that      |
|                        | > requires an approval to be obtained from  |
|                        | > us before incurring expenses for certain  |
|                        | > covered services. When care is evaluated, |
|                        | > the medical necessity will be determined. |
|                        | > For admissions, the appropriate length of |
|                        | > stay will also be determined. For certain |
|                        | > services you will be required to use the  |
|                        | > provider designated by our Health Care    |
|                        | > Management staff.                         |
|                        | >                                           |
|                        | > Medical necessity includes a review of    |
|                        | > both the service and the setting. When    |
|                        | > approved, a copy of the approval will be  |
|                        | > provided to you, the physician, and the   |
|                        | > hospital or facility. The care will be    |
|                        | > covered according to your benefits for    |
|                        | > the number of days approved unless our    |
|                        | > concurrent review determines that the     |
|                        | > number of days should be revised. As a    |
|                        | > result of concurrent review, additional   |
|                        | > days of inpatient care may be approved    |
|                        | > which exceed the number of days           |
|                        | > originally authorized by our Health Care  |
|                        | > Management staff. With prior notice by    |
|                        | > us, the number of days originally         |
|                        | > authorized by precertification may be     |
|                        | > reduced when it is determined that        |
|                        | > continued inpatient care is no longer     |
|                        | > medically necessary.                      |
|                        |                                             |
|                        | Your PCP and other network providers know   |
|                        | which services require precertification and |
|                        | will obtain any required precertification.  |
|                        | If a request is denied, the provider may    |
|                        | request a reconsideration to be completed   |
|                        | within 3 days of the request. An expedited  |
|                        | reconsideration may be requested when the   |
|                        | member's health requires an earlier         |
|                        | decision.                                   |
|                        |                                             |
|                        | For emergency admissions, precertification  |
|                        | is not required; however, you must notify   |
|                        | your Primary Care Physician of your         |
|                        | admission within 24 hours or as soon as     |
|                        | possible within a reasonable period or      |
|                        | services after 24 hours could be denied.    |
|                        |                                             |
|                        | Predetermination is the process of          |
|                        | requesting approval of benefits before the  |
|                        | service or supply is rendered.              |
+------------------------+---------------------------------------------+

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

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

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

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

Example: When you see your primary care physician you pay a copayment of
\$10 per office visit.

**Deductible** We do not have a deductible.

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

Example: You pay 20% of our allowance for durable medical equipment.

+-------------------------+--------------------------------------------+
| ###### Your             | ###### After your co                       |
| catastrophic protection | payments and/or coinsurance total \$1,500  |
|  out-of-pocket maximum  | per person or \$3,000 per family enrollmen |
|                         | t in any calendar year, you do not have to |
|                         |  pay any more for covered services. Howeve |
|                         | r, copayments and/or coinsurance for the f |
|                         | ollowing services do not count toward your |
|                         |  catastrophic protection out-of-pocket max |
|                         | imum, and you must continue to pay copayme |
|                         | nts and/or coinsurance for these services: |
|                         |                                            |
|                         | -   Dental services                        |
|                         |                                            |
|                         | -   Prescription drugs                     |
|                         |                                            |
|                         | Be sure to keep accurate records of your   |
|                         | copayments and/or coinsurance since you    |
|                         | are responsible for informing us when you  |
|                         | reach the maximum.                         |
+-------------------------+--------------------------------------------+

+-----------------------------------------------------------------------+
| ######  Section 5. Benefits -- OVERVIEW                               |
|                                                                       |
| ***(See page 9 for how our benefits changed this year and page***     |
| ***61 for a benefits summary.)***                                     |
+-----------------------------------------------------------------------+

Note: This benefits section is divided into subsections. Please read the
important things you should keep in mind at the beginning of each
subsection. Also read the *General Exclusions* in Section 6; they apply
to the benefits in the following subsections. To obtain claim forms,
claims filing advice, or more information about our benefits, contact us
at 800/228-4375.

(a) Medical services and supplies provided by physicians and other
    health care professionals 16-23

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals 24-27

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

(c) Services provided by a hospital or other facility, and ambulance
    services 28-29

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

(d) Emergency services 30-31

+----------------------------------+-----------------------------------+
| -   Medical emergency            | -   Ambulance                     |
+----------------------------------+-----------------------------------+

(e) Mental health and substance abuse benefits 32-33

(f) Prescription drug benefits 34-36

(g) Special features 37-38

> Flexible benefits option

-   24 hour nurse line

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

-   Centers of Excellence for transplants/heart surgery

-   Discount programs

(h) Dental benefits 39-41

Summary of benefits 61

+----+---+------------------------------------------+---------+---+---+
| *  |   |                                          |         |   |   |
| *S |   |                                          |         |   |   |
| ec |   |                                          |         |   |   |
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| ** |   |                                          |         |   |   |
+----+---+------------------------------------------+---------+---+---+
|    | * | > **Here are some important things to    |         | * |   |
|    | * | > keep in mind about these benefits:**   |         | * |   |
|    | I |                                          |         | I |   |
|    | * | -   Please remember that all benefits    |         | * |   |
|    | * |     are subject to the definitions,      |         | * |   |
|    |   |     limitations, and exclusions in this  |         |   |   |
|    | * |     brochure and are payable only when   |         | * |   |
|    | * |     we determine they are medically      |         | * |   |
|    | M |     necessary.                           |         | M |   |
|    | * |                                          |         | * |   |
|    | * | -   Plan physicians must provide or      |         | * |   |
|    |   |     arrange your care.                   |         |   |   |
|    | * |                                          |         | * |   |
|    | * | -   We have no calendar year deductible. |         | * |   |
|    | P |                                          |         | P |   |
|    | * | -   Be sure to read Section 4, *Your     |         | * |   |
|    | * |     costs for covered services,* for     |         | * |   |
|    |   |     valuable information about how cost  |         |   |   |
|    | * |     sharing works. Also read Section 9   |         | * |   |
|    | * |     about coordinating benefits with     |         | * |   |
|    | O |     other coverage, including with       |         | O |   |
|    | * |     Medicare.                            |         | * |   |
|    | * |                                          |         | * |   |
|    |   |                                          |         |   |   |
|    | * |                                          |         | * |   |
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|    | * |                                          |         | * |   |
+----+---+------------------------------------------+---------+---+---+
| >  |   |                                          | **You   |   |   |
|  * |   |                                          | pay**   |   |   |
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+----+---+------------------------------------------+---------+---+---+
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+----+---+------------------------------------------+---------+---+---+
| >  |   |                                          | > \$10  |   |   |
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|  c |   |                                          |         |   |   |
| on |   |                                          |         |   |   |
| su |   |                                          |         |   |   |
| lt |   |                                          |         |   |   |
| at |   |                                          |         |   |   |
| io |   |                                          |         |   |   |
| ns |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Se |   |                                          |         |   |   |
| co |   |                                          |         |   |   |
| nd |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| su |   |                                          |         |   |   |
| rg |   |                                          |         |   |   |
| ic |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  o |   |                                          |         |   |   |
| pi |   |                                          |         |   |   |
| ni |   |                                          |         |   |   |
| on |   |                                          |         |   |   |
+----+---+------------------------------------------+---------+---+---+
| >  |   |                                          | > \$25  |   |   |
| Pr |   |                                          | > per   |   |   |
| of |   |                                          | > visit |   |   |
| es |   |                                          |         |   |   |
| si |   |                                          |         |   |   |
| on |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| se |   |                                          |         |   |   |
| rv |   |                                          |         |   |   |
| ic |   |                                          |         |   |   |
| es |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| of |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| ph |   |                                          |         |   |   |
| ys |   |                                          |         |   |   |
| ic |   |                                          |         |   |   |
| ia |   |                                          |         |   |   |
| ns |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| In |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| an |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ur |   |                                          |         |   |   |
| ge |   |                                          |         |   |   |
| nt |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ca |   |                                          |         |   |   |
| re |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ce |   |                                          |         |   |   |
| nt |   |                                          |         |   |   |
| er |   |                                          |         |   |   |
+----+---+------------------------------------------+---------+---+---+
| >  |   |                                          | >       |   |   |
| Pr |   |                                          | Nothing |   |   |
| of |   |                                          |         |   |   |
| es |   |                                          |         |   |   |
| si |   |                                          |         |   |   |
| on |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| se |   |                                          |         |   |   |
| rv |   |                                          |         |   |   |
| ic |   |                                          |         |   |   |
| es |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| of |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| ph |   |                                          |         |   |   |
| ys |   |                                          |         |   |   |
| ic |   |                                          |         |   |   |
| ia |   |                                          |         |   |   |
| ns |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Du |   |                                          |         |   |   |
| ri |   |                                          |         |   |   |
| ng |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ho |   |                                          |         |   |   |
| sp |   |                                          |         |   |   |
| it |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| st |   |                                          |         |   |   |
| ay |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| In |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  s |   |                                          |         |   |   |
| ki |   |                                          |         |   |   |
| ll |   |                                          |         |   |   |
| ed |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  n |   |                                          |         |   |   |
| ur |   |                                          |         |   |   |
| si |   |                                          |         |   |   |
| ng |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| fa |   |                                          |         |   |   |
| ci |   |                                          |         |   |   |
| li |   |                                          |         |   |   |
| ty |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| At |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ho |   |                                          |         |   |   |
| me |   |                                          |         |   |   |
+----+---+------------------------------------------+---------+---+---+
| #  |   |                                          |         |   |   |
| ## |   |                                          |         |   |   |
| ## |   |                                          |         |   |   |
|  L |   |                                          |         |   |   |
| ab |   |                                          |         |   |   |
| ,  |   |                                          |         |   |   |
| X- |   |                                          |         |   |   |
| ra |   |                                          |         |   |   |
| y  |   |                                          |         |   |   |
| an |   |                                          |         |   |   |
| d  |   |                                          |         |   |   |
| ot |   |                                          |         |   |   |
| he |   |                                          |         |   |   |
| r  |   |                                          |         |   |   |
| di |   |                                          |         |   |   |
| ag |   |                                          |         |   |   |
| no |   |                                          |         |   |   |
| st |   |                                          |         |   |   |
| ic |   |                                          |         |   |   |
|  t |   |                                          |         |   |   |
| es |   |                                          |         |   |   |
| ts |   |                                          |         |   |   |
+----+---+------------------------------------------+---------+---+---+
| Te |   |                                          | > \$10  |   |   |
| st |   |                                          | > per   |   |   |
| s, |   |                                          | >       |   |   |
| su |   |                                          |  office |   |   |
| ch |   |                                          | >       |   |   |
| a  |   |                                          |  visit; |   |   |
| s: |   |                                          | >       |   |   |
|    |   |                                          | Nothing |   |   |
| -  |   |                                          | > for   |   |   |
|    |   |                                          | > Lab,  |   |   |
|  B |   |                                          | > X-ray |   |   |
| lo |   |                                          | > and   |   |   |
| od |   |                                          | > other |   |   |
|    |   |                                          | > dia   |   |   |
|    |   |                                          | gnostic |   |   |
|  t |   |                                          | > tests |   |   |
| es |   |                                          |         |   |   |
| ts |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Ur |   |                                          |         |   |   |
| in |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
| ys |   |                                          |         |   |   |
| is |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  N |   |                                          |         |   |   |
| on |   |                                          |         |   |   |
| -r |   |                                          |         |   |   |
| ou |   |                                          |         |   |   |
| ti |   |                                          |         |   |   |
| ne |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ma |   |                                          |         |   |   |
| mm |   |                                          |         |   |   |
| og |   |                                          |         |   |   |
| ra |   |                                          |         |   |   |
| ms |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  P |   |                                          |         |   |   |
| at |   |                                          |         |   |   |
| ho |   |                                          |         |   |   |
| lo |   |                                          |         |   |   |
| gy |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| X- |   |                                          |         |   |   |
| ra |   |                                          |         |   |   |
| ys |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  C |   |                                          |         |   |   |
| at |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  S |   |                                          |         |   |   |
| ca |   |                                          |         |   |   |
| ns |   |                                          |         |   |   |
| /M |   |                                          |         |   |   |
| RI |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Ul |   |                                          |         |   |   |
| tr |   |                                          |         |   |   |
| as |   |                                          |         |   |   |
| ou |   |                                          |         |   |   |
| nd |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  E |   |                                          |         |   |   |
| le |   |                                          |         |   |   |
| ct |   |                                          |         |   |   |
| ro |   |                                          |         |   |   |
| ca |   |                                          |         |   |   |
| rd |   |                                          |         |   |   |
| io |   |                                          |         |   |   |
| gr |   |                                          |         |   |   |
| am |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| nd |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  E |   |                                          |         |   |   |
| EG |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| `` |   |                                          |         |   |   |
| `{ |   |                                          |         |   |   |
| =h |   |                                          |         |   |   |
| tm |   |                                          |         |   |   |
| l} |   |                                          |         |   |   |
| <! |   |                                          |         |   |   |
| -- |   |                                          |         |   |   |
|  - |   |                                          |         |   |   |
| -> |   |                                          |         |   |   |
| `  |   |                                          |         |   |   |
| `` |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  N |   |                                          |         |   |   |
| on |   |                                          |         |   |   |
| -r |   |                                          |         |   |   |
| ou |   |                                          |         |   |   |
| ti |   |                                          |         |   |   |
| ne |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  p |   |                                          |         |   |   |
| ap |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| te |   |                                          |         |   |   |
| st |   |                                          |         |   |   |
+----+---+------------------------------------------+---------+---+---+
| #  |   |                                          | **You   |   |   |
| ## |   |                                          | pay**   |   |   |
| ## |   |                                          |         |   |   |
|  P |   |                                          |         |   |   |
| re |   |                                          |         |   |   |
| ve |   |                                          |         |   |   |
| nt |   |                                          |         |   |   |
| iv |   |                                          |         |   |   |
| e  |   |                                          |         |   |   |
| ca |   |                                          |         |   |   |
| re |   |                                          |         |   |   |
| ,  |   |                                          |         |   |   |
| ad |   |                                          |         |   |   |
| ul |   |                                          |         |   |   |
| ts |   |                                          |         |   |   |
+----+---+------------------------------------------+---------+---+---+
| >  |   |                                          | > \$10  |   |   |
|  R |   |                                          | > per   |   |   |
| ou |   |                                          | >       |   |   |
| ti |   |                                          |  office |   |   |
| ne |   |                                          | >       |   |   |
| >  |   |                                          |  visit; |   |   |
|  s |   |                                          | >       |   |   |
| cr |   |                                          | Nothing |   |   |
| ee |   |                                          | > for   |   |   |
| ni |   |                                          | >       |   |   |
| ng |   |                                          | routine |   |   |
| s, |   |                                          | > scr   |   |   |
| >  |   |                                          | eenings |   |   |
| su |   |                                          |         |   |   |
| ch |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| s: |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  T |   |                                          |         |   |   |
| ot |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  B |   |                                          |         |   |   |
| lo |   |                                          |         |   |   |
| od |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  C |   |                                          |         |   |   |
| ho |   |                                          |         |   |   |
| le |   |                                          |         |   |   |
| st |   |                                          |         |   |   |
| er |   |                                          |         |   |   |
| ol |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Co |   |                                          |         |   |   |
| lo |   |                                          |         |   |   |
| re |   |                                          |         |   |   |
| ct |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Ca |   |                                          |         |   |   |
| nc |   |                                          |         |   |   |
| er |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Sc |   |                                          |         |   |   |
| re |   |                                          |         |   |   |
| en |   |                                          |         |   |   |
| in |   |                                          |         |   |   |
| g, |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  i |   |                                          |         |   |   |
| nc |   |                                          |         |   |   |
| lu |   |                                          |         |   |   |
| di |   |                                          |         |   |   |
| ng |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| `` |   |                                          |         |   |   |
| `{ |   |                                          |         |   |   |
| =h |   |                                          |         |   |   |
| tm |   |                                          |         |   |   |
| l} |   |                                          |         |   |   |
| <! |   |                                          |         |   |   |
| -- |   |                                          |         |   |   |
|  - |   |                                          |         |   |   |
| -> |   |                                          |         |   |   |
| `  |   |                                          |         |   |   |
| `` |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  F |   |                                          |         |   |   |
| ec |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| oc |   |                                          |         |   |   |
| cu |   |                                          |         |   |   |
| lt |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  b |   |                                          |         |   |   |
| lo |   |                                          |         |   |   |
| od |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| te |   |                                          |         |   |   |
| st |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Si |   |                                          |         |   |   |
| gm |   |                                          |         |   |   |
| oi |   |                                          |         |   |   |
| do |   |                                          |         |   |   |
| sc |   |                                          |         |   |   |
| op |   |                                          |         |   |   |
| y, |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  s |   |                                          |         |   |   |
| cr |   |                                          |         |   |   |
| ee |   |                                          |         |   |   |
| ni |   |                                          |         |   |   |
| ng |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -- |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| st |   |                                          |         |   |   |
| ar |   |                                          |         |   |   |
| ti |   |                                          |         |   |   |
| ng |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| at |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| ge |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| 50 |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  C |   |                                          |         |   |   |
| ol |   |                                          |         |   |   |
| on |   |                                          |         |   |   |
| os |   |                                          |         |   |   |
| co |   |                                          |         |   |   |
| py |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -- |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| on |   |                                          |         |   |   |
| ce |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  e |   |                                          |         |   |   |
| ve |   |                                          |         |   |   |
| ry |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| 10 |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  y |   |                                          |         |   |   |
| ea |   |                                          |         |   |   |
| rs |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| st |   |                                          |         |   |   |
| ar |   |                                          |         |   |   |
| ti |   |                                          |         |   |   |
| ng |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| at |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| ge |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| 50 |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Do |   |                                          |         |   |   |
| ub |   |                                          |         |   |   |
| le |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| co |   |                                          |         |   |   |
| nt |   |                                          |         |   |   |
| ra |   |                                          |         |   |   |
| st |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ba |   |                                          |         |   |   |
| ri |   |                                          |         |   |   |
| um |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  e |   |                                          |         |   |   |
| ne |   |                                          |         |   |   |
| ma |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| (D |   |                                          |         |   |   |
| CB |   |                                          |         |   |   |
| E) |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -- |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| on |   |                                          |         |   |   |
| ce |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  e |   |                                          |         |   |   |
| ve |   |                                          |         |   |   |
| ry |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| 5- |   |                                          |         |   |   |
| 10 |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  y |   |                                          |         |   |   |
| ea |   |                                          |         |   |   |
| rs |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| st |   |                                          |         |   |   |
| ar |   |                                          |         |   |   |
| ti |   |                                          |         |   |   |
| ng |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| at |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| ge |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| 50 |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| `` |   |                                          |         |   |   |
| `{ |   |                                          |         |   |   |
| =h |   |                                          |         |   |   |
| tm |   |                                          |         |   |   |
| l} |   |                                          |         |   |   |
| <! |   |                                          |         |   |   |
| -- |   |                                          |         |   |   |
|  - |   |                                          |         |   |   |
| -> |   |                                          |         |   |   |
| `  |   |                                          |         |   |   |
| `` |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Pr |   |                                          |         |   |   |
| os |   |                                          |         |   |   |
| ta |   |                                          |         |   |   |
| te |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Sp |   |                                          |         |   |   |
| ec |   |                                          |         |   |   |
| if |   |                                          |         |   |   |
| ic |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  A |   |                                          |         |   |   |
| nt |   |                                          |         |   |   |
| ig |   |                                          |         |   |   |
| en |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| (P |   |                                          |         |   |   |
| SA |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  t |   |                                          |         |   |   |
| es |   |                                          |         |   |   |
| t) |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -- |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  o |   |                                          |         |   |   |
| ne |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| an |   |                                          |         |   |   |
| nu |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
| ly |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  f |   |                                          |         |   |   |
| or |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  m |   |                                          |         |   |   |
| en |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| ge |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| 40 |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| nd |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  o |   |                                          |         |   |   |
| ld |   |                                          |         |   |   |
| er |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  R |   |                                          |         |   |   |
| ou |   |                                          |         |   |   |
| ti |   |                                          |         |   |   |
| ne |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  p |   |                                          |         |   |   |
| ap |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| te |   |                                          |         |   |   |
| st |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  O |   |                                          |         |   |   |
| ne |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  r |   |                                          |         |   |   |
| ou |   |                                          |         |   |   |
| ti |   |                                          |         |   |   |
| ne |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ma |   |                                          |         |   |   |
| mm |   |                                          |         |   |   |
| og |   |                                          |         |   |   |
| ra |   |                                          |         |   |   |
| m, |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  p |   |                                          |         |   |   |
| er |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ca |   |                                          |         |   |   |
| le |   |                                          |         |   |   |
| nd |   |                                          |         |   |   |
| ar |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  y |   |                                          |         |   |   |
| ea |   |                                          |         |   |   |
| r, |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| re |   |                                          |         |   |   |
| ga |   |                                          |         |   |   |
| rd |   |                                          |         |   |   |
| le |   |                                          |         |   |   |
| ss |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| of |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| ge |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  F |   |                                          |         |   |   |
| as |   |                                          |         |   |   |
| ti |   |                                          |         |   |   |
| ng |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  L |   |                                          |         |   |   |
| ip |   |                                          |         |   |   |
| op |   |                                          |         |   |   |
| ro |   |                                          |         |   |   |
| te |   |                                          |         |   |   |
| in |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  p |   |                                          |         |   |   |
| ro |   |                                          |         |   |   |
| fi |   |                                          |         |   |   |
| le |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| (t |   |                                          |         |   |   |
| ot |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ch |   |                                          |         |   |   |
| ol |   |                                          |         |   |   |
| es |   |                                          |         |   |   |
| te |   |                                          |         |   |   |
| ro |   |                                          |         |   |   |
| l, |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| LD |   |                                          |         |   |   |
| L, |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  H |   |                                          |         |   |   |
| DL |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| nd |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| tr |   |                                          |         |   |   |
| ig |   |                                          |         |   |   |
| ly |   |                                          |         |   |   |
| ce |   |                                          |         |   |   |
| ri |   |                                          |         |   |   |
| de |   |                                          |         |   |   |
| s) |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Bo |   |                                          |         |   |   |
| ne |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  d |   |                                          |         |   |   |
| en |   |                                          |         |   |   |
| si |   |                                          |         |   |   |
| ty |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| sc |   |                                          |         |   |   |
| re |   |                                          |         |   |   |
| en |   |                                          |         |   |   |
| in |   |                                          |         |   |   |
| gs |   |                                          |         |   |   |
+----+---+------------------------------------------+---------+---+---+
| >  |   |                                          | > *All  |   |   |
| *N |   |                                          | > c     |   |   |
| ot |   |                                          | harges* |   |   |
| >  |   |                                          |         |   |   |
| co |   |                                          |         |   |   |
| ve |   |                                          |         |   |   |
| re |   |                                          |         |   |   |
| d: |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| Ph |   |                                          |         |   |   |
| ys |   |                                          |         |   |   |
| ic |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
|  e |   |                                          |         |   |   |
| xa |   |                                          |         |   |   |
| ms |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| re |   |                                          |         |   |   |
| qu |   |                                          |         |   |   |
| ir |   |                                          |         |   |   |
| ed |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
|  f |   |                                          |         |   |   |
| or |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
|  o |   |                                          |         |   |   |
| bt |   |                                          |         |   |   |
| ai |   |                                          |         |   |   |
| ni |   |                                          |         |   |   |
| ng |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| or |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| co |   |                                          |         |   |   |
| nt |   |                                          |         |   |   |
| in |   |                                          |         |   |   |
| ui |   |                                          |         |   |   |
| ng |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| em |   |                                          |         |   |   |
| pl |   |                                          |         |   |   |
| oy |   |                                          |         |   |   |
| me |   |                                          |         |   |   |
| nt |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| or |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| in |   |                                          |         |   |   |
| su |   |                                          |         |   |   |
| ra |   |                                          |         |   |   |
| nc |   |                                          |         |   |   |
| e, |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| tt |   |                                          |         |   |   |
| en |   |                                          |         |   |   |
| di |   |                                          |         |   |   |
| ng |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
|  s |   |                                          |         |   |   |
| ch |   |                                          |         |   |   |
| oo |   |                                          |         |   |   |
| ls |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| or |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
|  c |   |                                          |         |   |   |
| am |   |                                          |         |   |   |
| p, |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
| or |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
|  t |   |                                          |         |   |   |
| ra |   |                                          |         |   |   |
| ve |   |                                          |         |   |   |
| l* |   |                                          |         |   |   |
+----+---+------------------------------------------+---------+---+---+
| >  |   |                                          | > \$10  |   |   |
|  R |   |                                          | > per   |   |   |
| ou |   |                                          | >       |   |   |
| ti |   |                                          |  office |   |   |
| ne |   |                                          | >       |   |   |
| >  |   |                                          |  visit; |   |   |
| im |   |                                          | >       |   |   |
| mu |   |                                          | Nothing |   |   |
| ni |   |                                          | > for   |   |   |
| za |   |                                          | >       |   |   |
| ti |   |                                          |  immuni |   |   |
| on |   |                                          | zations |   |   |
| s, |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
|  l |   |                                          |         |   |   |
| im |   |                                          |         |   |   |
| it |   |                                          |         |   |   |
| ed |   |                                          |         |   |   |
| >  |   |                                          |         |   |   |
|  t |   |                                          |         |   |   |
| o: |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Te |   |                                          |         |   |   |
| ta |   |                                          |         |   |   |
| nu |   |                                          |         |   |   |
| s- |   |                                          |         |   |   |
| di |   |                                          |         |   |   |
| ph |   |                                          |         |   |   |
| th |   |                                          |         |   |   |
| er |   |                                          |         |   |   |
| ia |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| (T |   |                                          |         |   |   |
| d) |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  b |   |                                          |         |   |   |
| oo |   |                                          |         |   |   |
| st |   |                                          |         |   |   |
| er |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -- |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| on |   |                                          |         |   |   |
| ce |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  e |   |                                          |         |   |   |
| ve |   |                                          |         |   |   |
| ry |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| 10 |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ye |   |                                          |         |   |   |
| ar |   |                                          |         |   |   |
| s, |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ag |   |                                          |         |   |   |
| es |   |                                          |         |   |   |
| 19 |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| nd |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| ov |   |                                          |         |   |   |
| er |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  ( |   |                                          |         |   |   |
| ex |   |                                          |         |   |   |
| ce |   |                                          |         |   |   |
| pt |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| as |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| pr |   |                                          |         |   |   |
| ov |   |                                          |         |   |   |
| id |   |                                          |         |   |   |
| ed |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  f |   |                                          |         |   |   |
| or |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  u |   |                                          |         |   |   |
| nd |   |                                          |         |   |   |
| er |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  C |   |                                          |         |   |   |
| hi |   |                                          |         |   |   |
| ld |   |                                          |         |   |   |
| ho |   |                                          |         |   |   |
| od |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| im |   |                                          |         |   |   |
| mu |   |                                          |         |   |   |
| ni |   |                                          |         |   |   |
| za |   |                                          |         |   |   |
| ti |   |                                          |         |   |   |
| on |   |                                          |         |   |   |
| s) |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| `` |   |                                          |         |   |   |
| `{ |   |                                          |         |   |   |
| =h |   |                                          |         |   |   |
| tm |   |                                          |         |   |   |
| l} |   |                                          |         |   |   |
| <! |   |                                          |         |   |   |
| -- |   |                                          |         |   |   |
|  - |   |                                          |         |   |   |
| -> |   |                                          |         |   |   |
| `  |   |                                          |         |   |   |
| `` |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  I |   |                                          |         |   |   |
| nf |   |                                          |         |   |   |
| lu |   |                                          |         |   |   |
| en |   |                                          |         |   |   |
| za |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| va |   |                                          |         |   |   |
| cc |   |                                          |         |   |   |
| in |   |                                          |         |   |   |
| es |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| an |   |                                          |         |   |   |
| nu |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
| ly |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| Pn |   |                                          |         |   |   |
| eu |   |                                          |         |   |   |
| mo |   |                                          |         |   |   |
| co |   |                                          |         |   |   |
| cc |   |                                          |         |   |   |
| al |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| va |   |                                          |         |   |   |
| cc |   |                                          |         |   |   |
| in |   |                                          |         |   |   |
| e, |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| ge |   |                                          |         |   |   |
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+----+---+------------------------------------------+---------+---+---+
| #  |   |                                          |         |   |   |
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+----+---+------------------------------------------+---------+---+---+
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|    |   |                                          | > per   |   |   |
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+----+---+------------------------------------------+---------+---+---+
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|    |   |                                          | > per   |   |   |
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|    |   |                                          |         |   |   |
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| `` |   |                                          |         |   |   |
| -  |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
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|    |   |                                          |         |   |   |
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|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  i |   |                                          |         |   |   |
| mm |   |                                          |         |   |   |
| un |   |                                          |         |   |   |
| iz |   |                                          |         |   |   |
| at |   |                                          |         |   |   |
| io |   |                                          |         |   |   |
| ns |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
| (t |   |                                          |         |   |   |
| hr |   |                                          |         |   |   |
| ou |   |                                          |         |   |   |
| gh |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  a |   |                                          |         |   |   |
| ge |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|    |   |                                          |         |   |   |
|  2 |   |                                          |         |   |   |
| 1) |   |                                          |         |   |   |
+----+---+------------------------------------------+---------+---+---+

+---------------------------------------------------+------------------+
| ######## Maternity care                           | **You Pay**      |
+---------------------------------------------------+------------------+
| > Complete maternity (obstetrical) care, such as: | > Nothing        |
|                                                   |                  |
| -   Prenatal care                                 |                  |
|                                                   |                  |
| -   Delivery                                      |                  |
|                                                   |                  |
| -   Postnatal care                                |                  |
|                                                   |                  |
| -   One routine sonogram                          |                  |
+---------------------------------------------------+------------------+
| > Note: Here are some things to keep in mind:     |                  |
|                                                   |                  |
| -   You do not need to precertify your normal     |                  |
|     delivery; see page 13 for other               |                  |
|     circumstances, such as extended stays for you |                  |
|     or your baby.                                 |                  |
|                                                   |                  |
| -   You may remain in the hospital up to 48 hours |                  |
|     after a regular delivery and 96 hours after a |                  |
|     cesarean delivery. We will extend your        |                  |
|     inpatient stay if medically necessary.        |                  |
|                                                   |                  |
| -   We cover routine nursery care of the newborn  |                  |
|     child during the covered portion of the       |                  |
|     mother's maternity stay. We will cover other  |                  |
|     care (including circumcision) of an infant    |                  |
|     who requires non-routine treatment only if we |                  |
|     cover the infant under a Self and Family      |                  |
|     enrollment.                                   |                  |
|                                                   |                  |
| -   We pay hospitalization and surgeon services   |                  |
|     (delivery) the same as for illness and        |                  |
|     injury. See Hospital benefits (Section 5c)    |                  |
|     and Surgery benefits (Section 5b).            |                  |
+---------------------------------------------------+------------------+
| *Not covered: Subsequent routine sonograms to     | > *All charges*  |
| determine fetal* *age, size or sex*               |                  |
+---------------------------------------------------+------------------+
| ######## Family planning                          |                  |
+---------------------------------------------------+------------------+
| > A range of voluntary family planning services,  | > \$10 per       |
| > limited to:                                     | > office visit;  |
|                                                   | > Nothing for    |
| -   Voluntary sterilization See Section 5(b)      | > Family         |
|                                                   | > planning       |
| ```{=html}                                        | > services       |
| <!-- -->                                          |                  |
| ```                                               |                  |
| -   Surgically implanted contraceptives           |                  |
|                                                   |                  |
| > Note: We cover oral and injectable              |                  |
| > contraceptives (such as Depo provera) under the |                  |
| > prescription drug benefit                       |                  |
+---------------------------------------------------+------------------+
| -   Intrauterine devices (IUDs)                   | > \$10 per       |
|                                                   | > office visit;  |
| ```{=html}                                        | > 20% of our     |
| <!-- -->                                          | > allowance for  |
| ```                                               | > Birth control  |
| -   Diaphragms (when provided in a physician's    | > devices        |
|     office)                                       |                  |
|                                                   |                  |
| > Note: See Section 5(f), *Prescription drug      |                  |
| > benefit*, for coverage when purchased through a |                  |
| > retail pharmacy                                 |                  |
+---------------------------------------------------+------------------+
| > *Not covered: Reversal of voluntary surgical    | > *All charges*  |
| > sterilization*                                  |                  |
+---------------------------------------------------+------------------+

+---------------------------------------------------+------------------+
| ######## Infertility services                     | **You Pay**      |
+---------------------------------------------------+------------------+
| > Diagnosis and treatment of infertility, such    | > \$10 per       |
| > as:                                             | > office visit   |
|                                                   |                  |
| -   Artificial insemination:                      |                  |
|                                                   |                  |
| ```{=html}                                        |                  |
| <!-- -->                                          |                  |
| ```                                               |                  |
| -   Intravaginal insemination (IVI)               |                  |
|                                                   |                  |
| -   Intra­cervical insemination (ICI)              |                  |
|                                                   |                  |
| -   Intrauterine insemina­tion (IUI)               |                  |
+---------------------------------------------------+------------------+
| > Diagnosis and treatment of infertility, such    | > \$10 per       |
| > as:                                             | > office visit;  |
|                                                   | > 50% of our     |
| -   Fertility drugs                               | > allowance for  |
|                                                   | > Fertility      |
| > Note: We cover injectable fertility drugs under | > drugs          |
| > medical benefits and oral fertility drugs under |                  |
| > the prescription drug benefit.                  |                  |
+---------------------------------------------------+------------------+
| > *Not covered:*                                  | > *All charges*  |
|                                                   |                  |
| -   *Assisted reproductive technology (ART)       |                  |
|     procedures, such as:*                         |                  |
|                                                   |                  |
| ```{=html}                                        |                  |
| <!-- -->                                          |                  |
| ```                                               |                  |
| -   *In vitro fertilization*                      |                  |
|                                                   |                  |
| -   *Embryo transfer, gamete GIFT and zygote      |                  |
|     ZIFT*                                         |                  |
|                                                   |                  |
| -   *Zygote transfer*                             |                  |
|                                                   |                  |
| ```{=html}                                        |                  |
| <!-- -->                                          |                  |
| ```                                               |                  |
| -   *Services and supplies related to excluded    |                  |
|     ART procedures*                               |                  |
|                                                   |                  |
| -   *Cost of donor sperm*                         |                  |
|                                                   |                  |
| -   *Cost of donor egg*                           |                  |
+---------------------------------------------------+------------------+
| > **Allergy care**                                |                  |
+---------------------------------------------------+------------------+
| -   Testing                                       | > \$10 per       |
|                                                   | > office visit;  |
|                                                   | > 20% of our     |
|                                                   | > allowance for  |
|                                                   | > Allergy        |
|                                                   | > testing        |
+---------------------------------------------------+------------------+
| -   Treatment                                     | > \$10 per       |
|                                                   | > office visit;  |
| ```{=html}                                        | > Nothing for    |
| <!-- -->                                          | > Allergy        |
| ```                                               | > injections and |
| -   Allergy injections                            | > serum          |
|                                                   |                  |
| -   Allergy serum                                 |                  |
+---------------------------------------------------+------------------+
| > *Not covered: Provocative food testing and      | > *All charges*  |
| > sublingual allergy desensitization*             |                  |
+---------------------------------------------------+------------------+

+---------------------------------------------------+------------------+
| ######## Treatment therapies                      | **You pay**      |
+---------------------------------------------------+------------------+
| -   Chemotherapy and radiation therapy            | > \$10 per       |
|                                                   | > office visit;  |
| > Note: High dose chemotherapy in association     | > Nothing for    |
| > with autologous bone marrow transplants are     | > Treatment      |
| > limited to those transplants listed under       | > therapies      |
| > Organ/Tissue Transplants on page 27             |                  |
|                                                   |                  |
| -   Respiratory and inhalation therapy            |                  |
|                                                   |                  |
| ```{=html}                                        |                  |
| <!-- -->                                          |                  |
| ```                                               |                  |
| -   Dialysis -- hemodialysis and peritoneal       |                  |
|     dialysis                                      |                  |
|                                                   |                  |
| ```{=html}                                        |                  |
| <!-- -->                                          |                  |
| ```                                               |                  |
| -   Intravenous (IV)/Infusion Therapy -- Home IV  |                  |
|     and antibiotic therapy                        |                  |
+---------------------------------------------------+------------------+
| -   Growth hormone therapy (GHT)                  | > \$10 per       |
|                                                   | > office visit;  |
| Note: Growth hormone is covered under the         | > 50% of our     |
| prescription drug benefit                         | > allowance for  |
|                                                   | > Growth hormone |
| > Note: Approval is based on our medical policy.  | > therapy (GHT)  |
| > We may ask you or your physician to submit,     |                  |
| > through our predetermination process, for the   |                  |
| > following:                                      |                  |
|                                                   |                  |
| -   A letter of medical necessity                 |                  |
|                                                   |                  |
| -   Laboratory results, and                       |                  |
|                                                   |                  |
| -   A growth chart                                |                  |
+---------------------------------------------------+------------------+
| > **Physical and occupational therapies**         |                  |
+---------------------------------------------------+------------------+
| -   60 visits, per calendar year, for services by | > \$10 per visit |
|     the following:                                |                  |
|                                                   |                  |
| ```{=html}                                        |                  |
| <!-- -->                                          |                  |
| ```                                               |                  |
| -   Qualified physical therapists                 |                  |
|                                                   |                  |
| -   Qualified chiropractors (physical therapy     |                  |
|     only) and                                     |                  |
|                                                   |                  |
| -   Occupational therapists                       |                  |
|                                                   |                  |
| > Note: We only cover therapy to restore bodily   |                  |
| > function when there has been a total or partial |                  |
| > loss of bodily function due to illness or       |                  |
| > injury                                          |                  |
|                                                   |                  |
| -   Cardiac rehabilitation following a heart      |                  |
|     transplant, bypass surgery or a myocardial    |                  |
|     infarction.                                   |                  |
+---------------------------------------------------+------------------+
| > *Not covered:*                                  | > *All charges*  |
|                                                   |                  |
| -   *Long-term rehabilitative therapy*            |                  |
|                                                   |                  |
| -   *Exercise programs*                           |                  |
|                                                   |                  |
| -   *Inpatient hospital stays for physical        |                  |
|     therapy purposes only*                        |                  |
+---------------------------------------------------+------------------+
| > **Speech therapy**                              |                  |
+---------------------------------------------------+------------------+
| -   60 visits, per calendar year                  | > \$10 per visit |
+---------------------------------------------------+------------------+

+--------------------------------------------------+-------------------+
| > **Hearing services (testing, treatment, and    | **You pay**       |
| > supplies)**                                    |                   |
+--------------------------------------------------+-------------------+
| -   Hearing examinations to determine the need   | > Nothing if you  |
|     for hearing correction                       | > receive these   |
|                                                  | > services during |
|                                                  | > your office     |
|                                                  | > visit;          |
|                                                  | > otherwise \$10  |
|                                                  | > per exam        |
+--------------------------------------------------+-------------------+
| > *Not covered:*                                 | > *All charges*   |
|                                                  |                   |
| -   *All other hearing testing*                  |                   |
|                                                  |                   |
| -   *Hearing aids, testing and examinations for  |                   |
|     them*                                        |                   |
+--------------------------------------------------+-------------------+
| > **Vision services (testing, treatment, and     |                   |
| > supplies)**                                    |                   |
+--------------------------------------------------+-------------------+
| -   One routine eye exam with refraction per     | > \$10 per office |
|     year                                         | > visit           |
|                                                  |                   |
| > Note: See Preventive care, children for eye    |                   |
| > exams for children                             |                   |
+--------------------------------------------------+-------------------+
| -   First pair of lenses following cataract      | > \$10 per office |
|     surgery                                      | > visit; 20% of   |
|                                                  | > our allowance   |
|                                                  | > for First pair  |
|                                                  | > of lenses       |
+--------------------------------------------------+-------------------+
| > *Not covered:*                                 | > *All charges*   |
|                                                  |                   |
| -   *Eyeglasses*                                 |                   |
|                                                  |                   |
| -   *Contact lenses, contact* *fittings or       |                   |
|     contact* *examinations*                      |                   |
|                                                  |                   |
| -   *Eye exercises and vision training*          |                   |
|                                                  |                   |
| -   *Radial keratotomy and other refractive      |                   |
|     surgeries*                                   |                   |
|                                                  |                   |
| -   *Photo-Refractive keratectomy (PRK)*         |                   |
+--------------------------------------------------+-------------------+
| ######## Foot care                               |                   |
+--------------------------------------------------+-------------------+
| > Routine foot care when you are under active    | > \$10 per office |
| > treatment for a metabolic or peripheral        | > visit           |
| > vascular disease, such as diabetes.            |                   |
| >                                                |                   |
| > See orthopedic and prosthetic devices for      |                   |
| > information on podiatric shoe inserts.         |                   |
+--------------------------------------------------+-------------------+
| > *Not covered:*                                 | > *All charges*   |
|                                                  |                   |
| -   *Cutting, trimming or removal of corns,      |                   |
|     calluses, or the free edge of toenails, and  |                   |
|     similar routine treatment of conditions of   |                   |
|     the foot, except as stated above*            |                   |
|                                                  |                   |
| -   *Treatment of weak, strained or flat feet or |                   |
|     bunions or spurs; and of any instability,    |                   |
|     imbalance or subluxation of the foot (unless |                   |
|     the treatment is by open cutting surgery)*   |                   |
+--------------------------------------------------+-------------------+
| > **Orthopedic and prosthetic devices**          |                   |
+--------------------------------------------------+-------------------+
| > Externally worn orthopedic and prosthetic      | > \$10 per office |
| > devices such as:                               | > visit; 20% of   |
|                                                  | > our allowance   |
| -   Artificial limbs and eyes; stump hose        | > for Orthopedic  |
|                                                  | > and prosthetic  |
| -   Braces, slings, splints and certain          | > devices         |
|     orthotics                                    |                   |
|                                                  |                   |
| ```{=html}                                       |                   |
| <!-- -->                                         |                   |
| ```                                              |                   |
| -   Externally worn breast prostheses and        |                   |
|     surgical bras or necessary replacements,     |                   |
|     following a mastectomy                       |                   |
|                                                  |                   |
| -   Corrective orthopedic appliances for         |                   |
|     non-dental treatment of temporomandibular    |                   |
|     joint (TMJ) pain dysfunction syndrome        |                   |
|                                                  |                   |
| > Note: See Section 5(b) for coverage of the     |                   |
| > medical treatment of TMJ pain dysfunction      |                   |
| > syndrome                                       |                   |
+--------------------------------------------------+-------------------+

*Orthopedic and prosthetic devices -- Continued on next page*

+--------------------------------------------------+-------------------+
| > **Orthopedic and prosthetic devices            | **You pay**       |
| > *(continued) ***                               |                   |
+--------------------------------------------------+-------------------+
| -   Internal prosthetic devices, such as         | > Nothing         |
|     artificial joints, pacemakers, cochlear      |                   |
|     implants, and surgically implanted breast    |                   |
|     implants following mastectomy.               |                   |
|                                                  |                   |
| > Note: We pay internal prosthetic devices as    |                   |
| > hospital benefits; see Section 5(c) for        |                   |
| > payment information. See Section 5(b) for      |                   |
| > coverage of the surgery to insert the device   |                   |
+--------------------------------------------------+-------------------+
| > *Not covered:*                                 | > *All charges*   |
|                                                  |                   |
| -   *Orthopedic shoes*                           |                   |
|                                                  |                   |
| -   *Foot support devices, such as arch supports |                   |
|     and corrective shoes, unless they are an     |                   |
|     integral part of a leg brace*                |                   |
|                                                  |                   |
| -   *[Bionic, bioelectric, or computer           |                   |
|     programmed prosthetic devices unless         |                   |
|     authorized by the plan]{.mark}*              |                   |
+--------------------------------------------------+-------------------+
| ######## Durable medical equipment (DME)         |                   |
+--------------------------------------------------+-------------------+
| > Rental or purchase, at our option, including   | > \$10 per office |
| > repair and adjustment of durable medical       | > visit; 20% of   |
| > equipment prescribed by your Plan physician,   | > our allowance   |
| > such as oxygen and oxygen equipment. Under     | > for DME         |
| > this benefit, we also cover items such as:     | > services        |
|                                                  | > rendered in a   |
| -   Hospital beds                                | > physician's     |
|                                                  | > office or from  |
| -   Wheelchairs                                  | > a medical       |
|                                                  | > supplier        |
| -   Crutches                                     |                   |
|                                                  |                   |
| -   Walkers                                      |                   |
|                                                  |                   |
| -   Blood glucose monitors (when purchased at a  |                   |
|     participating medical supply provider)       |                   |
|                                                  |                   |
| ```{=html}                                       |                   |
| <!-- -->                                         |                   |
| ```                                              |                   |
| -   Insulin pumps                                |                   |
|                                                  |                   |
| -   First pair of lenses following cataract      |                   |
|     removal                                      |                   |
|                                                  |                   |
| -   Wig (one per year following cancer treatment |                   |
|     up to plan allowable)                        |                   |
|                                                  |                   |
| -   Surgical stockings (30mm/hg) or supports     |                   |
|     when purchased by prescription or dispensed  |                   |
|     by a participating hospital not to exceed 4  |                   |
|     pair per year                                |                   |
|                                                  |                   |
| -   Hemodialysis equipment                       |                   |
|                                                  |                   |
| -   Traction and suspension equipment            |                   |
|                                                  |                   |
| -   Sleep apnea, cardiac and neonatal (high risk |                   |
|     infant) monitors                             |                   |
|                                                  |                   |
| -   Medical supplies, such as surgical dressings |                   |
|     and colostomy bags and casting supplies      |                   |
|                                                  |                   |
| > Note: Rental cost must not be more than        |                   |
| > purchase price                                 |                   |
| >                                                |                   |
| > Note: Medical equipment must serve only a      |                   |
| > medical purpose and be able to withstand       |                   |
| > repeated use.                                  |                   |
+--------------------------------------------------+-------------------+
| > *Not covered:*                                 | > *All charges*   |
|                                                  |                   |
| -   *Devices and equipment used for              |                   |
|     environmental control or to enhance the      |                   |
|     environmental setting, such as air           |                   |
|     conditioners, humidifiers or air filters*    |                   |
|                                                  |                   |
| -   *Supplies that can be used by other family   |                   |
|     members such as: adhesive tape, band-aids,   |                   |
|     alcohol and cotton balls*                    |                   |
|                                                  |                   |
| -   *Raised toilet seats*                        |                   |
|                                                  |                   |
| -   *Personal hygiene and convenience items*     |                   |
|                                                  |                   |
| -   *Mechanical beds, such as Craftmatic         |                   |
|     Adjustable Beds*                             |                   |
|                                                  |                   |
| -   *Mattresses, sheets, pads, pillows, rubber   |                   |
|     sheets*                                      |                   |
|                                                  |                   |
| -   *Therabath, hot tubs, Jacuzzis, saunas,      |                   |
|     portable whirlpool pumps*                    |                   |
|                                                  |                   |
| -   *Chair lifts and tub chairs*                 |                   |
|                                                  |                   |
| -   *Exercise equipment, including but not       |                   |
|     limited to exercise bikes and treadmills*    |                   |
+--------------------------------------------------+-------------------+
| ######## Home health services                    | **You pay**       |
+--------------------------------------------------+-------------------+
| -   Home health care ordered by a Plan physician | > Nothing         |
|     and provided by a registered nurse (RN),     |                   |
|     licensed practical nurse (LPN), or home      |                   |
|     health aide                                  |                   |
|                                                  |                   |
| -   Services include oxygen therapy, intravenous |                   |
|     therapy and medications                      |                   |
+--------------------------------------------------+-------------------+
| > Not covered:                                   | > *All charges*   |
|                                                  |                   |
| -   *Nursing care requested by, or for the       |                   |
|     convenience of, the patient or the patient's |                   |
|     family*                                      |                   |
|                                                  |                   |
| -   *Home care primarily for personal assistance |                   |
|     that does not include a medical component    |                   |
|     and is not diagnostic, therapeutic, or       |                   |
|     rehabilitative*                              |                   |
|                                                  |                   |
| -   *Services primarily for hygiene, feeding,    |                   |
|     exercising, moving the patient, homemaking,  |                   |
|     companionship or giving oral medication*     |                   |
+--------------------------------------------------+-------------------+
| #### **Chiropractic**                            |                   |
+--------------------------------------------------+-------------------+
| > Limited to:                                    | > \$10 per visit  |
|                                                  |                   |
| -   12 Spinal manipulations, per calendar year,  |                   |
|     provided by the following:                   |                   |
|                                                  |                   |
| ```{=html}                                       |                   |
| <!-- -->                                         |                   |
| ```                                              |                   |
| -   Participating chiropractors                  |                   |
|                                                  |                   |
| -   Doctors of Osteopathy                        |                   |
+--------------------------------------------------+-------------------+
| #### **Alternative treatments**                  |                   |
+--------------------------------------------------+-------------------+
| > No Benefits                                    | > *All charges*   |
+--------------------------------------------------+-------------------+
| > *Not covered services such as:*                | > *All charges*   |
|                                                  |                   |
| -   *Naturopathic services*                      |                   |
|                                                  |                   |
| -   *Hypnotherapy*                               |                   |
|                                                  |                   |
| -   *Biofeedback*                                |                   |
|                                                  |                   |
| -   *Acupuncture*                                |                   |
|                                                  |                   |
| > Note: Please contact the Plan at 800/228-4375  |                   |
| > for further clarification                      |                   |
+--------------------------------------------------+-------------------+
| #### **Educational classes and programs**        |                   |
+--------------------------------------------------+-------------------+
| > Coverage is limited to:                        | > \$10 per office |
|                                                  | > visit           |
| -   Diabetes self-management                     |                   |
+--------------------------------------------------+-------------------+
| -   Smoking cessation (one smoking cessation     | > Nothing up to   |
|     program per member, per lifetime)            | > \$100; *All     |
|                                                  | > charges         |
| > Note: See Section 5(e) for individual or group | > thereafter*     |
| > counseling coverage                            |                   |
+--------------------------------------------------+-------------------+
| > *Not covered:*                                 | > *All charges*   |
|                                                  |                   |
| -   *Second and subsequent smoking cessation     |                   |
|     programs*                                    |                   |
|                                                  |                   |
| ```{=html}                                       |                   |
| <!-- -->                                         |                   |
| ```                                              |                   |
| -   *Services or supplies primarily for          |                   |
|     educational, vocational, nutritional or      |                   |
|     training purposes, except as otherwise       |                   |
|     specified herein*                            |                   |
+--------------------------------------------------+-------------------+

+---+---+-----------------------------------------+-----------+---+---+
| * |   |                                         |           |   |   |
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| d |   |                                         |           |   |   |
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| d |   |                                         |           |   |   |
| b |   |                                         |           |   |   |
| y |   |                                         |           |   |   |
| p |   |                                         |           |   |   |
| h |   |                                         |           |   |   |
| y |   |                                         |           |   |   |
| s |   |                                         |           |   |   |
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| c |   |                                         |           |   |   |
| i |   |                                         |           |   |   |
| a |   |                                         |           |   |   |
| n |   |                                         |           |   |   |
| s |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
| a |   |                                         |           |   |   |
| n |   |                                         |           |   |   |
| d |   |                                         |           |   |   |
| o |   |                                         |           |   |   |
| t |   |                                         |           |   |   |
| h |   |                                         |           |   |   |
| e |   |                                         |           |   |   |
| r |   |                                         |           |   |   |
| h |   |                                         |           |   |   |
| e |   |                                         |           |   |   |
| a |   |                                         |           |   |   |
| l |   |                                         |           |   |   |
| t |   |                                         |           |   |   |
| h |   |                                         |           |   |   |
| c |   |                                         |           |   |   |
| a |   |                                         |           |   |   |
| r |   |                                         |           |   |   |
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| p |   |                                         |           |   |   |
| r |   |                                         |           |   |   |
| o |   |                                         |           |   |   |
| f |   |                                         |           |   |   |
| e |   |                                         |           |   |   |
| s |   |                                         |           |   |   |
| s |   |                                         |           |   |   |
| i |   |                                         |           |   |   |
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| s |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
+---+---+-----------------------------------------+-----------+---+---+
|   | * | > **Here are some important things to   |           | * |   |
|   | * | > keep in mind about these benefits:**  |           | * |   |
|   | I |                                         |           | I |   |
|   | * | -   Please remember that all benefits   |           | * |   |
|   | * |     are subject to the definitions,     |           | * |   |
|   |   |     limitations, and exclusions in this |           |   |   |
|   | * |     brochure and are payable only when  |           | * |   |
|   | * |     we determine they are medically     |           | * |   |
|   | M |     necessary.                          |           | M |   |
|   | * |                                         |           | * |   |
|   | * | -   Plan physicians must provide or     |           | * |   |
|   |   |     arrange your care.                  |           |   |   |
|   | * |                                         |           | * |   |
|   | * | -   We have no calendar year            |           | * |   |
|   | P |     deductible.                         |           | P |   |
|   | * |                                         |           | * |   |
|   | * | -   Be sure to read Section 4, *Your    |           | * |   |
|   |   |     costs for covered services,* for    |           |   |   |
|   | * |     valuable information about how cost |           | * |   |
|   | * |     sharing works. Also read Section 9  |           | * |   |
|   | O |     about coordinating benefits with    |           | O |   |
|   | * |     other coverage, including with      |           | * |   |
|   | * |     Medicare.                           |           | * |   |
|   |   |                                         |           |   |   |
|   | * | -   The amounts listed below are for    |           | * |   |
|   | * |     the charges billed by a physician   |           | * |   |
|   | R |     or other health care professional   |           | R |   |
|   | * |     for your surgical care. Look in     |           | * |   |
|   | * |     Section 5(c) for charges associated |           | * |   |
|   |   |     with the facility (i.e. hospital,   |           |   |   |
|   | * |     surgical center, etc).              |           | * |   |
|   | * |                                         |           | * |   |
|   | T | -   YOUR PHYSICIAN MUST GET             |           | T |   |
|   | * |     PRECERTIFICATION FOR SOME SURGICAL  |           | * |   |
|   | * |     PROCEDURES. Please refer to the     |           | * |   |
|   |   |     precertification information shown  |           |   |   |
|   | * |     in Section 3 to be sure which       |           | * |   |
|   | * |     services require precertification   |           | * |   |
|   | A |     and identify which surgeries        |           | A |   |
|   | * |     require precertification.           |           | * |   |
|   | * |                                         |           | * |   |
|   |   |                                         |           |   |   |
|   | * |                                         |           | * |   |
|   | * |                                         |           | * |   |
|   | N |                                         |           | N |   |
|   | * |                                         |           | * |   |
|   | * |                                         |           | * |   |
|   |   |                                         |           |   |   |
|   | * |                                         |           | * |   |
|   | * |                                         |           | * |   |
|   | T |                                         |           | T |   |
|   | * |                                         |           | * |   |
|   | * |                                         |           | * |   |
+---+---+-----------------------------------------+-----------+---+---+
| > |   |                                         | **You     |   |   |
|   |   |                                         | pay**     |   |   |
| * |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
| B |   |                                         |           |   |   |
| e |   |                                         |           |   |   |
| n |   |                                         |           |   |   |
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| f |   |                                         |           |   |   |
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| t |   |                                         |           |   |   |
| > |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| D |   |                                         |           |   |   |
| e |   |                                         |           |   |   |
| s |   |                                         |           |   |   |
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| r |   |                                         |           |   |   |
| i |   |                                         |           |   |   |
| p |   |                                         |           |   |   |
| t |   |                                         |           |   |   |
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| n |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
+---+---+-----------------------------------------+-----------+---+---+
| > |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
| S |   |                                         |           |   |   |
| u |   |                                         |           |   |   |
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| g |   |                                         |           |   |   |
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| c |   |                                         |           |   |   |
| a |   |                                         |           |   |   |
| l |   |                                         |           |   |   |
| > |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| p |   |                                         |           |   |   |
| r |   |                                         |           |   |   |
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| e |   |                                         |           |   |   |
| d |   |                                         |           |   |   |
| u |   |                                         |           |   |   |
| r |   |                                         |           |   |   |
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| s |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
| * |   |                                         |           |   |   |
+---+---+-----------------------------------------+-----------+---+---+
| > |   |                                         | > Nothing |   |   |
|   |   |                                         |           |   |   |
| A |   |                                         |           |   |   |
| > |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| c |   |                                         |           |   |   |
| o |   |                                         |           |   |   |
| m |   |                                         |           |   |   |
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| e |   |                                         |           |   |   |
| n |   |                                         |           |   |   |
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| m |   |                                         |           |   |   |
| a |   |                                         |           |   |   |
| k |   |                                         |           |   |   |
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|   |   |                                         |           |   |   |
| a |   |                                         |           |   |   |
| n |   |                                         |           |   |   |
| d |   |                                         |           |   |   |
| > |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| S |   |                                         |           |   |   |
| u |   |                                         |           |   |   |
| r |   |                                         |           |   |   |
| g |   |                                         |           |   |   |
| e |   |                                         |           |   |   |
| r |   |                                         |           |   |   |
| y |   |                                         |           |   |   |
| > |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| b |   |                                         |           |   |   |
| e |   |                                         |           |   |   |
| n |   |                                         |           |   |   |
| e |   |                                         |           |   |   |
| f |   |                                         |           |   |   |
| i |   |                                         |           |   |   |
| t |   |                                         |           |   |   |
| s |   |                                         |           |   |   |
| > |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| f |   |                                         |           |   |   |
| o |   |                                         |           |   |   |
| r |   |                                         |           |   |   |
| > |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| i |   |                                         |           |   |   |
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| e |   |                                         |           |   |   |
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| i |   |                                         |           |   |   |
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| n |   |                                         |           |   |   |
| > |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| o |   |                                         |           |   |   |
| f |   |                                         |           |   |   |
| > |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| t |   |                                         |           |   |   |
| h |   |                                         |           |   |   |
| e |   |                                         |           |   |   |
| > |   |                                         |           |   |   |
|   |   |                                         |           |   |   |
| p |   |                                         |           |   |   |
| a |   |                                         |           |   |   |
| c |   |                                         |           |   |   |
| e |   |                                         |           |   |   |
| m |   |                                         |           |   |   |
| a |   |                                         |           |   |   |
| k |   |                                         |           |   |   |
| e |   |                                         |           |   |   |
| r |   |                                         |           |   |   |
| . |   |                                         |           |   |   |
+---+---+-----------------------------------------+-----------+---+---+

*Surgical procedures - Continued on next page*

+--------------------------------------------------+-------------------+
| > **Surgical procedures** *(Continued)*          | > **You pay**     |
+--------------------------------------------------+-------------------+
| -   Voluntary sterilization (e.g., Tubal         | > Nothing         |
|     ligation, Vasectomy)                         |                   |
+--------------------------------------------------+-------------------+
| > *Not covered:*                                 | > *All charges*   |
|                                                  |                   |
| -   *Reversal of voluntary sterilization*        |                   |
|                                                  |                   |
| -   *Routine treatment of conditions of the      |                   |
|     foot; see Foot care in Section 5(a)*         |                   |
|                                                  |                   |
| -   *Non-surgical treatment of morbid obesity as |                   |
|     set-forth by our predetermination process*   |                   |
+--------------------------------------------------+-------------------+
| > **Reconstructive surgery**                     |                   |
+--------------------------------------------------+-------------------+
| -   Surgery to correct a functional defect       | > Nothing         |
|                                                  |                   |
| -   Surgery to correct a condition caused by     |                   |
|     injury or illness                            |                   |
|                                                  |                   |
| -   Surgery to correct a condition that existed  |                   |
|     at or from birth and is a significant        |                   |
|     deviation from the common form or norm       |                   |
|                                                  |                   |
| -   All stages of breast reconstruction surgery  |                   |
|     following a mastectomy, such as:             |                   |
|                                                  |                   |
| ```{=html}                                       |                   |
| <!-- -->                                         |                   |
| ```                                              |                   |
| -   Surgery to produce a symmetrical appearance  |                   |
|     on the other breast                          |                   |
|                                                  |                   |
| -   Treatment of any physical complications,     |                   |
|     such as lymphedemas                          |                   |
+--------------------------------------------------+-------------------+
| -   Breast prostheses and surgical bras or       | > 20% of our      |
|     replacements (see Section 5(a) Prosthetic    | > allowance       |
|     devices)                                     |                   |
|                                                  |                   |
| > Note: If you need a mastectomy, you may choose |                   |
| > to have the procedure performed on an          |                   |
| > inpatient basis and remain in the hospital up  |                   |
| > to 48 hours after the procedure                |                   |
+--------------------------------------------------+-------------------+
| > *Not covered:*                                 | > *All charges*   |
|                                                  |                   |
| -   *Cosmetic surgery -- any surgical procedure  |                   |
|     connected with or incidental to treatment    |                   |
|     that is primarily intended to improve        |                   |
|     appearance as set-forth by our               |                   |
|     predetermination process*                    |                   |
|                                                  |                   |
| -   *Surgeries related to sex transformation, or |                   |
|     the reversal thereof*                        |                   |
+--------------------------------------------------+-------------------+

+--------------------------------------------------+-------------------+
| > **Oral and maxillofacial surgery**             | > **You pay**     |
+--------------------------------------------------+-------------------+
| > Oral surgical procedures, such as:             | > Nothing         |
|                                                  |                   |
| -   Excision of exostoses of the jaws and hard   |                   |
|     palate. (If pathology exists, generally done |                   |
|     to prepare the mouth for dentures.)          |                   |
|                                                  |                   |
| -   Excision of tumors and cysts of the jaws,    |                   |
|     cheeks, lips, tongue, roof and floor of the  |                   |
|     mouth                                        |                   |
|                                                  |                   |
| -   External (extra-oral) incision and drainage  |                   |
|     of cellulitis                                |                   |
|                                                  |                   |
| -   Incision of accessory sinuses, salivary      |                   |
|     glands or ducts                              |                   |
|                                                  |                   |
| -   Reduction of dislocations and excision of    |                   |
|     the temporomandibular joints (TMJ)           |                   |
|                                                  |                   |
| -   Surgery for correction of accidental         |                   |
|     injuries of the jaws, cheeks, lips, tongue,  |                   |
|     roof and floor of the mouth                  |                   |
|                                                  |                   |
| -   Treatment of fractures of facial bones       |                   |
|                                                  |                   |
| -   Correction of orthognanthic when severe      |                   |
|     handicapping malocclusion is present         |                   |
|                                                  |                   |
| -   Other surgical procedures that do not        |                   |
|     involve the teeth or their supporting        |                   |
|     structures                                   |                   |
|                                                  |                   |
| > Note: See Section 5(a), *Orthopedic and        |                   |
| > prosthetic devices,* for appliance cost.       |                   |
+--------------------------------------------------+-------------------+
| > *Not covered:*                                 | > *All charges*   |
|                                                  |                   |
| -   *Oral implants and transplants*              |                   |
|                                                  |                   |
| -   *Procedures that involve the teeth or their  |                   |
|     supporting structures (such as the           |                   |
|     periodontal membrane, gingiva, and alveolar  |                   |
|     bone)*                                       |                   |
|                                                  |                   |
| -   *Dental care involved in the treatment of    |                   |
|     temporomandibular joint (TMJ) pain           |                   |
|     dysfunction or syndrome*                     |                   |
|                                                  |                   |
| -   *Dentures and dental appliances*             |                   |
+--------------------------------------------------+-------------------+

+--------------------------------------------------+-------------------+
| > **Organ/tissue transplants**                   | > **You pay**     |
+--------------------------------------------------+-------------------+
| > Limited to:                                    | > Nothing         |
|                                                  |                   |
| -   Cornea                                       |                   |
|                                                  |                   |
| -   Heart                                        |                   |
|                                                  |                   |
| -   Heart/lung                                   |                   |
|                                                  |                   |
| -   Kidney                                       |                   |
|                                                  |                   |
| -   Kidney/Pancreas                              |                   |
|                                                  |                   |
| -   Liver                                        |                   |
|                                                  |                   |
| -   Lung: Single --Double                        |                   |
|                                                  |                   |
| -   Pancreas                                     |                   |
|                                                  |                   |
| -   Allogeneic (donor) bone marrow transplants   |                   |
|                                                  |                   |
| -   Autologous bone marrow transplants           |                   |
|     (autologous stem cell and peripheral stem    |                   |
|     cell support) for the following conditions:  |                   |
|     acute lymphoctyic or non-lymphocytic         |                   |
|     leukemia; advanced Hodgkin's lymphoma;       |                   |
|     advance non-Hodgkin's lymphoma; advance      |                   |
|     neuroblastoma; breast cancer; multiple       |                   |
|     myeloma; epithelial ovarian cancer; and      |                   |
|     testicular, mediastinal, retroperitoneal and |                   |
|     ovarian germ cell tumors                     |                   |
|                                                  |                   |
| -   Intestinal transplants (small intestine) and |                   |
|     the small intestine with the liver or small  |                   |
|     intestine with multiple organs such as the   |                   |
|     liver, stomach, and pancreas                 |                   |
|                                                  |                   |
| -   Autologous tandem transplant for testicular  |                   |
|     and other germ cell tumors                   |                   |
|                                                  |                   |
| -   Travel expenses related to covered           |                   |
|     transplants outside a 75 mile radius,        |                   |
|     subject to Plan\'s procedures.               |                   |
|                                                  |                   |
| -   Blue Quality Centers for Transplant (BQCT)   |                   |
|     (See page 37 for a description of BQCT)      |                   |
|                                                  |                   |
| > Note: We cover related medical and hospital    |                   |
| > expenses of the donor when we cover the        |                   |
| > recipient, within six weeks of acquisition.    |                   |
| >                                                |                   |
| > Note: All transplants are subject to the       |                   |
| > Plan\'s medical policy through case            |                   |
| > management. When you or your provider become   |                   |
| > aware that a transplant is needed, you should  |                   |
| > contact us.                                    |                   |
| >                                                |                   |
| > Note: See Section 5(f), *Prescription drug     |                   |
| > benefits,* for related drug coverage           |                   |
+--------------------------------------------------+-------------------+
| > *Not covered:*                                 | > *All charges*   |
|                                                  |                   |
| -   *Implants of artificial organs*              |                   |
|                                                  |                   |
| ```{=html}                                       |                   |
| <!-- -->                                         |                   |
| ```                                              |                   |
| -   *Transplants not listed as covered*          |                   |
|                                                  |                   |
| -   *Transplants performed in a non-designated   |                   |
|     organ transplant facility except as          |                   |
|     authorized by the Plan.*                     |                   |
+--------------------------------------------------+-------------------+
| > **Anesthesia**                                 |                   |
+--------------------------------------------------+-------------------+
| > Professional services provided in:             | > Nothing         |
|                                                  |                   |
| -   Hospital (inpatient)                         |                   |
|                                                  |                   |
| -   Hospital outpatient department               |                   |
|                                                  |                   |
| -   Skilled nursing facility                     |                   |
|                                                  |                   |
| -   Ambulatory surgical center                   |                   |
|                                                  |                   |
| -   Office                                       |                   |
+--------------------------------------------------+-------------------+
| > *Not covered: Professional services provided   | > *All charges*   |
| > in a dentist\'s office. See Section 5(h) for   |                   |
| > dental benefits.*                              |                   |
+--------------------------------------------------+-------------------+

+---+---+------------------------------------------+------------+---+---+
| > |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
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| s |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
+---+---+------------------------------------------+------------+---+---+
|   | * | > **Here are some important things to    |            | * |   |
|   | * | > remember about these benefits:**       |            | * |   |
|   | I |                                          |            | I |   |
|   | * | -   Please remember that all benefits    |            | * |   |
|   | * |     are subject to the definitions,      |            | * |   |
|   |   |     limitations and exclusions in this   |            |   |   |
|   | * |     brochure and are payable only when   |            | * |   |
|   | * |     we determine they are medically      |            | * |   |
|   | M |     necessary.                           |            | M |   |
|   | * |                                          |            | * |   |
|   | * | -   Plan physicians must provide or      |            | * |   |
|   |   |     arrange your care and you must be    |            |   |   |
|   | * |     hospitalized in a Plan facility.     |            | * |   |
|   | * |                                          |            | * |   |
|   | P | -   We have no calendar year deductible. |            | P |   |
|   | * |                                          |            | * |   |
|   | * | -   Be sure to read Section 4, *Your     |            | * |   |
|   |   |     costs for covered services,* for     |            |   |   |
|   | * |     valuable information about how cost  |            | * |   |
|   | * |     sharing works. Also read Section 9   |            | * |   |
|   | O |     about coordinating benefits with     |            | O |   |
|   | * |     other coverage, including with       |            | * |   |
|   | * |     Medicare.                            |            | * |   |
|   |   |                                          |            |   |   |
|   | * | -   The amounts listed below are for the |            | * |   |
|   | * |     charges billed by the facility       |            | * |   |
|   | R |     (i.e., hospital or surgical center)  |            | R |   |
|   | * |     or ambulance service for your        |            | * |   |
|   | * |     surgery or care. Any costs           |            | * |   |
|   |   |     associated with the professional     |            |   |   |
|   | * |     charge (i.e., physicians, etc.) are  |            | * |   |
|   | * |     covered in Sections 5(a) or (b).     |            | * |   |
|   | T |                                          |            | T |   |
|   | * | ```{=html}                               |            | * |   |
|   | * | <!-- -->                                 |            | * |   |
|   |   | ```                                      |            |   |   |
|   | * | -   **YOUR PHYSICIAN MUST GET            |            | * |   |
|   | * |     PRECERTIFICATION OF HOSPITAL         |            | * |   |
|   | A |     STAYS.** Please refer to Section 3   |            | A |   |
|   | * |     to be sure which services require    |            | * |   |
|   | * |     precertification.                    |            | * |   |
|   |   |                                          |            |   |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   | N |                                          |            | N |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   |   |                                          |            |   |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   | T |                                          |            | T |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
+---+---+------------------------------------------+------------+---+---+
| > |   |                                          | **You      |   |   |
|   |   |                                          | pay**      |   |   |
| * |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
| B |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| n |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| f |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| > |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
| D |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| s |   |                                          |            |   |   |
| c |   |                                          |            |   |   |
| r |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| p |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| o |   |                                          |            |   |   |
| n |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
+---+---+------------------------------------------+------------+---+---+
| # |   |                                          | ########   |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
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| n |   |                                          |            |   |   |
| p |   |                                          |            |   |   |
| a |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| n |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
| h |   |                                          |            |   |   |
| o |   |                                          |            |   |   |
| s |   |                                          |            |   |   |
| p |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| a |   |                                          |            |   |   |
| l |   |                                          |            |   |   |
+---+---+------------------------------------------+------------+---+---+
| > |   |                                          | > Nothing  |   |   |
|   |   |                                          |            |   |   |
| R |   |                                          |            |   |   |
| o |   |                                          |            |   |   |
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| m |   |                                          |            |   |   |
| > |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
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| , |   |                                          |            |   |   |
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| a |   |                                          |            |   |   |
| s |   |                                          |            |   |   |
| : |   |                                          |            |   |   |
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|   |   |                                          | > charges* |   |   |
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+---+---+------------------------------------------+------------+---+---+
| # |   |                                          | > **You    |   |   |
| # |   |                                          | > pay**    |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
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| s |   |                                          |            |   |   |
| k |   |                                          |            |   |   |
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| l |   |                                          |            |   |   |
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| d |   |                                          |            |   |   |
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| r |   |                                          |            |   |   |
| s |   |                                          |            |   |   |
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| p |   |                                          |            |   |   |
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+---+---+------------------------------------------+------------+---+---+
| > |   |                                          | > *All     |   |   |
|   |   |                                          | > charges* |   |   |
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| a |   |                                          |            |   |   |
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+---+---+------------------------------------------+------------+---+---+
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
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| a |   |                                          |            |   |   |
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+---+---+------------------------------------------+------------+---+---+
| > |   |                                          | > Nothing  |   |   |
|   |   |                                          |            |   |   |
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|   |   |                                          |            |   |   |
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| > |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
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|   |   |                                          |            |   |   |
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|   |   |                                          |            |   |   |
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| s |   |                                          |            |   |   |
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+---+---+------------------------------------------+------------+---+---+
| > |   |                                          | > *All     |   |   |
|   |   |                                          | > charges* |   |   |
| * |   |                                          |            |   |   |
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|   |   |                                          |            |   |   |
| h |   |                                          |            |   |   |
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| s |   |                                          |            |   |   |
| p |   |                                          |            |   |   |
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| c |   |                                          |            |   |   |
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| > |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
| f |   |                                          |            |   |   |
| a |   |                                          |            |   |   |
| c |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| l |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| y |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
+---+---+------------------------------------------+------------+---+---+
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
| # |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
| A |   |                                          |            |   |   |
| m |   |                                          |            |   |   |
| b |   |                                          |            |   |   |
| u |   |                                          |            |   |   |
| l |   |                                          |            |   |   |
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| n |   |                                          |            |   |   |
| c |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
+---+---+------------------------------------------+------------+---+---+
| - |   |                                          | > Nothing  |   |   |
|   |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
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| p |   |                                          |            |   |   |
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+---+---+------------------------------------------+------------+---+---+

+---+---+-------------------------------------------------------+---+---+
| # |   |                                                       |   |   |
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+---+---+-------------------------------------------------------+---+---+
|   | * | > Here are some important things to keep in mind      | * | # |
|   | * | > about these benefits:                               | * | # |
|   | I |                                                       | I | # |
|   | * | -   Please remember that all benefits are subject to  | * | # |
|   | * |     the definitions, limitations, and exclusions in   | * | # |
|   |   |     this brochure and are payable only when we        |   |   |
|   | * |     determine they are medically necessary.           | * |   |
|   | * |                                                       | * |   |
|   | M | ```{=html}                                            | M |   |
|   | * | <!-- -->                                              | * |   |
|   | * | ```                                                   | * |   |
|   |   | -   We have no calendar year deductible.              |   |   |
|   | * |                                                       | * |   |
|   | * | -   Be sure to read Section 4, *Your costs for        | * |   |
|   | P |     covered services,* for valuable information about | P |   |
|   | * |     how cost sharing works. Also read Section 9 about | * |   |
|   | * |     coordinating benefits with other coverage,        | * |   |
|   |   |     including with Medicare.                          |   |   |
|   | * |                                                       | * |   |
|   | * |                                                       | * |   |
|   | O |                                                       | O |   |
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+---+---+-------------------------------------------------------+---+---+
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| d |   |                                                       |   |   |
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| d |   |                                                       |   |   |
| > |   |                                                       |   |   |
|   |   |                                                       |   |   |
| b |   |                                                       |   |   |
| y |   |                                                       |   |   |
| > |   |                                                       |   |   |
|   |   |                                                       |   |   |
| P |   |                                                       |   |   |
| l |   |                                                       |   |   |
| a |   |                                                       |   |   |
| n |   |                                                       |   |   |
| > |   |                                                       |   |   |
|   |   |                                                       |   |   |
| p |   |                                                       |   |   |
| r |   |                                                       |   |   |
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| s |   |                                                       |   |   |
| . |   |                                                       |   |   |
+---+---+-------------------------------------------------------+---+---+

+--------------------------------------------------+-------------------+
| > **Benefit Description**                        | **You pay**       |
+--------------------------------------------------+-------------------+
| ######## Emergency within our service area       |                   |
+--------------------------------------------------+-------------------+
| -   Emergency care at a doctor\'s office         | > \$10 per office |
|                                                  | > visit           |
+--------------------------------------------------+-------------------+
| -   Emergency care at an urgent care center or   | > \$25 per visit  |
|     in the outpatient urgent care department of  |                   |
|     a hospital, including doctors\' services     |                   |
+--------------------------------------------------+-------------------+
| -   Emergency care as an outpatient at a         | > \$50 per visit; |
|     hospital, including doctors\' services       | > if visit        |
|                                                  | > results in an   |
|                                                  | > inpatient       |
|                                                  | > admission, you  |
|                                                  | > pay nothing     |
+--------------------------------------------------+-------------------+
| > *Not covered: Elective care or non-emergency   | > *All charges*   |
| > care*                                          |                   |
+--------------------------------------------------+-------------------+
| ######## Emergency outside our service area      |                   |
+--------------------------------------------------+-------------------+
| -   Emergency care at a doctor's office          | > \$10 per office |
|                                                  | > visit           |
+--------------------------------------------------+-------------------+
| -   Emergency care at an urgent care center or   | > \$25 per visit  |
|     in the outpatient urgent care department of  |                   |
|     a hospital, including doctors\' services     |                   |
+--------------------------------------------------+-------------------+
| -   Emergency care as an outpatient at a         | > \$50 per visit; |
|     hospital, including doctors\' services       | > if visit        |
|                                                  | > results in an   |
|                                                  | > inpatient       |
|                                                  | > admission, you  |
|                                                  | > pay nothing     |
+--------------------------------------------------+-------------------+
| > *Not covered:*                                 | > *All charges*   |
|                                                  |                   |
| -   *Elective care or non-emergency care*        |                   |
|                                                  |                   |
| -   *Emergency care provided outside the service |                   |
|     area if the need for care could have been    |                   |
|     foreseen before leaving the service area*    |                   |
|                                                  |                   |
| -   *Medical and hospital costs resulting from a |                   |
|     normal full-term delivery of a baby outside  |                   |
|     the service area*                            |                   |
|                                                  |                   |
| ########                                         |                   |
+--------------------------------------------------+-------------------+
| ######## Ambulance                               |                   |
+--------------------------------------------------+-------------------+
| > Professional land and air ambulance service    | > Nothing         |
| > when medically appropriate                     |                   |
| >                                                |                   |
| > See Section 5(c) for non-emergency service     |                   |
+--------------------------------------------------+-------------------+

+---+---+--------------------------------------------+---------+---+---+
| * |   |                                            |         |   |   |
| * |   |                                            |         |   |   |
| S |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| 5 |   |                                            |         |   |   |
| ( |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| ) |   |                                            |         |   |   |
| . |   |                                            |         |   |   |
| M |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
| h |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| h |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| d |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| u |   |                                            |         |   |   |
| b |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| b |   |                                            |         |   |   |
| u |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| b |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| f |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| * |   |                                            |         |   |   |
| * |   |                                            |         |   |   |
+---+---+--------------------------------------------+---------+---+---+
|   | * | > When you get our approval for services   |         | * |   |
|   | * | > and follow a treatment plan we approve,  |         | * |   |
|   | I | > cost-sharing and limitations for Plan    |         | I |   |
|   | * | > mental health and substance abuse        |         | * |   |
|   | * | > benefits will be no greater than for     |         | * |   |
|   |   | > similar benefits for other illnesses and |         |   |   |
|   | * | > conditions.                              |         | * |   |
|   | * | >                                          |         | * |   |
|   | M | > **Here are some important things to keep |         | M |   |
|   | * | > in mind about these benefits:**          |         | * |   |
|   | * |                                            |         | * |   |
|   |   | -   Please remember that all benefits are  |         |   |   |
|   | * |     subject to the definitions,            |         | * |   |
|   | * |     limitations, and exclusions in this    |         | * |   |
|   | P |     brochure and are payable only when we  |         | P |   |
|   | * |     determine they are medically           |         | * |   |
|   | * |     necessary.                             |         | * |   |
|   |   |                                            |         |   |   |
|   | * | > All benefits are subject to the          |         | * |   |
|   | * | > definitions, limitations, and exclusions |         | * |   |
|   | O | > in this brochure.                        |         | O |   |
|   | * |                                            |         | * |   |
|   | * | -   We have no deductible.                 |         | * |   |
|   |   |                                            |         |   |   |
|   | * | > Be sure to read Section 4, *Your costs   |         | * |   |
|   | * | > for covered services,* for valuable      |         | * |   |
|   | R | > information about how cost sharing       |         | R |   |
|   | * | > works. Also read Section 9 about         |         | * |   |
|   | * | > coordinating benefits with other         |         | * |   |
|   |   | > coverage, including with Medicare.       |         |   |   |
|   | * | >                                          |         | * |   |
|   | * | > YOUR PHYSICIAN MUST GET PREAUTHORIZATION |         | * |   |
|   | T | > OF THESE SERVICES.                       |         | T |   |
|   | * | >                                          |         | * |   |
|   | * | > See the instructions after the benefits  |         | * |   |
|   |   | > description below.                       |         |   |   |
|   | * |                                            |         | * |   |
|   | * |                                            |         | * |   |
|   | A |                                            |         | A |   |
|   | * |                                            |         | * |   |
|   | * |                                            |         | * |   |
|   |   |                                            |         |   |   |
|   | * |                                            |         | * |   |
|   | * |                                            |         | * |   |
|   | N |                                            |         | N |   |
|   | * |                                            |         | * |   |
|   | * |                                            |         | * |   |
|   |   |                                            |         |   |   |
|   | * |                                            |         | * |   |
|   | * |                                            |         | * |   |
|   | T |                                            |         | T |   |
|   | * |                                            |         | * |   |
|   | * |                                            |         | * |   |
+---+---+--------------------------------------------+---------+---+---+
| > |   |                                            | **You   |   |   |
|   |   |                                            | pay**   |   |   |
| * |   |                                            |         |   |   |
| * |   |                                            |         |   |   |
| B |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| f |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| D |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| p |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| * |   |                                            |         |   |   |
| * |   |                                            |         |   |   |
+---+---+--------------------------------------------+---------+---+---+
| # |   |                                            | ###     |   |   |
| # |   |                                            |         |   |   |
| # |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| * |   |                                            |         |   |   |
| * |   |                                            |         |   |   |
| M |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| h |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| h |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| d |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| u |   |                                            |         |   |   |
| b |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| b |   |                                            |         |   |   |
| u |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| b |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| f |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| * |   |                                            |         |   |   |
| * |   |                                            |         |   |   |
+---+---+--------------------------------------------+---------+---+---+
| > |   |                                            | > Your  |   |   |
|   |   |                                            | > cost  |   |   |
| A |   |                                            | >       |   |   |
| l |   |                                            | sharing |   |   |
| l |   |                                            | > re    |   |   |
| > |   |                                            | sponsib |   |   |
|   |   |                                            | ilities |   |   |
| d |   |                                            | > are   |   |   |
| i |   |                                            | > no    |   |   |
| a |   |                                            | >       |   |   |
| g |   |                                            | greater |   |   |
| n |   |                                            | > than  |   |   |
| o |   |                                            | > for   |   |   |
| s |   |                                            | > other |   |   |
| t |   |                                            | > il    |   |   |
| i |   |                                            | lnesses |   |   |
| c |   |                                            | > or    |   |   |
| > |   |                                            | > con   |   |   |
|   |   |                                            | ditions |   |   |
| a |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| d |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| m |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
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| r |   |                                            |         |   |   |
| v |   |                                            |         |   |   |
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| l |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| w |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| k |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| p |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| v |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| d |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| d |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| : |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| - |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| O |   |                                            |         |   |   |
| f |   |                                            |         |   |   |
| f |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
+---+---+--------------------------------------------+---------+---+---+
| > |   |                                            | >       |   |   |
|   |   |                                            | Nothing |   |   |
| P |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| f |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
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|   |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| v |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
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| s |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| b |   |                                            |         |   |   |
| y |   |                                            |         |   |   |
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|   |   |                                            |         |   |   |
| p |   |                                            |         |   |   |
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| d |   |                                            |         |   |   |
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| s |   |                                            |         |   |   |
| y |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| h |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
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| t |   |                                            |         |   |   |
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| , |   |                                            |         |   |   |
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|   |   |                                            |         |   |   |
| p |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| y |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| h |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| g |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
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| , |   |                                            |         |   |   |
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|   |   |                                            |         |   |   |
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| r |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
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|   |   |                                            |         |   |   |
| w |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| k |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
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| s |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| p |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| v |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| d |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| d |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| h |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| f |   |                                            |         |   |   |
| f |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| f |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| m |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| f |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| b |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| o |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
+---+---+--------------------------------------------+---------+---+---+
| > |   |                                            | >       |   |   |
|   |   |                                            | Nothing |   |   |
| P |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
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| s |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
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| n |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
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|   |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| v |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| s |   |                                            |         |   |   |
| , |   |                                            |         |   |   |
| > |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| c |   |                                            |         |   |   |
| l |   |                                            |         |   |   |
| u |   |                                            |         |   |   |
| d |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
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|   |   |                                            |         |   |   |
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| c |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
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| m |   |                                            |         |   |   |
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| t |   |                                            |         |   |   |
| i |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
|   |   |                                            |         |   |   |
| d |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| p |   |                                            |         |   |   |
| a |   |                                            |         |   |   |
| r |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
| m |   |                                            |         |   |   |
| e |   |                                            |         |   |   |
| n |   |                                            |         |   |   |
| t |   |                                            |         |   |   |
+---+---+--------------------------------------------+---------+---+---+

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

+----------------------------------------------------+-----------------+
| ### **Mental he                                    | ### **You pay** |
| alth and substance abuse benefits** *(Continued)*  |                 |
+----------------------------------------------------+-----------------+
| -   Diagnostic tests                               | > Nothing       |
+----------------------------------------------------+-----------------+
| -   Services provided by a hospital or other       | > Nothing       |
|     facility                                       |                 |
|                                                    |                 |
| -   Services in approved alternative care settings |                 |
|     such as partial hospitalization, full-day      |                 |
|     hospitalization or facility based intensive    |                 |
|     outpatient treatment                           |                 |
+----------------------------------------------------+-----------------+
| ## Not covered:                                    | > *All charges* |
|                                                    |                 |
| ## Services we have not approved                   |                 |
|                                                    |                 |
| -   *Care for psychiatric conditions that in the   |                 |
|     professional judgment of Plan doctors are not  |                 |
|     subject to significant improvement through     |                 |
|     relatively short-term treatment*               |                 |
|                                                    |                 |
| -   *Psychological testing when not medically      |                 |
|     necessary to determine the appropriate         |                 |
|     treatment of a short‑term psychiatric          |                 |
|     condition*                                     |                 |
|                                                    |                 |
| -   *Services for marital counseling or personal   |                 |
|     growth*                                        |                 |
|                                                    |                 |
| -   *Inpatient hospital stays when the patient     |                 |
|     checks out Against Medical Advice (A.M.A.)*    |                 |
|                                                    |                 |
| -   *Service, drugs, or supplies related to weight |                 |
|     loss or treatment of obesity, except for       |                 |
|     surgical treatment of morbid obesity*          |                 |
|                                                    |                 |
| > *The same exclusions contained in this brochure  |                 |
| > that apply to other benefits apply to these      |                 |
| > mental health and substance abuse benefits,      |                 |
| > unless the services are included in a treatment  |                 |
| > plan that we approve.*                           |                 |
|                                                    |                 |
| ## Note: OPM will base its revi                    |                 |
| ew of disputes about treatment plans on the treatm |                 |
| ent plan\'s clinical appropriateness. OPM will gen |                 |
| erally not order us to pay or provide one clinical |                 |
| ly appropriate treatment plan in favor of another. |                 |
+----------------------------------------------------+-----------------+
| **Preauthorization** To be eligible to receive     |                 |
| these benefits you must obtain a treatment plan    |                 |
| and follow all of the following authorization      |                 |
| processes:                                         |                 |
|                                                    |                 |
| -   If you feel you need mental health or          |                 |
|     substance abuse services, you or your PCP      |                 |
|     should call Magellan Behavioral Health at      |                 |
|     800/788-4003.                                  |                 |
|                                                    |                 |
| -   Magellan will work with you to determine your  |                 |
|     needs and begin the treatment planning         |                 |
|     process. Referrals for any necessary services  |                 |
|     will also be handled by Magellan.              |                 |
|                                                    |                 |
| -   Your mental health and substance abuse         |                 |
|     services must be provided by Plan providers.   |                 |
+----------------------------------------------------+-----------------+
| **Limitation** We may limit your benefits if you   |                 |
| do not obtain a treatment plan.                    |                 |
+----------------------------------------------------+-----------------+
|                                                    |                 |
+----------------------------------------------------+-----------------+

+---+---+-----------------------------------------------------------+---+---+
| * |   |                                                           |   |   |
| * |   |                                                           |   |   |
| S |   |                                                           |   |   |
| e |   |                                                           |   |   |
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| d |   |                                                           |   |   |
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| u |   |                                                           |   |   |
| g |   |                                                           |   |   |
| b |   |                                                           |   |   |
| e |   |                                                           |   |   |
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| s |   |                                                           |   |   |
| * |   |                                                           |   |   |
| * |   |                                                           |   |   |
+---+---+-----------------------------------------------------------+---+---+
|   | * | > **Here are some important things to keep in mind about  | * |   |
|   | * | > these benefits:**                                       | * |   |
|   | I |                                                           | I |   |
|   | * | -   We cover prescribed drugs and medications as          | * |   |
|   | * |     described in the chart beginning on page 36.          | * |   |
|   |   |                                                           |   |   |
|   | * | -   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.                                            | * |   |
|   | * |                                                           | * |   |
|   |   | ```{=html}                                                |   |   |
|   | * | <!-- -->                                                  | * |   |
|   | * | ```                                                       | * |   |
|   | P | -   We have no calendar year deductible***.***            | P |   |
|   | * |                                                           | * |   |
|   | * | ```{=html}                                                | * |   |
|   |   | <!-- -->                                                  |   |   |
|   | * | ```                                                       | * |   |
|   | * | -   Prior authorization is the process required to        | * |   |
|   | O |     dispense certain drugs when the use of a drug is      | O |   |
|   | * |     defined or limited by your medical condition.         | * |   |
|   | * |                                                           | * |   |
|   |   | ```{=html}                                                |   |   |
|   | * | <!-- -->                                                  | * |   |
|   | * | ```                                                       | * |   |
|   | R | -   Be sure to read Section 4, *Your costs for covered    | R |   |
|   | * |     services,* for valuable information about how cost    | * |   |
|   | * |     sharing works. Also read Section 9 about coordinating | * |   |
|   |   |     benefits with other coverage, including with          |   |   |
|   | * |     Medicare.                                             | * |   |
|   | * |                                                           | * |   |
|   | T |                                                           | T |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   |   |                                                           |   |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   | A |                                                           | A |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   |   |                                                           |   |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   | N |                                                           | N |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   |   |                                                           |   |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   | T |                                                           | T |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
+---+---+-----------------------------------------------------------+---+---+
| > |   |                                                           |   |   |
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|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
| c |   |                                                           |   |   |
| o |   |                                                           |   |   |
| n |   |                                                           |   |   |
| t |   |                                                           |   |   |
| a |   |                                                           |   |   |
| c |   |                                                           |   |   |
| t |   |                                                           |   |   |
|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
| u |   |                                                           |   |   |
| s |   |                                                           |   |   |
|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
| a |   |                                                           |   |   |
| t |   |                                                           |   |   |
|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
|   |   |                                                           |   |   |
| 8 |   |                                                           |   |   |
| 0 |   |                                                           |   |   |
| 0 |   |                                                           |   |   |
| / |   |                                                           |   |   |
| 2 |   |                                                           |   |   |
| 2 |   |                                                           |   |   |
| 8 |   |                                                           |   |   |
| - |   |                                                           |   |   |
| 4 |   |                                                           |   |   |
| 3 |   |                                                           |   |   |
| 7 |   |                                                           |   |   |
| 5 |   |                                                           |   |   |
| . |   |                                                           |   |   |
+---+---+-----------------------------------------------------------+---+---+

*Prescription drug benefits begin on the next page*

+-------------------------------------------------+--------------------+
| > **Benefit Description**                       | **You pay**        |
+-------------------------------------------------+--------------------+
| > **Covered medications and supplies**          |                    |
+-------------------------------------------------+--------------------+
| > We cover the following medications and        | **Up to a 30-day   |
| > supplies prescribed by a Plan physician and   | supply at a Plan   |
| > obtained from a Plan pharmacy or through our  | pharmacy**         |
| > mail order program:                           |                    |
|                                                 | > \$10 copay for   |
| -   Drugs and medicines that by Federal law of  | > generic drugs    |
|     the United States requires a physician\'s   | >                  |
|     prescription for their purchase             | > \$20 copay for   |
|                                                 | > formulary name   |
| ```{=html}                                      | > brand drugs      |
| <!-- -->                                        | >                  |
| ```                                             | > \$30 copay for   |
| -   FDA-approved prescription drugs, injectable | > non-formulary    |
|     drugs (such as Depo Provera) and devices    | > name brand drugs |
|     for birth control                           |                    |
|                                                 | **Up to a 90-day   |
| ```{=html}                                      | supply through the |
| <!-- -->                                        | mail order         |
| ```                                             | program**          |
| -   Insulin                                     |                    |
|                                                 | > \$20 copay for   |
| ```{=html}                                      | > generic drugs    |
| <!-- -->                                        | >                  |
| ```                                             | > \$40 copay for   |
| -   Disposable needles and syringes needed to   | > formulary name   |
|     inject covered prescribed medications are   | > brand drugs      |
|     covered at the name brand copayment.        | >                  |
|                                                 | > \$60 copay for   |
| ```{=html}                                      | > non-formulary    |
| <!-- -->                                        | > name brand drugs |
| ```                                             |                    |
| -   Diabetic supplies including glucose test    | Note: If there is  |
|     tablets and test tape, Benedict's solution  | no generic         |
|     or equivalent, glucose monitors and acetone | equivalent         |
|     test tablets are covered at the name brand  | available, you     |
|     copayment. No copayment applies for insulin | will still have to |
|     syringes.                                   | pay the name brand |
|                                                 | copay              |
| -   Drugs for the treatment of impotence, such  |                    |
|     as Viagra: we require proof of medical      |                    |
|     necessity prior to approving benefits.      |                    |
|     Then, this Plan will cover a maximum of six |                    |
|     tablets per month, subject to the following |                    |
|     guidelines. The patient:                    |                    |
|                                                 |                    |
| ```{=html}                                      |                    |
| <!-- -->                                        |                    |
| ```                                             |                    |
| -   Must be a male over age 18                  |                    |
|                                                 |                    |
| -   Is being treated for erectile dysfunction   |                    |
|     (ED) regardless of cause, and               |                    |
|                                                 |                    |
| ```{=html}                                      |                    |
| <!-- -->                                        |                    |
| ```                                             |                    |
| -   Is not on medication containing nitrates    |                    |
|     for 90 days prior.                          |                    |
|                                                 |                    |
| ```{=html}                                      |                    |
| <!-- -->                                        |                    |
| ```                                             |                    |
| -   Smoking cessation prescription drugs and    |                    |
|     medications                                 |                    |
|                                                 |                    |
| > Note: Intravenous fluids and medications for  |                    |
| > home use, implantable drugs, and some         |                    |
| > injectable drugs, such as Depo Provera, may   |                    |
| > also be covered under Medical and Surgical    |                    |
| > Benefits. See Section 5(a)                    |                    |
+-------------------------------------------------+--------------------+
| -   Immuno-Suppressive Agent                    | > 50% of our       |
|                                                 | > allowance        |
| -   Fertility drugs                             |                    |
|                                                 |                    |
| -   Human growth hormones                       |                    |
+-------------------------------------------------+--------------------+
| *Not covered:*                                  | > *All Charges*    |
|                                                 |                    |
| -   *Drugs and supplies for cosmetic purposes*  |                    |
|                                                 |                    |
| -   *Vitamins, nutrients and food supplements   |                    |
|     even if a physician prescribes or           |                    |
|     administers them*                           |                    |
|                                                 |                    |
| -   *Nonprescription medicines*                 |                    |
|                                                 |                    |
| -   *Drugs available without a prescription or  |                    |
|     for which there is a nonprescription        |                    |
|     equivalent available*                       |                    |
|                                                 |                    |
| -   *Drugs obtained at a Non-network pharmacy   |                    |
|     except for out-of-area emergencies*         |                    |
|                                                 |                    |
| -   *Drugs to enhance athletic performance*     |                    |
|                                                 |                    |
| -   *Drugs for weight loss purposes (except     |                    |
|     when authorized by the Plan doctor, through |                    |
|     the predetermination process, for treatment |                    |
|     of morbid obesity)*                         |                    |
|                                                 |                    |
| -   *Replacement prescriptions such as lost,    |                    |
|     stolen or spilled*                          |                    |
|                                                 |                    |
| ```{=html}                                      |                    |
| <!-- -->                                        |                    |
| ```                                             |                    |
| -   *Drugs in connection with camp, travel,     |                    |
|     school or insurance exams*                  |                    |
|                                                 |                    |
| -   *Personal hygiene and convenience items*    |                    |
|                                                 |                    |
| -   *Refills requested too soon (prior to 85%   |                    |
|     usage)*                                     |                    |
+-------------------------------------------------+--------------------+

+---+--------------------+------------------------------------------------+
|   | **Section 5 (g).   |                                                |
|   | Special features** |                                                |
+---+--------------------+------------------------------------------------+
|   | > **Feature**      | > **Description**                              |
+---+--------------------+------------------------------------------------+
|   | > **Flexible       | > Under the flexible benefits option, we       |
|   | > benefits         | > determine the most effective way to provide  |
|   | > option**         | > 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.                         |
|   |                    |                                                |
|   |                    | ```{=html}                                     |
|   |                    | <!-- -->                                       |
|   |                    | ```                                            |
|   |                    | -   Our decision to offer or withdraw          |
|   |                    |     alternative benefits is not subject to OPM |
|   |                    |     review under the disputed claims process.  |
+---+--------------------+------------------------------------------------+
|   | > **24 hour nurse  | > The Plan now offers Tel-a-Nurse. This free,  |
|   | > line**           | > 24-hour phone service is you link to         |
|   |                    | > non-emergency health information. Simply     |
|   |                    | > call the toll-free number day or night to    |
|   |                    | > speak to a registered nurse. So, the next    |
|   |                    | > time you have a health question or want some |
|   |                    | > help making a health care decision, call:    |
|   |                    |                                                |
|   |                    | -   888/220-3891                               |
|   |                    |                                                |
|   |                    | -   800/877-8044 (TDD for those with hearing   |
|   |                    |     impairments)                               |
|   |                    |                                                |
|   |                    | > You also have access, through the internet   |
|   |                    | >                                              |
|   |                    |  [www.myanthem.com](http://www.myanthem.com/), |
|   |                    | > to receive customized health information.    |
+---+--------------------+------------------------------------------------+
|   | > **Centers of     | > We use the Blue Quality Centers for          |
|   | > excellence**     | > Transplant Network (BQCT) as our transplant  |
|   |                    | > network. The network consists of leading     |
|   |                    | > medical facilities throughout the nation.    |
|   |                    | > For a list of transplant hospitals near you, |
|   |                    | > call 800/824-0581.                           |
|   |                    | >                                              |
|   |                    | > We offer a network of institutions that have |
|   |                    | > met stringent clinical standards for the     |
|   |                    | > following heart services:                    |
|   |                    |                                                |
|   |                    | -   Coronary artery bypass graft (CABG)        |
|   |                    |                                                |
|   |                    | -   Percutaneous transluminal coronary         |
|   |                    |     angioplasty (PTCA)                         |
|   |                    |                                                |
|   |                    | -   Heart valve procedures                     |
|   |                    |                                                |
|   |                    | -   Other major cardiovascular procedures      |
|   |                    |                                                |
|   |                    | > You can refer to our provider directory for  |
|   |                    | > further information concerning our           |
|   |                    | > transplant and heart surgery centers of      |
|   |                    | > excellence.                                  |
+---+--------------------+------------------------------------------------+
|   | > **Reciprocity    | > **BlueCard® Program**                        |
|   | > benefit**        | >                                              |
|   |                    | > With the BlueCard® Program, Plan members     |
|   |                    | > have access to benefits when traveling       |
|   |                    | > outside the plan\'s service area for urgent  |
|   |                    | > care and emergency room services. To find a  |
|   |                    | > nearby health care provider, members can     |
|   |                    | > simply call BlueCard Access at 800/810-BLUE  |
|   |                    | > (2583).                                      |
+---+--------------------+------------------------------------------------+
|   | > *Special         |                                                |
|   | > features --      |                                                |
|   | > Continued on     |                                                |
|   | > next page*       |                                                |
+---+--------------------+------------------------------------------------+
| * |                    |                                                |
| * |                    |                                                |
| S |                    |                                                |
| e |                    |                                                |
| c |                    |                                                |
| t |                    |                                                |
| i |                    |                                                |
| o |                    |                                                |
| n |                    |                                                |
| 5 |                    |                                                |
| ( |                    |                                                |
| g |                    |                                                |
| ) |                    |                                                |
| . |                    |                                                |
| S |                    |                                                |
| p |                    |                                                |
| e |                    |                                                |
| c |                    |                                                |
| i |                    |                                                |
| a |                    |                                                |
| l |                    |                                                |
| f |                    |                                                |
| e |                    |                                                |
| a |                    |                                                |
| t |                    |                                                |
| u |                    |                                                |
| r |                    |                                                |
| e |                    |                                                |
| s |                    |                                                |
| * |                    |                                                |
| * |                    |                                                |
| * |                    |                                                |
| ( |                    |                                                |
| C |                    |                                                |
| o |                    |                                                |
| n |                    |                                                |
| t |                    |                                                |
| i |                    |                                                |
| n |                    |                                                |
| u |                    |                                                |
| e |                    |                                                |
| d |                    |                                                |
| ) |                    |                                                |
| * |                    |                                                |
+---+--------------------+------------------------------------------------+
| > |                    | > **Description**                              |
|   |                    |                                                |
| * |                    |                                                |
| * |                    |                                                |
| F |                    |                                                |
| e |                    |                                                |
| a |                    |                                                |
| t |                    |                                                |
| u |                    |                                                |
| r |                    |                                                |
| e |                    |                                                |
| * |                    |                                                |
| * |                    |                                                |
+---+--------------------+------------------------------------------------+
| > |                    | > **Guest Membership Program**                 |
|   |                    | >                                              |
| * |                    | > We offer guest memberships at affiliated HMO |
| * |                    | > plans through the Guest Membership Program.  |
| R |                    | > Whenever you or a family member is away from |
| e |                    | > our service area for more than 90 days, you  |
| c |                    | > may become a guest member at an affiliated   |
| i |                    | > HMO near your destination. Reasons to        |
| p |                    | > consider a guest membership include extended |
| r |                    | > out-of-town business, children away at       |
| o |                    | > school, dependent children in another state, |
| c |                    | > or a winter "snowbird" residency in the      |
| i |                    | > South. To determine if a guest membership is |
| t |                    | > available at your destination, call          |
| y |                    | > 800/355-6414.                                |
| > |                    |                                                |
|   |                    |                                                |
| b |                    |                                                |
| e |                    |                                                |
| n |                    |                                                |
| e |                    |                                                |
| f |                    |                                                |
| i |                    |                                                |
| t |                    |                                                |
| > |                    |                                                |
|   |                    |                                                |
| ( |                    |                                                |
| C |                    |                                                |
| o |                    |                                                |
| n |                    |                                                |
| t |                    |                                                |
| i |                    |                                                |
| n |                    |                                                |
| u |                    |                                                |
| e |                    |                                                |
| d |                    |                                                |
| ) |                    |                                                |
| * |                    |                                                |
| * |                    |                                                |
+---+--------------------+------------------------------------------------+
| > |                    | > **SpecialOffers@Anthem**                     |
|   |                    | >                                              |
| * |                    | > You can receive negotiated savings on        |
| * |                    | > selected health and wellness services and    |
| D |                    | > programs simply by being an eligible Anthem  |
| i |                    | > Blue Cross and Blue Shield Blue HMO member.  |
| s |                    | > To obtain information about these programs   |
| c |                    | > please call us at 800/228-4375 or visit our  |
| o |                    | > website at                                   |
| u |                    | > [www.anthem.com](http://www.anthem.com/).    |
| n |                    | > Services available through the               |
| t |                    | > SpecialOffers@Anthem program include:        |
| > |                    |                                                |
|   |                    | -   **Jenny Craig** -- Receive a free 30-day   |
| p |                    |     trial from Anthem and Jenny Craig          |
| r |                    |                                                |
| o |                    | -   **Hearing** -- Save on a wide variety of   |
| g |                    |     hearing aids and other products that help  |
| r |                    |     those with hearing problems. Your parents  |
| a |                    |     and grandparents are welcome to use this   |
| m |                    |     offer.                                     |
| s |                    |                                                |
| * |                    | -   **Complementary Medicine** -- Explore      |
| * |                    |     alternative paths to wellness with savings |
|   |                    |     on everything from yoga videos to massage  |
|   |                    |     therapy to vitamins.                       |
|   |                    |                                                |
|   |                    | -   **Fitness Clubs** -- Get fit for less.     |
|   |                    |     Save money at participating health clubs   |
|   |                    |     and get discounts on fitness equipment.    |
|   |                    |                                                |
|   |                    | -   **LensCrafters** -- Discounts on           |
|   |                    |     prescription eye glasses and accessories.  |
|   |                    |                                                |
|   |                    | -   **TruVision** -- Get substantial savings   |
|   |                    |     on laser vision correction surgery from    |
|   |                    |     TruVision's national network of providers. |
|   |                    |     And discounts on contact lenses.           |
|   |                    |                                                |
|   |                    | -   **Butt Out** -- Extinguish a tobacco habit |
|   |                    |     with discounts on smoking cessation        |
|   |                    |     programs and products.                     |
|   |                    |                                                |
|   |                    | -   **Books** -- Peruse the Anthem bookrack    |
|   |                    |     for discounts on a vast collection of      |
|   |                    |     health and wellness books.                 |
|   |                    |                                                |
|   |                    | -   **Baby, Toddler and Maternity** -- Save    |
|   |                    |     15% at babystyle, the one stop shop for    |
|   |                    |     all your maternity and baby needs.         |
|   |                    |                                                |
|   |                    | -   **Flowers** -- Save 15% on floral          |
|   |                    |     arrangements, gourmet baskets and more.    |
|   |                    |                                                |
|   |                    | -   **Women's Store --** An assortment of      |
|   |                    |     offers and resources in one place.         |
|   |                    |                                                |
|   |                    | -   **Eat Right --** Anthem offers you savings |
|   |                    |     on everything you need to switch to - and  |
|   |                    |     stick with - a healthy, delicious diet.    |
|   |                    |                                                |
|   |                    | -   **Cosmetic dentistry** -- Make your smile  |
|   |                    |     brighter with discounts on teeth whitening |
|   |                    |     and dental veneers.                        |
|   |                    |                                                |
|   |                    | -                                              |
|   |                    |                                                |
|   |                    | -                                              |
|   |                    |                                                |
|   |                    | -                                              |
+---+--------------------+------------------------------------------------+

+----+---+------------------------------------------------+-----+---+---+
| *  |   |                                                |     |   |   |
| *S |   |                                                |     |   |   |
| ec |   |                                                |     |   |   |
| ti |   |                                                |     |   |   |
| on |   |                                                |     |   |   |
| 5  |   |                                                |     |   |   |
| (h |   |                                                |     |   |   |
| ). |   |                                                |     |   |   |
| De |   |                                                |     |   |   |
| nt |   |                                                |     |   |   |
| al |   |                                                |     |   |   |
| be |   |                                                |     |   |   |
| ne |   |                                                |     |   |   |
| fi |   |                                                |     |   |   |
| ts |   |                                                |     |   |   |
| ** |   |                                                |     |   |   |
+----+---+------------------------------------------------+-----+---+---+
|    | * | > **Here are some important things to keep in  |     | * |   |
|    | * | > mind about these benefits:**                 |     | * |   |
|    | I |                                                |     | I |   |
|    | * | -   Please remember that all benefits are      |     | * |   |
|    | * |     subject to the definitions, limitations    |     | * |   |
|    |   |     and exclusions in this brochure and are    |     |   |   |
|    | * |     payable only when we determine they are    |     | * |   |
|    | * |     medically necessary.                       |     | * |   |
|    | M |                                                |     | M |   |
|    | * | -   Plan dentists must provide or arrange your |     | * |   |
|    | * |     care.                                      |     | * |   |
|    |   |                                                |     |   |   |
|    | * | -   We have no calendar year deductible.       |     | * |   |
|    | * |                                                |     | * |   |
|    | P | -   We cover hospitalization for dental        |     | P |   |
|    | * |     procedures only when a nondental physical  |     | * |   |
|    | * |     impairment exists which makes              |     | * |   |
|    |   |     hospitalization necessary to safeguard the |     |   |   |
|    | * |     health of the patient, See Section 5(c)    |     | * |   |
|    | * |     for inpatient hospital benefits. We do not |     | * |   |
|    | O |     cover the dental procedure unless it is    |     | O |   |
|    | * |     described below.                           |     | * |   |
|    | * |                                                |     | * |   |
|    |   | -   Be sure to read Section 4, Your costs for  |     |   |   |
|    | * |     covered services, for valuable information |     | * |   |
|    | * |     about how cost sharing works. Also read    |     | * |   |
|    | R |     Section 9 about coordinating benefits with |     | R |   |
|    | * |     other coverage, including with Medicare.   |     | * |   |
|    | * |                                                |     | * |   |
|    |   | -   All covered family members must receive    |     |   |   |
|    | * |     care from the same dental office. You may, |     | * |   |
|    | * |     however, choose different dentists for     |     | * |   |
|    | T |     each family member within the same dental  |     | T |   |
|    | * |     office.                                    |     | * |   |
|    | * |                                                |     | * |   |
|    |   |                                                |     |   |   |
|    | * |                                                |     | * |   |
|    | * |                                                |     | * |   |
|    | A |                                                |     | A |   |
|    | * |                                                |     | * |   |
|    | * |                                                |     | * |   |
|    |   |                                                |     |   |   |
|    | * |                                                |     | * |   |
|    | * |                                                |     | * |   |
|    | N |                                                |     | N |   |
|    | * |                                                |     | * |   |
|    | * |                                                |     | * |   |
|    |   |                                                |     |   |   |
|    | * |                                                |     | * |   |
|    | * |                                                |     | * |   |
|    | T |                                                |     | T |   |
|    | * |                                                |     | * |   |
|    | * |                                                |     | * |   |
+----+---+------------------------------------------------+-----+---+---+
| #  |   |                                                | >   |   |   |
| ## |   |                                                |  ** |   |   |
|  * |   |                                                | You |   |   |
| *A |   |                                                | >   |   |   |
| cc |   |                                                |  pa |   |   |
| id |   |                                                | y** |   |   |
| en |   |                                                |     |   |   |
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| ef |   |                                                |     |   |   |
| it |   |                                                |     |   |   |
| ** |   |                                                |     |   |   |
+----+---+------------------------------------------------+-----+---+---+
| >  |   |                                                | > N |   |   |
| We |   |                                                | oth |   |   |
| >  |   |                                                | ing |   |   |
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| y. |   |                                                |     |   |   |
+----+---+------------------------------------------------+-----+---+---+
| #  |   |                                                |     |   |   |
| ## |   |                                                |     |   |   |
|  * |   |                                                |     |   |   |
| *D |   |                                                |     |   |   |
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| fi |   |                                                |     |   |   |
| ts |   |                                                |     |   |   |
| ** |   |                                                |     |   |   |
+----+---+------------------------------------------------+-----+---+---+
| >  |   |                                                |     |   |   |
|  * |   |                                                |     |   |   |
| *S |   |                                                |     |   |   |
| ee |   |                                                |     |   |   |
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| >  |   |                                                |     |   |   |
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| ha |   |                                                |     |   |   |
| rt |   |                                                |     |   |   |
| >  |   |                                                |     |   |   |
| on |   |                                                |     |   |   |
| >  |   |                                                |     |   |   |
|  t |   |                                                |     |   |   |
| he |   |                                                |     |   |   |
| >  |   |                                                |     |   |   |
|  f |   |                                                |     |   |   |
| ol |   |                                                |     |   |   |
| lo |   |                                                |     |   |   |
| wi |   |                                                |     |   |   |
| ng |   |                                                |     |   |   |
| >  |   |                                                |     |   |   |
|  p |   |                                                |     |   |   |
| ag |   |                                                |     |   |   |
| e. |   |                                                |     |   |   |
| ** |   |                                                |     |   |   |
+----+---+------------------------------------------------+-----+---+---+

+-----------------------------------+----------------------------------+
| **We cover the following dental   |                                  |
| services when you use a           |                                  |
| participating Plan dentist and we |                                  |
| have indicated when copayments    |                                  |
| apply. This benefit description   |                                  |
| does not list exclusions. Contact |                                  |
| us for specific exclusions at     |                                  |
| 800/228-4375 or 513/872-8242 (in  |                                  |
| the local dialing area).**        |                                  |
+-----------------------------------+----------------------------------+
| **Dental Benefits**               |                                  |
+-----------------------------------+----------------------------------+
| ### **Service**                   | **You pay**                      |
+-----------------------------------+----------------------------------+
| > **DIAGNOSTIC**                  | > Nothing                        |
| >                                 |                                  |
| > X-rays including bite wings and |                                  |
| > panoramic; oral examinations    |                                  |
| > and treatment plan; vitality    |                                  |
| > test; and oral cancer exam      |                                  |
+-----------------------------------+----------------------------------+
| > **PREVENTIVE**                  | > Nothing                        |
| >                                 |                                  |
| > Prophylaxis; annual topical     |                                  |
| > application of fluoride to      |                                  |
| > children age 12, preventive     |                                  |
| > dental instructions             |                                  |
+-----------------------------------+----------------------------------+
| > **RESTORATIVE (Fillings)**      | > 80% of our allowance           |
| >                                 |                                  |
| > Amalgam -- one surface          |                                  |
| >                                 |                                  |
| > Amalgam -- two surfaces         |                                  |
| >                                 |                                  |
| > Amalgam -- three surfaces       |                                  |
| > (Build up per tooth)            |                                  |
| >                                 |                                  |
| > Plastic or composite -- single  |                                  |
| > surface                         |                                  |
| >                                 |                                  |
| > Plastic or composite -- two     |                                  |
| > surfaces                        |                                  |
+-----------------------------------+----------------------------------+
| > **ORAL SURGERY (Including       | > 80% of our allowance           |
| > preoperative and postoperative  |                                  |
| > treatments under local          |                                  |
| > anesthetics)**                  |                                  |
| >                                 |                                  |
| > Extraction (simple)             |                                  |
| >                                 |                                  |
| > Alveolectomy per quadrant       |                                  |
| >                                 |                                  |
| > Impaction (soft tissue)         |                                  |
| >                                 |                                  |
| > Impaction (complete bony)       |                                  |
+-----------------------------------+----------------------------------+
| > **PROSTHODONTICS**              | > 80% of our allowance           |
| >                                 |                                  |
| > Complete upper or lower denture |                                  |
| >                                 |                                  |
| > Cast chrome partial -- upper or |                                  |
| > lower                           |                                  |
| >                                 |                                  |
| > Acrylic partial -- upper or     |                                  |
| > lower (with clasps)             |                                  |
| >                                 |                                  |
| > Repair broken denture           |                                  |
| >                                 |                                  |
| > Denture adjustment              |                                  |
| >                                 |                                  |
| > Reline upper or lower complete  |                                  |
| > denture or partial (office)     |                                  |
| >                                 |                                  |
| > Reline upper or lower complete  |                                  |
| > denture or partial (laboratory) |                                  |
| >                                 |                                  |
| > Space maintainers (for primary  |                                  |
| > teeth)                          |                                  |
+-----------------------------------+----------------------------------+

*Dental Benefits - Continued on next page*

+-----------------------------------+----------------------------------+
| **Dental Benefits** *(Continued)* |                                  |
+-----------------------------------+----------------------------------+
| ### **Service**                   | **You pay**                      |
+-----------------------------------+----------------------------------+
| > **PROSTHODONTICS -**            | > 80% of our allowance           |
| > *Continued*                     |                                  |
| >                                 |                                  |
| > Stainless steel crown (for      |                                  |
| > primary teeth)                  |                                  |
| >                                 |                                  |
| > Bridge abutments or pontics     |                                  |
+-----------------------------------+----------------------------------+
| > **PERIODONTICS (Under local     | > 80% of our allowance           |
| > anesthetics)**                  |                                  |
| >                                 |                                  |
| > Examination, treatment plan     |                                  |
| >                                 |                                  |
| > Periodontal, root planing and   |                                  |
| > curettage                       |                                  |
| >                                 |                                  |
| > Hemisection                     |                                  |
| >                                 |                                  |
| > Gingivectomy or gingivoplasty   |                                  |
| >                                 |                                  |
| > Osseous surgery (per quadrant)  |                                  |
| >                                 |                                  |
| > Equilibration (entire mouth)    |                                  |
+-----------------------------------+----------------------------------+
| > **ENDODONTICS (Under local      | > 80% of our allowance           |
| > anesthetics)**                  |                                  |
| >                                 |                                  |
| > Pulpotomy (including            |                                  |
| > restoration)                    |                                  |
| >                                 |                                  |
| > Root canal filling -- one canal |                                  |
| >                                 |                                  |
| > Each additional canal           |                                  |
| >                                 |                                  |
| > Apicoectomy, performed as       |                                  |
| > separate surgical procedure     |                                  |
+-----------------------------------+----------------------------------+
| > **ORTHODONTICS (Braces)**       | > 80% of our allowance           |
| >                                 |                                  |
| > Initial Consultation            |                                  |
| >                                 |                                  |
| > Diagnosis and treatment plan    |                                  |
| >                                 |                                  |
| > *(Limited to one, two-year      |                                  |
| > course of phase II*             |                                  |
| >                                 |                                  |
| > *treatment per eligible child   |                                  |
| > up to age 19)*                  |                                  |
+-----------------------------------+----------------------------------+
| > Missed appointments without 24  | > \$10.00                        |
| > hours prior notification        |                                  |
+-----------------------------------+----------------------------------+
| > **ACCIDENTAL INJURY BENEFIT**   | > Nothing                        |
| >                                 |                                  |
| > Restorative services and        |                                  |
| > supplies necessary to promptly  |                                  |
| > repair within three days of     |                                  |
| > accident (but not replace)      |                                  |
| > sound natural teeth.            |                                  |
| >                                 |                                  |
| > *(The need for these services   |                                  |
| > **must** result from an         |                                  |
| > accidental injury)*             |                                  |
+-----------------------------------+----------------------------------+
| > *Not covered:*                  | > *All charges*                  |
| >                                 |                                  |
| > *All other dental services not  |                                  |
| > shown as covered*               |                                  |
+-----------------------------------+----------------------------------+

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

> **Although we may list a specific service as a benefit, we will not
> cover it unless your Plan doctor determines it is medically necessary
> to prevent, diagnose, or treat your illness, disease, injury, or
> condition.**
>
> We do not cover the following:

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

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

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

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

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

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

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

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

-   Services, drugs, or supplies for court ordered testing or care,
    unless Medically Necessary;

-   Services, drugs, or supplies received from a member of your
    immediate family (parent, child, spouse, sister, brother, or
    corresponding in-laws);

-   Services for completion of claim forms or charges for medical
    records or reports;

-   Missed or canceled appointments;

-   Mileage costs or other travel expenses, except as authorized by the
    plan;

-   Services, or supplies at a health spa or similar facility;

-   Services, drugs, or supplies for research studies or screening
    examinations, except as specified elsewhere in the brochure; or

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

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

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

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

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

**Medical and hospital benefits** In most cases, providers and
facilities file claims for you. Physicians must file on the form
HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at
800/228-4375.

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

-   Covered member's name and ID number

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

-   Dates you received the services or supplies

-   Diagnosis

-   Type of each service or supply

-   The charge for each service or supply

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

-   Receipts, if you paid for your services

**Submit your claims to: Anthem Blue HMO**

> **PO Box 37180**
>
> **Louisville, KY 40233-7180**

**Prescription drugs** When you must file a claim for prescription drugs
that you had to pay for, submit the original itemized Pharmacy receipt
that comes with the prescription and the completed Prescription Drug
Claim Form.

**Submit your claims to: Anthem Prescription Management LLC**

> **PO Box 145433**
>
> **Cincinnati, OH 45250-5433**

**Other supplies or services** When you must file a dental claim, such
as out-of-network care, submit a completed Standard ADA (American Dental
Association) Claim Form.

> **Submit your claims to: Anthem Dental**

**555 Middle Creek Parkway**

> **Colorado Springs, CO 80921-3634**

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

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

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

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

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

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) Write to us within 6 months from the date of our decision;   |
| * |     and                                                          |
| * |                                                                  |
|   | (b) Send your request to us at: Blue HMO, Mail No. CE2-014, 1351 |
|   |     William Howard Taft Road, Cincinnati, OH 45206-1775; and     |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms.            |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or, if applicable, arrange for the health     |
| * |     care provider to give you the care); or                      |
| * |                                                                  |
|   | (b) Write to you and maintain our denial \-- go to step 4; or    |
|   |                                                                  |
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our request\--go   |
|   |     to step 3.                                                   |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us if we did not answer    |
|   |     that request in some way within 30 days; or                  |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: United States Office of Personnel Management,   |
|   | Insurance Services Programs, Health Insurance Group 2, 1900 E    |
|   | Street, NW, Washington, D.C. 20415-3620.                         |
+---+------------------------------------------------------------------+

+---+------------------------------------------------------------------+
| S |                                                                  |
| e |                                                                  |
| c |                                                                  |
| t |                                                                  |
| i |                                                                  |
| o |                                                                  |
| n |                                                                  |
| 8 |                                                                  |
| . |                                                                  |
| T |                                                                  |
| h |                                                                  |
| e |                                                                  |
| d |                                                                  |
| i |                                                                  |
| s |                                                                  |
| p |                                                                  |
| u |                                                                  |
| t |                                                                  |
| e |                                                                  |
| d |                                                                  |
| c |                                                                  |
| l |                                                                  |
| a |                                                                  |
| i |                                                                  |
| m |                                                                  |
| s |                                                                  |
| p |                                                                  |
| r |                                                                  |
| o |                                                                  |
| c |                                                                  |
| e |                                                                  |
| s |                                                                  |
| s |                                                                  |
| * |                                                                  |
| ( |                                                                  |
| C |                                                                  |
| o |                                                                  |
| n |                                                                  |
| t |                                                                  |
| i |                                                                  |
| n |                                                                  |
| u |                                                                  |
| e |                                                                  |
| d |                                                                  |
| ) |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians\' letters, operative reports, bills, medical      |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must include a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
|   | If you do not agree with OPM's decision, your only recourse is   |
|   | to sue. If you decide to sue, you must file the suit against OPM |
|   | in Federal court by December 31 of the third year after the year |
|   | in which you received the disputed services, drugs, or supplies  |
|   | or from the year in which you were denied precertification or    |
|   | prior approval. This is the only deadline that may not be        |
|   | extended.                                                        |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support their disputed claim decision. This           |
|   | information will become part of the court record.                |
|   |                                                                  |
|   | You may not sue until you have completed the disputed claims     |
|   | process. Further, Federal law governs your lawsuit, benefits,    |
|   | and payment of benefits. The Federal court will base its review  |
|   | on the record that was before OPM when OPM decided to uphold or  |
|   | overturn our decision. You may recover only the amount of        |
|   | benefits in dispute.                                             |
+---+------------------------------------------------------------------+

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

(a) We haven\'t responded yet to your initial request for care or
    preauthorization/prior approval, then call us at 800/228-4375 and we
    will expedite our review; or

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

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

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

+---------------+------------------------------------------------------+
| Section 9.    |                                                      |
| Coordinating  |                                                      |
| benefits with |                                                      |
| other         |                                                      |
| coverage      |                                                      |
+---------------+------------------------------------------------------+
| **When you    | > You must tell us if you or a covered family member |
| have other    | > have coverage under another group health plan or   |
| health        | > have automobile insurance that pays health care    |
| coverage**    | > 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 is a Health Insurance Program for:        |
| Medicare?**   |                                                      |
|               | -   People 65 years of age and older.                |
|               |                                                      |
|               | -   Some people with disabilities, under 65 years of |
|               |     age.                                             |
|               |                                                      |
|               | ```{=html}                                           |
|               | <!-- -->                                             |
|               | ```                                                  |
|               | -   People with End-Stage Renal Disease (permanent   |
|               |     kidney failure requiring dialysis or a           |
|               |     transplant).                                     |
|               |                                                      |
|               | > Medicare has two parts:                            |
|               |                                                      |
|               | -   Part A (Hospital Insurance). Most people do not  |
|               |     have to pay for Part A. If you or your spouse    |
|               |     worked for at least 10 years in Medicare-covered |
|               |     employment, you should be able to qualify for    |
|               |     premium-free Part A insurance. (Someone who was  |
|               |     a Federal employee on January 1, 1983 or since   |
|               |     automatically qualifies.) Otherwise, if you are  |
|               |     age 65 or older, you may be able to buy it.      |
|               |     Contact 800/MEDICARE (800/633-4227) for more     |
|               |     information.                                     |
|               |                                                      |
|               | -   Part B (Medical Insurance). Most people pay      |
|               |     monthly for Part B. Generally, Part B premiums   |
|               |     are withheld from your monthly Social Security   |
|               |     check or your retirement check.                  |
+---------------+------------------------------------------------------+
| -   **Should  | > The decision to enroll in Medicare is yours. We    |
|     I enroll  | > encourage you to apply for Medicare benefits 3     |
|     in        | > months before you turn age 65. It's easy. Just     |
|               | > call the Social Security Administration toll-free  |
|   Medicare?** | > number 1-800-772-1213 to set up an appointment to  |
|               | > apply. If you do not apply for one or both Parts   |
|               | > of Medicare, you can still be covered under the    |
|               | > FEHB Program.                                      |
|               | >                                                    |
|               | > If you can get premium-free Part A coverage, we    |
|               | > advise you to enroll in it. Most Federal employees |
|               | > and annuitants are entitled to Medicare Part A at  |
|               | > age 65 **without cost**. When you don't have to    |
|               | > pay premiums for Medicare Part A, it makes good    |
|               | > sense to obtain the coverage. It can reduce your   |
|               | > out-of-pocket expenses as well as costs to the     |
|               | > FEHB, which can help keep FEHB premiums down.      |
|               | >                                                    |
|               | > Everyone is charged a premium for Medicare Part B  |
|               | > coverage. The Social Security Administration can   |
|               | > provide you with premium and benefit information.  |
|               | > Review the information and decide if it makes      |
|               | > sense for you to buy the Medicare Part B coverage. |
|               | >                                                    |
|               | > If you are eligible for Medicare, you may have     |
|               | > choices in how you get your health care.           |
|               | > Medicare + Choice is the term used to describe the |
|               | > various health plan choices available to Medicare  |
|               | > beneficiaries. The information in the next few     |
|               | > pages shows how we coordinate benefits with        |
|               | > Medicare, depending on the type of Medicare        |
|               | > managed care plan you have.                        |
+---------------+------------------------------------------------------+

+---------------+------------------------------------------------------+
| -   **The     | > The Original Medicare Plan (Original Medicare) is  |
|     Original  | > available everywhere in the United States. It is   |
|     Medicare  | > the way everyone used to get Medicare benefits and |
|     Plan**    | > is the way most people get their Medicare Part A   |
|               | > and Part B benefits now. You may go to any doctor, |
| **(Part A or  | > specialist, or hospital that accepts Medicare. The |
| Part B)**     | > Original Medicare Plan pays its share and you pay  |
|               | > your share. Some things are not covered under      |
|               | > Original Medicare, like prescription drugs.        |
|               | >                                                    |
|               | > When you are enrolled in Original Medicare along   |
|               | > with this Plan, you still need to follow the rules |
|               | > in this brochure for us to cover your care. Your   |
|               | > care must continue to be authorized by your Plan   |
|               | > PCP, or precertified as required. We will not      |
|               | > waive any of our copayments and/or coinsurance.    |
|               | >                                                    |
|               | > **Claims process when you have the Original        |
|               | > Medicare Plan\--**You probably will never have to  |
|               | > file a claim when you have both our Plan and the   |
|               | > Original Medicare Plan.                            |
|               |                                                      |
|               | -   When we are the primary payer, we process the    |
|               |     claim first.                                     |
|               |                                                      |
|               | -   When Original Medicare is the primary payer,     |
|               |     Medicare processes your claim first. In most     |
|               |     cases, your claim will be coordinated            |
|               |     automatically and we will then provide secondary |
|               |     benefits 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        |
|               |     800/228-4375.                                    |
|               |                                                      |
|               | > **We do not waive any costs if the Original        |
|               | > Medicare Plan is your primary payer.**             |
+---------------+------------------------------------------------------+

The following chart

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

+-----------------------------------------------------+------+---------+
| > **Primary Payer Chart**                           |      |         |
+-----------------------------------------------------+------+---------+
| **A. When you - or your covered spouse - are age 65 | *    |         |
| or over and have Medicare and you...**              | *The |         |
|                                                     | pri  |         |
|                                                     | mary |         |
|                                                     | p    |         |
|                                                     | ayer |         |
|                                                     | for  |         |
|                                                     | the  |         |
|                                                     | in   |         |
|                                                     | divi |         |
|                                                     | dual |         |
|                                                     | with |         |
|                                                     | Medi |         |
|                                                     | care |         |
|                                                     | is.  |         |
|                                                     | ..** |         |
+-----------------------------------------------------+------+---------+
|                                                     | **Me | **This  |
|                                                     | dica | Plan**  |
|                                                     | re** |         |
+-----------------------------------------------------+------+---------+
| 1)  Are an active employee with the Federal         |      |         |
|     government and**...**                           |      |         |
|                                                     |      |         |
|     -   You have FEHB coverage on your own or       |      |         |
|         through your spouse who is also an active   |      |         |
|         employee                                    |      |         |
+-----------------------------------------------------+------+---------+
| -   You have FEHB coverage through your spouse who  |      |         |
|     is an annuitant                                 |      |         |
+-----------------------------------------------------+------+---------+
| 2)  Are an annuitant and**...**                     |      |         |
|                                                     |      |         |
|     -   You have FEHB coverage on your own or       |      |         |
|         through your spouse who is also an          |      |         |
|         annuitant                                   |      |         |
+-----------------------------------------------------+------+---------+
| -   You have FEHB coverage through your spouse who  |      |         |
|     is an active employee                           |      |         |
+-----------------------------------------------------+------+---------+
| 3)  Are a reemployed annuitant with the Federal     | \*   |         |
|     government and your position is excluded from   |      |         |
|     the FEHB (your employing office will know if    |      |         |
|     this is the case)                               |      |         |
+-----------------------------------------------------+------+---------+
| 4)  Are a reemployed annuitant with the Federal     |      |         |
|     government and your position is not excluded    |      |         |
|     from the FEHB (your employing office will know  |      |         |
|     if this is the case) and**...**                 |      |         |
|                                                     |      |         |
|     -   You have FEHB coverage on your own or       |      |         |
|         through your spouse who is also an active   |      |         |
|         employee                                    |      |         |
+-----------------------------------------------------+------+---------+
| -   You have FEHB coverage through your spouse who  |      |         |
|     is an annuitant                                 |      |         |
+-----------------------------------------------------+------+---------+
| 5)  Are a Federal judge who retired under title 28, | #    |         |
|     U.S.C., or a Tax Court judge who retired under  | #### |         |
|     Section 7447 of title 26, U.S.C. (or if your    | # \* |         |
|     covered spouse is this type of judge)           |      |         |
+-----------------------------------------------------+------+---------+
| 6)  Are enrolled in Part B only, regardless of your | for  | for     |
|     employment status                               | Part | other   |
|                                                     | B    | s       |
|                                                     | serv | ervices |
|                                                     | ices |         |
+-----------------------------------------------------+------+---------+
| 7)  Are a former Federal employee receiving         | \*\* |         |
|     Workers' Compensation and the Office of         |      |         |
|     Workers' Compensation Programs has determined   |      |         |
|     that you are unable to return to duty)          |      |         |
+-----------------------------------------------------+------+---------+
| **B. When you or a covered family member...**       |      |         |
+-----------------------------------------------------+------+---------+
| ###### Have Medicare so                             |      |         |
| lely based on end stage renal disease (ESRD) and... |      |         |
|                                                     |      |         |
| -   It is within the first 30 months of eligibility |      |         |
|     for or entitlement to Medicare due to ESRD      |      |         |
|     (30-month coordination period)                  |      |         |
+-----------------------------------------------------+------+---------+
| -   It is beyond the 30-month coordination period   |      |         |
|     and you or a family member are still entitled   |      |         |
|     to Medicare due to ESRD                         |      |         |
+-----------------------------------------------------+------+---------+
| 1)  Become eligible for Medicare due to ESRD while  |      | for     |
|     already a Medicare beneficiary and**...**       |      | 3       |
|                                                     |      | 0-month |
| -   This Plan was the primary payer before          |      | coord   |
|     eligibility due to ESRD                         |      | ination |
|                                                     |      | period  |
+-----------------------------------------------------+------+---------+
| -   Medicare was the primary payer before           |      |         |
|     eligibility due to ESRD                         |      |         |
+-----------------------------------------------------+------+---------+
| **C. When either you or your spouse are eligible    |      |         |
| for Medicare solely due to disability and you**     |      |         |
+-----------------------------------------------------+------+---------+
| 1)  Are an active employee with the Federal         |      |         |
|     government and**...**                           |      |         |
|                                                     |      |         |
|     -   You have FEHB coverage on your own or       |      |         |
|         through your spouse who is also an active   |      |         |
|         employee                                    |      |         |
+-----------------------------------------------------+------+---------+
| -   You have FEHB coverage through your spouse who  |      |         |
|     is an annuitant                                 |      |         |
+-----------------------------------------------------+------+---------+
| 2)  Are an annuitant and**...**                     |      | []      |
|                                                     |      | {.mark} |
|     -   You have FEHB coverage on your own or       |      |         |
|         through your spouse who is also an          |      |         |
|         annuitant                                   |      |         |
+-----------------------------------------------------+------+---------+
| -   You have FEHB coverage through your spouse who  |      |         |
|     is an active employee                           |      |         |
+-----------------------------------------------------+------+---------+
| **D. Are covered under the FEHB Spouse Equity       |      |         |
| provision as a former spouse**                      |      |         |
+-----------------------------------------------------+------+---------+

> \* Unless you have FEHB coverage through your spouse who is an active
> employee
>
> \*\* Workers' Compensation is primary for claims related to your
> condition under Workers' Compensation

+------------------------------------------------+------------+--------+
|                                                |            |        |
+------------------------------------------------+------------+--------+
|                                                |            |        |
+------------------------------------------------+------------+--------+
|                                                |            |        |
+------------------------------------------------+------------+--------+
| 1)                                             |            |        |
+------------------------------------------------+------------+--------+
| 2)                                             |            |        |
+------------------------------------------------+------------+--------+
| 3)                                             |            |        |
|                                                |            |        |
| ```{=html}                                     |            |        |
| <!-- -->                                       |            |        |
| ```                                            |            |        |
| a)                                             |            |        |
+------------------------------------------------+------------+--------+
| b)                                             |            |        |
+------------------------------------------------+------------+--------+
| 4)                                             | ##         |        |
|                                                | ####  {#se |        |
|                                                | ction-5 .u |        |
|                                                | nnumbered} |        |
+------------------------------------------------+------------+--------+
| 5)                                             |            |        |
+------------------------------------------------+------------+--------+
| 6)                                             |            |        |
+------------------------------------------------+------------+--------+
|                                                |            |        |
+------------------------------------------------+------------+--------+
| ######                                         |            |        |
+------------------------------------------------+------------+--------+
| 1)                                             |            |        |
+------------------------------------------------+------------+--------+
| 2)                                             |            |        |
+------------------------------------------------+------------+--------+
|                                                |            |        |
+------------------------------------------------+------------+--------+
| 1)                                             |            |        |
|                                                |            |        |
| ```{=html}                                     |            |        |
| <!-- -->                                       |            |        |
| ```                                            |            |        |
| a)                                             |            |        |
+------------------------------------------------+------------+--------+
| b)                                             |            |        |
+------------------------------------------------+------------+--------+
| c)                                             |            |        |
+------------------------------------------------+------------+--------+
| d)                                             |            |        |
+------------------------------------------------+------------+--------+

+---------------+------------------------------------------------------+
| -             | If you are eligible for Medicare, you may choose to  |
|  **Medicare + | enroll in and get your Medicare benefits from a      |
|     Choice**  | Medicare + Choice. These are health care choices     |
|               | (like HMOs) in some areas of the country. In most    |
|               | Medicare + Choices, you can only go to doctors,      |
|               | specialists, or hospitals that are part of the plan. |
|               | Medicare + Choices provide all the benefits that     |
|               | Original Medicare covers. Some cover extras, like    |
|               | prescription drugs. To learn more about enrolling in |
|               | a Medicare + Choice, contact Medicare at             |
|               | 800/MEDICARE (800/633-4227) or at                    |
|               | [www.medicare.gov](http://www.medicare.gov/).        |
|               |                                                      |
|               | If you enroll in a Medicare + Choice, the following  |
|               | options are available to you:                        |
|               |                                                      |
|               | **This Plan and our** **Medicare + Choice:** You may |
|               | enroll in our Medicare managed care plan and also    |
|               | remain enrolled in our FEHB plan. In this case, we   |
|               | do not waive cost sharing for your FEHB coverage.    |
|               |                                                      |
|               | **This Plan and another plan's** **Medicare +        |
|               | Choice:** You may enroll in another plan's           |
|               | Medicare + Choice and also remain enrolled in our    |
|               | FEHB plan. We will still provide benefits when your  |
|               | Medicare + Choice is primary, even out of the        |
|               | managed care plan's network and/or service area (if  |
|               | you use our Plan providers), but we will not waive   |
|               | any of our copayments and/or coinsurance. If you     |
|               | enroll in a Medicare + Choice, tell us. We will need |
|               | to know whether you are in the Original Medicare     |
|               | Plan or in a Medicare + Choice so we can correctly   |
|               | coordinate benefits with Medicare.                   |
|               |                                                      |
|               | **Suspended FEHB coverage to enroll in a**           |
|               | **Medicare + Choice:** If you are an annuitant or    |
|               | former spouse, you can suspend your FEHB coverage to |
|               | enroll in a Medicare + Choice, eliminating your FEHB |
|               | premium. (OPM does not contribute to your Medicare + |
|               | Choice 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's service area.             |
+---------------+------------------------------------------------------+
| **TRICARE and | TRICARE is the health care program for eligible      |
| CHAMPVA**     | dependents of military persons, and retirees of the  |
|               | military. TRICARE includes the CHAMPUS program.      |
|               | CHAMPVA provides health coverage to disabled         |
|               | Veterans and their eligible dependents. If TRICARE   |
|               | or CHAMPVA and this Plan cover you, we pay first.    |
|               | See your TRICARE or CHAMPVA Health Benefits Advisor  |
|               | if you have questions about these programs.          |
|               |                                                      |
|               | **Suspended FEHB coverage to enroll in TRICARE or    |
|               | CHAMPVA:** If you are an annuitant or former spouse, |
|               | you can suspend your FEHB coverage to enroll in one  |
|               | of these programs, eliminating your FEHB premium.    |
|               | (OPM does not contribute to any applicable plan      |
|               | premiums.) For information on suspending your FEHB   |
|               | enrollment, contact your retirement office. If you   |
|               | later want to re-enroll in the FEHB Program,         |
|               | generally you may do so only at the next Open Season |
|               | unless you involuntarily lose coverage under the     |
|               | program.                                             |
+---------------+------------------------------------------------------+
| **Workers\'   | We do not cover services that:                       |
| C             |                                                      |
| ompensation** | -   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                                      |
|               |                                                      |
|               | ```{=html}                                           |
|               | <!-- -->                                             |
|               | ```                                                  |
|               | -   OWCP or a similar agency pays for through a      |
|               |     third party injury settlement or other similar   |
|               |     proceeding that is based on a claim you filed    |
|               |     under OWCP or similar laws.                      |
|               |                                                      |
|               | Once OWCP or similar agency pays its maximum         |
|               | benefits for your treatment, we will cover your      |
|               | care. You must use our providers.                    |
+---------------+------------------------------------------------------+
| **Medicaid**  | When you have this Plan and Medicaid, we pay first.  |
|               |                                                      |
|               | **Suspended FEHB coverage to enroll in Medicaid or a |
|               | similar State-sponsored program of medical           |
|               | assistance:** If you are an annuitant or former      |
|               | spouse, you can suspend your FEHB coverage to enroll |
|               | in one of these State programs, eliminating your     |
|               | FEHB premium. For information on suspending your     |
|               | FEHB enrollment, contact your retirement office. If  |
|               | you later want to re-enroll in the FEHB Program,     |
|               | generally you may do so only at the next Open Season |
|               | unless you involuntarily lose coverage under the     |
|               | State program.                                       |
+---------------+------------------------------------------------------+
| **When other  | We do not cover services and supplies when a local,  |
| Government    | State, or Federal Government agency directly or      |
| agencies are  | indirectly pays for them.                            |
| responsible   |                                                      |
| for your      |                                                      |
| care**        |                                                      |
+---------------+------------------------------------------------------+
| **When others | When you receive money to compensate you for medical |
| are           | or hospital care for injuries or illness caused by   |
| responsible   | another person, you must reimburse us for any        |
| for           | expenses we paid. However, we will cover the cost of |
| injuries**    | treatment that exceeds the amount you received in    |
|               | the settlement.                                      |
|               |                                                      |
|               | If you do not seek damages you must agree to let us  |
|               | try. This is called subrogation. If you need more    |
|               | information, contact us for our subrogation          |
|               | procedures.                                          |
+---------------+------------------------------------------------------+

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

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

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

**Coinsurance** Coinsurance is the percentage of our allowance that you
must pay for your care. See page 14.

**Copayment** A copayment is a fixed amount of money you pay when you
receive covered services. See page 14.

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

+-------------+--------------------------------------------------------+
| **Custodial | Treatment or services, regardless of who recommends    |
| care**      | them or where they are provided, that could be         |
|             | rendered safely and reasonably by a person not         |
|             | medically skilled, or that are designed mainly to help |
|             | the patient with daily living activities. These        |
|             | activities include, but are not limited to:            |
|             |                                                        |
|             | -   Personal care such as help in walking, getting in  |
|             |     and out of bed, bathing, eating by spoon, tube or  |
|             |     gastrostomy, exercising or dressing                |
|             |                                                        |
|             | -   Homemaking such as preparing meals or special      |
|             |     diets                                              |
|             |                                                        |
|             | -   Moving the patient                                 |
|             |                                                        |
|             | -   Acting as a companion or sitter                    |
|             |                                                        |
|             | -   Supervising medication that can usually be self    |
|             |     administered                                       |
|             |                                                        |
|             | -   Treatment services that any person may be able to  |
|             |     perform with minimal instruction, including, but   |
|             |     not limited to, recording temperature, pulse and   |
|             |     respirations or administration and monitoring of   |
|             |     feeding systems                                    |
|             |                                                        |
|             |     We determine which services are custodial.         |
|             |                                                        |
|             |     Note: Custodial care that last 90 days or more is  |
|             |     sometimes known as Long term care.                 |
+-------------+--------------------------------------------------------+
| **E         | A drug, device, or biological product is experimental  |
| xperimental | or investigational if the drug, device, or biological  |
| or          | product cannot be lawfully marketed without approval   |
| inve        | of the U.S. Food and Drug Administration (FDA) and     |
| stigational | approval for marketing has not been given at the time  |
| services**  | it is furnished. Approval means all forms of           |
|             | acceptance by the FDA.                                 |
|             |                                                        |
|             | A medical treatment or procedure, or biological        |
|             | product is experimental or investigational if 1)       |
|             | reliable evidence shows that it is the subject of      |
|             | ongoing phase I, II or III clinical trials or under    |
|             | study to determine its maximum tolerated dose, its     |
|             | toxicity, its safety, its efficacy, or its efficacy as |
|             | compared with the standard means of treatment or       |
|             | diagnosis; or 2) reliable evidence shows that the      |
|             | consensus of opinion among experts regarding the drug, |
|             | device, or biological product or medical treatment or  |
|             | procedure is that further studies or clinical trials   |
|             | are necessary to determine its maximum tolerated dose, |
|             | its toxicity, its safety, its efficacy, or its         |
|             | efficacy as compared with the standard means of        |
|             | treatment or diagnosis.                                |
|             |                                                        |
|             | Reliable evidence shall mean only published reports    |
|             | and articles in the authoritative medical and          |
|             | scientific literature; the written protocol or         |
|             | protocols used by the treating facility or the         |
|             | protocol(s) of another facility studying substantially |
|             | the same drug, device, or medical treatment or         |
|             | procedure; or the written informed consent used by the |
|             | treating facility or by another facility studying      |
|             | substantially the same drug, device or medical         |
|             | treatment or procedure.                                |
+-------------+--------------------------------------------------------+
| **Group     | Health care coverage that a member is eligible for     |
| health      | because of employment, membership in, or connection    |
| coverage**  | with, a particular organization or group that provides |
|             | payment for hospital, medical, or other health care    |
|             | services or supplies, or that pays a specific amount   |
|             | for each day or period of hospitalization.             |
+-------------+--------------------------------------------------------+

+-------------+--------------------------------------------------------+
| **Medical   | Services, drugs, supplies or equipment provided by a   |
| necessity** | hospital or covered provider of the health care        |
|             | services that the Carrier determines:                  |
|             |                                                        |
|             | -   Are appropriate to diagnose or treat the patient's |
|             |     condition, illness or injury                       |
|             |                                                        |
|             | -   Are consistent with standards of good medical      |
|             |     practice in the United States                      |
|             |                                                        |
|             | -   Are not primarily for the personal comfort of the  |
|             |     patient, the family or the provider                |
|             |                                                        |
|             | -   Are not a part of or associated with scholastic    |
|             |     education or vocational training of the patient    |
|             |     and                                                |
|             |                                                        |
|             | -   In the case of inpatient care, cannot be provided  |
|             |     safely on an outpatient basis                      |
|             |                                                        |
|             | The fact that a covered provider has prescribed,       |
|             | recommended or approved a service, supply, drug or     |
|             | equipment does not, in itself, make it medically       |
|             | necessary.                                             |
+-------------+--------------------------------------------------------+
| **Our       | Our allowance is the amount we use to determine our    |
| allowance** | payment and your coinsurance for covered services.     |
|             | Plans determine their allowances in different ways. We |
|             | determine our allowance as follows:                    |
|             |                                                        |
|             | -   Amounts charged by other providers for the same or |
|             |     similar service                                    |
|             |                                                        |
|             | -   Any unusual medical circumstances requiring        |
|             |     additional time, skill or experience and           |
|             |                                                        |
|             | -   Other factors we determine are relevant,           |
|             |     including, but not limited to, a resource based    |
|             |     relative value scale                               |
+-------------+--------------------------------------------------------+
| **Predete   | The process of requesting approval of benefits before  |
| rmination** | the service or supply is rendered. Your provider       |
|             | should submit the appropriate documentation for        |
|             | review.                                                |
+-------------+--------------------------------------------------------+

**Us/We** Us and we refer to Blue HMO

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

+------------------------+---+---+---------------------------------------------+
| Section 11. FEHB facts |   |   |                                             |
+------------------------+---+---+---------------------------------------------+
| **Coverage             |   |   | We will not refuse to cover the treatment   |
| information**          |   |   | of a condition that you had before you      |
|                        |   |   | enrolled in this Plan solely because you    |
| **No pre-existing      |   |   | had the condition before you enrolled.      |
| condition limitation** |   |   |                                             |
+------------------------+---+---+---------------------------------------------+
| **Where you can get    |   |   | See                                         |
| information about      |   |   | [www.                                       |
| enrolling in the FEHB  |   |   | opm.gov/insure](http://www.opm.gov/insure). |
| Program**              |   |   | Also, your employing or retirement office   |
|                        |   |   | can answer your questions, and give you a   |
|                        |   |   | *Guide to Federal* *Employees Health        |
|                        |   |   | Benefits Plans,* brochures for other plans, |
|                        |   |   | and other materials you need to make an     |
|                        |   |   | informed decision about your FEHB coverage. |
|                        |   |   | These materials tell you:                   |
|                        |   |   |                                             |
|                        |   |   | -   When you may change your enrollment     |
|                        |   |   |                                             |
|                        |   |   | -   How you can cover your family members   |
|                        |   |   |                                             |
|                        |   |   | -   What happens when you transfer to       |
|                        |   |   |     another Federal agency, go on leave     |
|                        |   |   |     without pay, enter military service, or |
|                        |   |   |     retire                                  |
|                        |   |   |                                             |
|                        |   |   | -   When your enrollment ends and           |
|                        |   |   |                                             |
|                        |   |   | -   When the next open season for           |
|                        |   |   |     enrollment begins.                      |
|                        |   |   |                                             |
|                        |   |   |     We don't determine who is eligible for  |
|                        |   |   |     coverage and, in most cases, cannot     |
|                        |   |   |     change your enrollment status without   |
|                        |   |   |     information from your employing or      |
|                        |   |   |     retirement office.                      |
+------------------------+---+---+---------------------------------------------+
| **Types of coverage    |   |   | Self Only coverage is for you alone. Self   |
| available for you and  |   |   | and Family coverage is for you, your        |
| your family**          |   |   | spouse, and your unmarried dependent        |
|                        |   |   | children under age 22, including any foster |
|                        |   |   | children or stepchildren your employing or  |
|                        |   |   | retirement office authorizes coverage for.  |
|                        |   |   | Under certain circumstances, you may also   |
|                        |   |   | continue coverage for a disabled child 22   |
|                        |   |   | years of age or older who is incapable of   |
|                        |   |   | self-support.                               |
|                        |   |   |                                             |
|                        |   |   | If you have a Self Only enrollment, you may |
|                        |   |   | change to a Self and Family enrollment if   |
|                        |   |   | you marry, give birth, or add a child to    |
|                        |   |   | your family. You may change your enrollment |
|                        |   |   | 31 days before to 60 days after that event. |
|                        |   |   | The Self and Family enrollment begins on    |
|                        |   |   | the first day of the pay period in which    |
|                        |   |   | the child is born or becomes an eligible    |
|                        |   |   | family member. When you change to Self and  |
|                        |   |   | Family because you marry, the change is     |
|                        |   |   | effective on the first day of the pay       |
|                        |   |   | period that begins after your employing     |
|                        |   |   | office receives your enrollment form;       |
|                        |   |   | benefits will not be available to your      |
|                        |   |   | spouse until you marry.                     |
|                        |   |   |                                             |
|                        |   |   | Your employing or retirement office will    |
|                        |   |   | **not** notify you when a family member is  |
|                        |   |   | no longer eligible to receive health        |
|                        |   |   | benefits, nor will we. Please tell us       |
|                        |   |   | immediately when you add or remove family   |
|                        |   |   | members from your coverage for any reason,  |
|                        |   |   | including divorce, or when your child under |
|                        |   |   | age 22 marries or turns 22.                 |
|                        |   |   |                                             |
|                        |   |   | If you or one of your family members is     |
|                        |   |   | enrolled in one FEHB plan, that person may  |
|                        |   |   | not be enrolled in or covered as a family   |
|                        |   |   | member by another FEHB plan.                |
+------------------------+---+---+---------------------------------------------+
| **Children\'s Equity   |   |   | OPM has implemented the Federal Employees   |
| Act**                  |   |   | Health Benefits Children\'s Equity Act of   |
|                        |   |   | 2000. This law mandates that you be         |
|                        |   |   | enrolled for self and family coverage in    |
|                        |   |   | the Federal Employees Health Benefits       |
|                        |   |   | (FEHB) Program, if you are an employee      |
|                        |   |   | subject to a court or administrative order  |
|                        |   |   | requiring you to provide health benefits    |
|                        |   |   | for your child(ren).                        |
|                        |   |   |                                             |
|                        |   |   | If this law applies to you, you must enroll |
|                        |   |   | for self and family coverage in a health    |
|                        |   |   | plan that provides full benefits in the     |
|                        |   |   | area where your children live or provide    |
|                        |   |   | documentation to your employing office that |
|                        |   |   | you have obtained other health benefits     |
|                        |   |   | coverage for your children. If you do not   |
|                        |   |   | do so, your employing office will enroll    |
|                        |   |   | you involuntarily as follows:               |
|                        |   |   |                                             |
|                        |   |   | -   If you have no FEHB coverage, your      |
|                        |   |   |     employing office will enroll you for    |
|                        |   |   |     Self and Family coverage in the Blue    |
|                        |   |   |     Cross and Blue Shield Service Benefit   |
|                        |   |   |     Plan's Basic Option,                    |
|                        |   |   |                                             |
|                        |   |   | -   if you have a self only enrollment in a |
|                        |   |   |     fee-for-service plan or in an HMO that  |
|                        |   |   |     serves the area where your children     |
|                        |   |   |     live, your employing office will change |
|                        |   |   |     your enrollment to self and family in   |
|                        |   |   |     the same option of the same plan; or    |
|                        |   |   |                                             |
|                        |   |   | -   if you are enrolled in an HMO that does |
|                        |   |   |     not serve the area where the children   |
|                        |   |   |     live, your employing office will change |
|                        |   |   |     your enrollment to Self and Family in   |
|                        |   |   |     the Blue Cross and Blue Shield Service  |
|                        |   |   |     Benefit Plan's Basic Option.            |
|                        |   |   |                                             |
|                        |   |   | > As long as the court/administrative order |
|                        |   |   | > is in effect, and you have at least one   |
|                        |   |   | > child identified in the order who is      |
|                        |   |   | > still eligible under the FEHB Program,    |
|                        |   |   | > you cannot cancel your enrollment, change |
|                        |   |   | > to self only, or change to a plan that    |
|                        |   |   | > doesn\'t serve the area in which your     |
|                        |   |   | > children live, unless you provide         |
|                        |   |   | > documentation that you have other         |
|                        |   |   | > coverage for the children. If the         |
|                        |   |   | > court/administrative order is still in    |
|                        |   |   | > effect when you retire, and you have at   |
|                        |   |   | > least one child still eligible for FEHB   |
|                        |   |   | > coverage, you must continue your FEHB     |
|                        |   |   | > coverage into retirement (if eligible)    |
|                        |   |   | > and cannot cancel your coverage, change   |
|                        |   |   | > to Self Only or change to a plan that     |
|                        |   |   | > doesn't serve the area in which your      |
|                        |   |   | > children live as long as the              |
|                        |   |   | > court/administrative order is in effect.  |
|                        |   |   | > Contact your employing office for further |
|                        |   |   | > information.                              |
+------------------------+---+---+---------------------------------------------+
| **When benefits and    |   |   | The benefits in this brochure are effective |
| premiums start**       |   |   | on January 1. If you joined this Plan       |
|                        |   |   | during Open Season, your coverage begins on |
|                        |   |   | the first day of your first pay period that |
|                        |   |   | starts on or after January 1. If you        |
|                        |   |   | changed plans or plan options during Open   |
|                        |   |   | Season and you receive care between January |
|                        |   |   | 1 and the effective date of coverage under  |
|                        |   |   | your new plan or option, your claims will   |
|                        |   |   | be paid according to the 2004 benefits of   |
|                        |   |   | your old plan or option. 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        |   |   | You will receive an additional 31 days of   |
|     coverage ends**    |   |   | coverage, for no additional premium, when:  |
|                        |   |   |                                             |
|                        |   |   | -   Your enrollment ends, unless you cancel |
|                        |   |   |     your enrollment or                      |
|                        |   |   |                                             |
|                        |   |   | ```{=html}                                  |
|                        |   |   | <!-- -->                                    |
|                        |   |   | ```                                         |
|                        |   |   | -   You are a family member no longer       |
|                        |   |   |     eligible for coverage                   |
|                        |   |   |                                             |
|                        |   |   |     You may be eligible for spouse equity   |
|                        |   |   |     coverage or Temporary Continuation of   |
|                        |   |   |     Coverage (TCC), or a conversion policy  |
|                        |   |   |     (a non-FEHB individual policy).         |
+------------------------+---+---+---------------------------------------------+
| -   **Spouse equity    |   |   | If you are divorced from a Federal employee |
|     coverage**         |   |   | or annuitant, you may not continue to get   |
|                        |   |   | benefits under your former spouse's         |
|                        |   |   | enrollment. This is the case even when the  |
|                        |   |   | court has ordered your former spouse to     |
|                        |   |   | supply health coverage to you. But, you may |
|                        |   |   | be eligible for your own FEHB coverage      |
|                        |   |   | under the spouse equity law or Temporary    |
|                        |   |   | Continuation of Coverage (TCC). If you are  |
|                        |   |   | recently divorced or are anticipating a     |
|                        |   |   | divorce, contact your ex-spouse's employing |
|                        |   |   | or retirement office to get RI 70-5, the    |
|                        |   |   | *Guide to Federal Employees Health Benefits |
|                        |   |   | Plans for Temporary Continuation of         |
|                        |   |   | Coverage and Former Spouse Enrollees*, or   |
|                        |   |   | other information about your coverage       |
|                        |   |   | choices. You can also download the guide    |
|                        |   |   | from OPM\'s website,                        |
|                        |   |   | [www.                                       |
|                        |   |   | opm.gov/insure](http://www.opm.gov/insure). |
+------------------------+---+---+---------------------------------------------+
| -   **Temporary        |   | I |                                             |
|     Continuation of    |   | f |                                             |
|     Coverage (TCC)**   |   | y |                                             |
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| -   **Getting a        | T |   |                                             |
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|                        | i |   |                                             |
|                        | o |   |                                             |
|                        | n |   |                                             |
|                        | a |   |                                             |
|                        | b |   |                                             |
|                        | o |   |                                             |
|                        | u |   |                                             |
|                        | t |   |                                             |
|                        | F |   |                                             |
|                        | e |   |                                             |
|                        | d |   |                                             |
|                        | e |   |                                             |
|                        | r |   |                                             |
|                        | a |   |                                             |
|                        | l |   |                                             |
|                        | a |   |                                             |
|                        | n |   |                                             |
|                        | d |   |                                             |
|                        | S |   |                                             |
|                        | t |   |                                             |
|                        | a |   |                                             |
|                        | t |   |                                             |
|                        | e |   |                                             |
|                        | a |   |                                             |
|                        | g |   |                                             |
|                        | e |   |                                             |
|                        | n |   |                                             |
|                        | c |   |                                             |
|                        | i |   |                                             |
|                        | e |   |                                             |
|                        | s |   |                                             |
|                        | y |   |                                             |
|                        | o |   |                                             |
|                        | u |   |                                             |
|                        | c |   |                                             |
|                        | a |   |                                             |
|                        | n |   |                                             |
|                        | c |   |                                             |
|                        | o |   |                                             |
|                        | n |   |                                             |
|                        | t |   |                                             |
|                        | a |   |                                             |
|                        | c |   |                                             |
|                        | t |   |                                             |
|                        | f |   |                                             |
|                        | o |   |                                             |
|                        | r |   |                                             |
|                        | m |   |                                             |
|                        | o |   |                                             |
|                        | r |   |                                             |
|                        | e |   |                                             |
|                        | i |   |                                             |
|                        | n |   |                                             |
|                        | f |   |                                             |
|                        | o |   |                                             |
|                        | r |   |                                             |
|                        | m |   |                                             |
|                        | a |   |                                             |
|                        | t |   |                                             |
|                        | i |   |                                             |
|                        | o |   |                                             |
|                        | n |   |                                             |
|                        | . |   |                                             |
+------------------------+---+---+---------------------------------------------+

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

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

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

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

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

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

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

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

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

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

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

```{=html}
<!-- -->
```
-   Covers eligible dependent care expenses incurred so you can work, or
    if you are married, so you and your spouse can work, or your spouse
    can look for work or attend school full-time.

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

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

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

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

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

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

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

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

**contribute to my FSA?** benefits of an FSA, the IRS places strict
guidelines on them. You need to estimate

> how much you want to allocate to an FSA because current IRS
> regulations require you forfeit any funds remaining in your account(s)
> at the end of the FSA plan year. This is referred to as the
> "use-it-or-lose-it" rule. You will have until April 29, 2004 to submit
> claims for your eligible expenses incurred during 2003 if you enrolled
> in FSAFEDS when it was initially offered. You will have until April
> 30, 2005 to submit claims for your eligible expenses incurred from
> January 1 through December 31, 2004 if you elect FSAFEDS during this
> Open Season.
>
> The **FSAFEDS Calculator** at
> [www.fsafeds.com](http://www.fsafeds.com/) will help you plan your FSA
> allocations and provide an estimate of your tax savings based on your
> individual situation.

-   **What can my HCFSA** Every FEHB health plan includes cost sharing
    features, such as deductibles you must **pay for?** 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 14 and detailed throughout
> this brochure. Your HCFSA will reimburse you for such costs when they
> are for tax deductible medical care for you and your dependents that
> is NOT covered by this FEHB Plan or any other coverage that you have.
>
> Under this Plan, typical out-of-pocket expenses include:

-   Copayments for office visits, emergency room visits and prescription
    drugs, and

-   Assisted reproductive technology (ART) procedures, i.e., GIFT and
    ZIFT

-   Long term rehabilitative therapy

-   Chiropractic care beyond 12 spinal manipulations

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

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

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

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

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

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

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

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

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

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

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

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

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

**deductions** reimbursement for them from your HCFSA or DCFSA. Below
are some guidelines

> that may help you decide whether to participate in FSAFEDS.

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

> from the HCFSA at any time during the year for expenses up to the
> annual amount you've elected to contribute.
>
> Only health care expenses exceeding 7.5% of your adjusted gross income
> are eligible to be deducted on your Federal income tax return. Using
> the example listed in the above chart, only health care expenses
> exceeding \$3,750 (7.5% of \$50,000) would be eligible to be deducted
> on your Federal income tax return. In addition, money set aside
> through a HCFSA is also exempt from FICA taxes. This exemption is not
> available on your Federal income tax return.

**Dependent care expenses** The DCFSA generally allows many families to
save more than they would with the

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

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

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

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

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

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

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

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

**The Federal Long Term Care Insurance Program**

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

Program:

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

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

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

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

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

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

**A**bortion, 42

Accidental injury, 26, 39, 40

Allergy care, 19

Alternative treatments, 25

Ambulance, 29, 31

Anesthesia, 27

**B**iopsies, 24

Blood or blood plasma, 28-29

**C**ardiac rehabilitation, 20

Casts, 28, 29

Catastrophic protection out-of-pocket maximum, 14, 61

Changes for 2004, 9

Chemotherapy, 20

Chiropractic, 23

Cholesterol tests, 17

Circumcision, 18

Claims filing, 43

Coinsurance, 14

Colorectal cancer screening, 17

Congenital anomalies, 24

Contraceptive devices and drugs, 18, 36

Coordination of benefits, 46

Copayments, 14, 51

Covered charges, 51

Covered providers, 10, 11

Crutches, 22

**D**eductible, 14

Definitions, 51-52

Dental, 39-41

Diabetic supplies, 36

Diagnostic services, 16, 28

Dialysis, 20

Disputed claims review, 44-45

Donor expenses (transplants), 27

Dressings, 22

Durable medical equipment (DME), 22

**E**ducational classes and programs, 23

Effective date of enrollment, 54

Emergency, 30-31

Experimental or investigational, 51

Extended care, 29

Eyeglasses, 21, 38

**F**amily planning, 18

Fecal occult blood test, 17

Fertility drugs, 19, 36

Foot care, 21

Formulary drugs, 34

Fraud, 5

**G**eneral Exclusions, 42

Growth hormone services, 20, 36

**H**earing services, 21

Home health services, 23

Hospice care, 29

Home nursing care, 23

**I**mmunizations, 17

Infertility, 19, 36

Inhospital physician care, 16

Inpatient hospital benefits, 24-28

Insulin, 36

Intravenous (IV)/infusion therapy, 20

**L**aboratory/pathological services, 16

Long Term Care Insurance, 59

**M**agnetic Resonance Imaging (MRI), 16

Mail order prescription drugs, 36

Mammogram, 16-17

Maternity, 18

Medicaid, 49

Medical necessity, 52

Medicare, 46-49

Medical supplies, 22

Mental health/substance abuse, 32-33

Morbid obesity, 24

**N**ewborn care, 18

Nurse, 16

> Licensed Practical Nurse, 23
>
> Nurse Anesthetist, 28
>
> Registered Nurse, 23

Nursery charges, 28

**O**bstetrical care, 18

Occupational therapy, 20

Office visit, 16

Oral and maxillofacial surgery, 26

Orthopedic devices, 21-22

Ostomy supplies, 22

Out-of-pocket expenses, 14

Outpatient hospital, 29

Oxygen, 22, 23, 28, 29

**P**ap test, 16, 17

Physical therapy, 20

Preauthorization, 33

Precertification, 13

Predetermination, 13, 52

Pre-existing condition, 53

Prescription drugs, 34-36

Preventive care, adults, 17

Preventive care, children, 17

Preventive services, 17

Prior approval, 13

Primary care, 11

Prostate Specific Antigen (PSA) test, 17

Prosthetic devices, 21-22

Providers, 10-12

Psychologist, 32

Psychotherapy, 32

**R**adiation therapy, 20

Reconstructive surgery, 25

Respiratory and inhalation therapy, 20

Room and board, 28

**S**econd surgical opinion, 16

Service area, 8

Skilled nursing care, 29

Smoking cessation, 23, 36

Special features, 37-38

Specialty care, 11

Speech therapy, 20

Splints, 28

Sterilization procedures, 18, 25

Subrogation, 50

Substance abuse, 32-33

Surgical procedures, 24-27

Syringes, 36

**T**emporary continuation of coverage, 55

Transplants, 27

Treatment therapies, 20

**U**rgent Care, 16, 31

**V**ision services, 21

**W**ell child care, 17

Wheelchairs, 22

Workers' compensation, 49

**X**-ray, 28-29

+-----------------------------------------------------------------------+
| # Summary of benefits for Blue HMO -- 2004                            |
+-----------------------------------------------------------------------+

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

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

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

+-----------------------------------+---+-----------------------------+---+
| **Benefits**                      | * |                             | * |
|                                   | * |                             | * |
|                                   | Y |                             | P |
|                                   | o |                             | a |
|                                   | u |                             | g |
|                                   | P |                             | e |
|                                   | a |                             | * |
|                                   | y |                             | * |
|                                   | * |                             |   |
|                                   | * |                             |   |
+-----------------------------------+---+-----------------------------+---+
| Medical services provided by      | O |                             | 1 |
| physicians:                       | f |                             | 6 |
|                                   | f |                             |   |
| -   Diagnostic and treatment      | i |                             |   |
|     services provided in the      | c |                             |   |
|     office                        | e |                             |   |
|                                   | v |                             |   |
|                                   | i |                             |   |
|                                   | s |                             |   |
|                                   | i |                             |   |
|                                   | t |                             |   |
|                                   | c |                             |   |
|                                   | o |                             |   |
|                                   | p |                             |   |
|                                   | a |                             |   |
|                                   | y |                             |   |
|                                   | : |                             |   |
|                                   | \ |                             |   |
|                                   | $ |                             |   |
|                                   | 1 |                             |   |
|                                   | 0 |                             |   |
|                                   | p |                             |   |
|                                   | r |                             |   |
|                                   | i |                             |   |
|                                   | m |                             |   |
|                                   | a |                             |   |
|                                   | r |                             |   |
|                                   | y |                             |   |
|                                   | c |                             |   |
|                                   | a |                             |   |
|                                   | r |                             |   |
|                                   | e |                             |   |
|                                   | ; |                             |   |
|                                   | \ |                             |   |
|                                   | $ |                             |   |
|                                   | 1 |                             |   |
|                                   | 0 |                             |   |
|                                   | s |                             |   |
|                                   | p |                             |   |
|                                   | e |                             |   |
|                                   | c |                             |   |
|                                   | i |                             |   |
|                                   | a |                             |   |
|                                   | l |                             |   |
|                                   | i |                             |   |
|                                   | s |                             |   |
|                                   | t |                             |   |
+-----------------------------------+---+-----------------------------+---+
| Services provided by a hospital:  | N |                             | 2 |
|                                   | o |                             | 8 |
| -   Inpatient                     | t |                             |   |
|                                   | h |                             | 2 |
| -   Outpatient                    | i |                             | 9 |
|                                   | n |                             |   |
|                                   | g |                             |   |
|                                   |   |                             |   |
|                                   | N |                             |   |
|                                   | o |                             |   |
|                                   | t |                             |   |
|                                   | h |                             |   |
|                                   | i |                             |   |
|                                   | n |                             |   |
|                                   | g |                             |   |
+-----------------------------------+---+-----------------------------+---+
| Emergency benefits:               | \ |                             | 3 |
|                                   | $ |                             | 1 |
| -   In-area                       | 5 |                             |   |
|                                   | 0 |                             | 3 |
| -   Out-of-area                   | p |                             | 1 |
|                                   | e |                             |   |
|                                   | r |                             |   |
|                                   | v |                             |   |
|                                   | i |                             |   |
|                                   | s |                             |   |
|                                   | i |                             |   |
|                                   | t |                             |   |
|                                   |   |                             |   |
|                                   | \ |                             |   |
|                                   | $ |                             |   |
|                                   | 5 |                             |   |
|                                   | 0 |                             |   |
|                                   | p |                             |   |
|                                   | e |                             |   |
|                                   | r |                             |   |
|                                   | v |                             |   |
|                                   | i |                             |   |
|                                   | s |                             |   |
|                                   | i |                             |   |
|                                   | t |                             |   |
+-----------------------------------+---+-----------------------------+---+
| Mental health and substance abuse | O |                             | 3 |
| treatment                         | f |                             | 2 |
|                                   | f |                             |   |
|                                   | i |                             |   |
|                                   | c |                             |   |
|                                   | e |                             |   |
|                                   | v |                             |   |
|                                   | i |                             |   |
|                                   | s |                             |   |
|                                   | i |                             |   |
|                                   | t |                             |   |
|                                   | c |                             |   |
|                                   | o |                             |   |
|                                   | p |                             |   |
|                                   | a |                             |   |
|                                   | y |                             |   |
|                                   | : |                             |   |
|                                   | \ |                             |   |
|                                   | $ |                             |   |
|                                   | 1 |                             |   |
|                                   | 0 |                             |   |
|                                   |   |                             |   |
|                                   | I |                             |   |
|                                   | n |                             |   |
|                                   | p |                             |   |
|                                   | a |                             |   |
|                                   | t |                             |   |
|                                   | i |                             |   |
|                                   | e |                             |   |
|                                   | n |                             |   |
|                                   | t |                             |   |
|                                   | h |                             |   |
|                                   | o |                             |   |
|                                   | s |                             |   |
|                                   | p |                             |   |
|                                   | i |                             |   |
|                                   | t |                             |   |
|                                   | a |                             |   |
|                                   | l |                             |   |
|                                   | : |                             |   |
|                                   | N |                             |   |
|                                   | o |                             |   |
|                                   | t |                             |   |
|                                   | h |                             |   |
|                                   | i |                             |   |
|                                   | n |                             |   |
|                                   | g |                             |   |
|                                   |   |                             |   |
|                                   | O |                             |   |
|                                   | u |                             |   |
|                                   | t |                             |   |
|                                   | p |                             |   |
|                                   | a |                             |   |
|                                   | t |                             |   |
|                                   | i |                             |   |
|                                   | e |                             |   |
|                                   | n |                             |   |
|                                   | t |                             |   |
|                                   | h |                             |   |
|                                   | o |                             |   |
|                                   | s |                             |   |
|                                   | p |                             |   |
|                                   | i |                             |   |
|                                   | t |                             |   |
|                                   | a |                             |   |
|                                   | l |                             |   |
|                                   | : |                             |   |
|                                   | N |                             |   |
|                                   | o |                             |   |
|                                   | t |                             |   |
|                                   | h |                             |   |
|                                   | i |                             |   |
|                                   | n |                             |   |
|                                   | g |                             |   |
+-----------------------------------+---+-----------------------------+---+
| Prescription drugs:               | \ |                             | 3 |
|                                   | $ |                             | 6 |
| -   Network Pharmacy              | 1 |                             |   |
|                                   | 0 |                             |   |
| -   Mail order                    | g |                             |   |
|                                   | e |                             |   |
|                                   | n |                             |   |
|                                   | e |                             |   |
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|                                   | ; |                             |   |
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|                                   | \ |                             |   |
|                                   | $ |                             |   |
|                                   | 2 |                             |   |
|                                   | 0 |                             |   |
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|                                   | ; |                             |   |
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|                                   | \ |                             |   |
|                                   | $ |                             |   |
|                                   | 3 |                             |   |
|                                   | 0 |                             |   |
|                                   | n |                             |   |
|                                   | o |                             |   |
|                                   | n |                             |   |
|                                   | - |                             |   |
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|                                   |   |                             |   |
|                                   | \ |                             |   |
|                                   | $ |                             |   |
|                                   | 2 |                             |   |
|                                   | 0 |                             |   |
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|                                   | ; |                             |   |
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|                                   | \ |                             |   |
|                                   | $ |                             |   |
|                                   | 4 |                             |   |
|                                   | 0 |                             |   |
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|                                   | l |                             |   |
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|                                   | n |                             |   |
|                                   | a |                             |   |
|                                   | m |                             |   |
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|                                   | r |                             |   |
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|                                   | a |                             |   |
|                                   | y |                             |   |
|                                   | ; |                             |   |
|                                   | \ |                             |   |
|                                   | $ |                             |   |
|                                   | 6 |                             |   |
|                                   | 0 |                             |   |
|                                   | n |                             |   |
|                                   | o |                             |   |
|                                   | n |                             |   |
|                                   | - |                             |   |
|                                   | f |                             |   |
|                                   | o |                             |   |
|                                   | r |                             |   |
|                                   | m |                             |   |
|                                   | u |                             |   |
|                                   | l |                             |   |
|                                   | a |                             |   |
|                                   | r |                             |   |
|                                   | y |                             |   |
|                                   | n |                             |   |
|                                   | a |                             |   |
|                                   | m |                             |   |
|                                   | e |                             |   |
|                                   | b |                             |   |
|                                   | r |                             |   |
|                                   | a |                             |   |
|                                   | n |                             |   |
|                                   | d |                             |   |
|                                   | c |                             |   |
|                                   | o |                             |   |
|                                   | p |                             |   |
|                                   | a |                             |   |
|                                   | y |                             |   |
+-----------------------------------+---+-----------------------------+---+
| Dental Care                       | N |                             | 4 |
|                                   | o |                             | 0 |
| -   Preventive Care               | t |                             |   |
|                                   | h |                             |   |
| -   Other services                | i |                             |   |
|                                   | n |                             |   |
|                                   | g |                             |   |
|                                   |   |                             |   |
|                                   | 8 |                             |   |
|                                   | 0 |                             |   |
|                                   | % |                             |   |
|                                   | o |                             |   |
|                                   | f |                             |   |
|                                   | o |                             |   |
|                                   | u |                             |   |
|                                   | r |                             |   |
|                                   | a |                             |   |
|                                   | l |                             |   |
|                                   | l |                             |   |
|                                   | o |                             |   |
|                                   | w |                             |   |
|                                   | a |                             |   |
|                                   | n |                             |   |
|                                   | c |                             |   |
|                                   | e |                             |   |
+-----------------------------------+---+-----------------------------+---+
| Vision Care                       | \ |                             | 2 |
|                                   | $ |                             | 1 |
| -   One annual routine eye exam   | 1 |                             |   |
|                                   | 0 |                             |   |
|                                   | p |                             |   |
|                                   | e |                             |   |
|                                   | r |                             |   |
|                                   | v |                             |   |
|                                   | i |                             |   |
|                                   | s |                             |   |
|                                   | i |                             |   |
|                                   | t |                             |   |
+-----------------------------------+---+-----------------------------+---+
| Special features:                 |   |                             | > |
|                                   |   |                             |   |
| -   Flexible benefits option      |   |                             | 3 |
|                                   |   |                             | 7 |
| -   24-hour nurse line            |   |                             |   |
|                                   |   |                             |   |
| -   Centers of excellence for     |   |                             |   |
|     transplants/heart surgery     |   |                             |   |
|                                   |   |                             |   |
| -   Reciprocity benefit           |   |                             |   |
|                                   |   |                             |   |
| -   Discount programs             |   |                             |   |
+-----------------------------------+---+-----------------------------+---+
| Protection against catastrophic   |   | Nothing after \$1,500/Self  | > |
| costs                             |   | Only or \$3,000/Family      |   |
|                                   |   | enrollment per year         | 1 |
| (your catastrophic protection     |   |                             | 4 |
| out-of-pocket maximum)            |   | Some costs do not count     |   |
|                                   |   | toward this protection.     |   |
+-----------------------------------+---+-----------------------------+---+

**2004 Rate Information for**

**Blue HMO**

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

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

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

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

+--------------+-----+-------+-------+-------+-------+-------+-------+
| #######      | *   | **    | *     | **    | *     | **    | **\$  |
| ## Self Only | *R5 | \$121 | *\$** | \$263 | *\$** | \$143 | 30    |
|              | 1** | .40** | **52  | .03** | **113 | .32** | .39** |
|              |     |       | .31** |       | .34** |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| #            | *   | **    | **    | **    | **    | **    | *     |
| ######## Sel | *R5 | \$277 | \$154 | \$600 | \$334 | \$327 | *\$** |
| f and Family | 2** | .09** | .34** | .36** | .41** | .12** | **104 |
|              |     |       |       |       |       |       | .31** |
+--------------+-----+-------+-------+-------+-------+-------+-------+