![](media/image1.png){width="1.0in" height="0.8638888888888889in"}
**FIRSTCARE**

[http://www.firstcare.com](http://www.planAddress.org/)

![](media/image2.png){width="1.3984251968503938in"
height="1.3251968503937008in"} **A Health Maintenance Organization**

**Serving: The entire Texas Panhandle and much of West Texas and the
Central Texas area.**

**Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See pages 8-9 for requirements.**

# [West Texas]{.underline}

**Enrollment codes for this Plan:**

**CK1 Self Only**

**CK2 Self and Family**

# [Central Texas]{.underline}

**Enrollment codes for this Plan:**

**6U1 Self Only**

**6U2 Self and Family**

![](media/image3.png) ![](media/image4.png){width="1.1888888888888889in"
height="0.8951388888888889in"}

**RI 73-496**

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Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

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

> Sincerely,
>
> ![](media/image6.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

#  

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

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

# Privacy Practices

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

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice,
look at www.opm.gov/insure 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! 4

Preventing medical
mistakes.........................................................................................................5

Section 1. Facts about this HMO plan 8

How we pay providers 8

Your Rights 8

Service Area 8

Section 2. How we change for
2004............................................... 10

Program-wide
changes.................................................................................................10

Changes to this Plan 10

Section 3. How you get care ............\... 11

Identification cards 11

Where you get covered care 11

• Plan providers 11

• Plan facilities 11

What you must do to get covered care 11

• Primary care 11

• Specialty care 12

• Hospital care 13

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 26

(c) Services provided by a hospital or other facility, and ambulance
    services 30

(d) Emergency services/accidents 33

(e) Mental health and substance abuse benefits 36

(f) Prescription drug benefits 37

(g) Special features 41

-   Services for deaf and hearing impaired 41

-   Centers of excellence for transplants/heart surgery/etc. 41

    h.  Dental benefits 42

Section 6. General exclusions \-- things we don\'t cover 43

Section 7. Filing a claim for covered services 44

Section 8. The disputed claims process 45

Section 9. Coordinating benefits with other coverage 47

When you have other health
coverage...............................................................................47

-   What is Medicare? 47

-   Should I enroll in
    Medicare?..................................................................................47

-   Medicare + Choice 50

-   TRICARE and CHAMPVA 50

-   Workers\' Compensation 51

-   Medicaid 51

-   Other Government agencies 51

-   When others are responsible for injuries 51

Section 10. Definitions of terms we use in this brochure 52

Section 11. FEHB facts 54

Coverage information 54

-   No pre-existing condition limitation 54

-   Where you get information about enrolling in the FEHB Program 54

-   Types of coverage available for you and your family 54

-   Children's Equity Act 55

-   When benefits and premiums start 55

-   When you retire 56

When you lose benefits 56

-   When FEHB coverage ends 56

-   Spouse equity coverage 56

-   Temporary Continuation of Coverage (TCC) 56

-   Converting to individual coverage 57

-   Getting a Certificate of Group Health Plan Coverage 57

Two new Federal Programs complement FEHB
benefits............................................................\...........58

> The Federal Flexible Spending Account Program --
> *FSAFEDS*...............................................58
>
> The Federal Long Term Care Insurance
> Program...............................................................61

Index...................................................................................................................................63

Summary of
benefits................................................................................................................64

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

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  Introduction

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This brochure describes the benefits of FIRSTCARE under our contract (CS
2321) with the Office of Personnel Management (OPM), as authorized by
the Federal Employees Health Benefits law. The address for FIRSTCARE
administrative offices is:

SHA, L.L.C. dba FIRSTCARE

12940 N. Highway 183

Austin, Texas 78750

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

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

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and changes are summarized on
page 10. Rates are shown at the end of this brochure.

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  Plain Language

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

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

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

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

If you have comments or suggestions about how to improve the structure
of this brochure, let OPM know. Visit OPM\'s \"Rate Us\" feedback area
at [www.opm.gov/insure](http://www.opm.gov/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 Programs,
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.

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

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

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

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

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

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

-   If the provider does not resolve the matter, call us at 800-884-4901
    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:

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

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

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

-   You can be prosecuted for fraud and your agency may take action
    against you if you falsify a claim to obtain FEHB benefits to 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 our 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 and
coinsurance 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](http://www.opm.gov/)) lists the specific types of
information that we must make available to you. Some of the required
information is listed below:

-   We have been operational since June, 1986, and we have been
    providing quality healthcare to Federal employees since January 1,
    1988.

-   As a state certified and federally qualified health plan, FIRSTCARE
    is in compliance with all the rules and regulations of these
    governing bodies.

-   FIRSTCARE is a limited liability company.

If you want more information about us, call 800-884-4901, or write to
12940 N. Highway 183, Austin, Texas 78750. You may also contact us by
fax at 877-878-8422 or visit our website at
[www.firstcare.com](http://www.firstcare.com/).

**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:

In **West Texas**, the counties of Andrews, Armstrong, Bailey, Borden,
Brewster, Briscoe, Carson, Castro, Childress, Cochran, Collingsworth,
Cottle, Crane, Crosby, Dallam, Dawson, Deaf Smith, Dickens, Donley,
Ector, Floyd, Gaines, Garza, Glasscock, Gray, Hale, Hall, Hansford,
Hartley, Hemphill, Hockley, Howard, Hutchinson, King, Lamb, Lipscomb,
Loving, Lubbock, Lynn, Martin, Midland, Moore, Motley, Ochiltree,
Oldham, Parmer, Pecos, Potter, Randall, Reagan, Reeves, Roberts, Scurry,
Sherman, Swisher, Terry, Upton, Ward, Wheeler, Winkler, and Yoakum.

In **Central Texas**, the counties of Bell, Bosque, Brazos, Burleson,
Burnet, Coryell, Falls, Freestone, Grimes, Hamilton, Hill, Houston,
Lampasas, Lee, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills,
Navarro, Robertson, San Saba, Somervell, Walker, and Washington.

Ordinarily, you must get your care from providers who contract with us.
If you receive care outside our service area, we will pay only for
emergency care benefits. We will not pay for any other health care
services 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 an HMO that has
agreements with affiliates in other areas. FIRSTCARE will only provide
coverage for emergency care outside our service area. 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 58.

-   We added information regarding Preventing medical mistakes. See page
    5.

-   We added information regarding enrolling Medicare. See page 47.

-   We revised the Medicare Primary Payer Chart. See page 49.

**Changes to this Plan**

-   Your share of the non-Postal premium for Enrollment Code CK will
    increase by 0.7% for Self Only and decrease 0.3% for Self and
    Family. Enrollment Code 6U will increase 21.3% for Self Only or
    21.3% for Self and Family.

-   There are no benefit changes for 2004.

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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
800-884-4901 or write to us at 12940 N. Highway 183, Austin, Texas
78750. You may also request replacement cards through our website at
[www.firstcare.com](http://www.firstcare.com/).

**Where you get covered care** You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and 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.

    FIRSTCARE services are provided through our large network of primary
    care physicians, specialists, contracted hospitals and many other
    health professionals and facilities. FIRSTCARE has been serving FEHB
    employees and eligible dependents since 1988.

We list Plan providers in the provider directory, which we update
periodically, or on our website at
[www.firstcare.com](http://www.firstcare.com/).

-   **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.firstcare.com](http://www.firstcare.com/).

**What you must do** It depends on the type of care you need. First, you
and each family member

**to get covered care** must choose a primary care physician. This
decision is important since your primary care physician provides or
arranges for most of your health care.

> Each female member may select an obstetrician-gynecologist (OB/GYN) in
> addition to her primary care physician. She may go directly to him/her
> for an annual well-woman examination, care for pregnancy and all
> gynecological conditions. The OB/GYN may diagnose, treat and refer for
> any disease or condition within the scope of professional practice of
> a credentialed obstetrician or gynecologist. Remember, you must choose
> your OB/GYN and notify the Plan of your choice prior to your first
> visit.
>
> Services of other providers are covered only when your primary care
> physician has referred you.

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

If you want to change your primary care physician or if your primary
care physician leaves the Plan, call us. We will help you select a new
one.

-   **Specialty care** Your primary care physician will refer you to a
    specialist for needed care. However, you may see your designated
    obstetrician/gynecologist (OB/GYN) or seek emergency care without a
    referral. Your primary care physician will arrange your referral to
    a specialist*.* Referral to a participating specialist is given at
    the primary care physician's discretion, if non-Plan specialists or
    consultants are required, the primary care physician will arrange
    appropriate referrals.

    When you receive a referral from your primary care physician, you
    must return to the primary care physician after the consultation
    unless your doctor authorizes additional visits. The primary care
    physician must provide or authorize all follow-up care. Do not go to
    the specialist for a return visit unless your primary care physician
    gives you a referral, and the Plan has issued an authorization for
    the referral in advance.

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 us to develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals.
Your primary care physician will use our criteria when creating your
treatment plan (the physician may have to get an authorization or
approval beforehand).

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

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

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

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

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

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

-   **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 Services Department immediately at 800-884-4901. 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 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 our control** Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your
services or we may be unable to provide them. In that case, we will make
all reasonable efforts to provide you with the necessary care.

**Services requiring our** Your primary care physician has authority to
refer you for most services.

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

We call this review and approval process preauthorization. Your
physician must obtain preauthorization for certain services, such as
outpatient surgery, inpatient hospital admissions, growth hormone
therapy (GHT) in children with documented growth hormone deficiency
disease, certain prescription drugs, and durable medical equipment (DME)
e.g., oxygen and monitoring devices.

> In some cases, charges for medical procedures may not be covered
> without proper authorization. If you have any questions, call our
> Customer Services Department at 800-884-4901. Remember, when in doubt,
> CALL!

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

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

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

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

Example: When you see your primary care physician you pay a copayment of
\$15 per office visit and when you go to the hospital, you pay \$150 per
inpatient admission.

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

-   **Coinsurance** Coinsurance is the percentage of our negotiated fee
    that you must pay for certain services.

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

+----------------------------+-----------------------------------------+
| **Your catastrophic        | After your copayments and coinsurance   |
| protection out-of-pocket   | total 200% of annual premium per Self   |
| maximum for copayments and | Only enrollment or 200% of annual       |
| coinsurance**              | premium per Self and Family enrollment  |
|                            | in any calendar year, you do not have   |
|                            | to pay any more for covered services.   |
|                            | However, copayments and coinsurance for |
|                            | prescription drugs and Durable Medical  |
|                            | Equipment (DME) do not count toward     |
|                            | your catastrophic protection            |
|                            | out-of-pocket maximum, and you must     |
|                            | continue to pay copayments and          |
|                            | coinsurance for prescription drug and   |
|                            | DME.                                    |
|                            |                                         |
|                            | Be sure to keep accurate records of     |
|                            | your copayments and coinsurance since   |
|                            | you are responsible for informing us    |
|                            | when you reach the maximum.             |
+----------------------------+-----------------------------------------+

+-----------------------------------------------------------------------+
| ####### Section 5. Benefits -- OVERVIEW                               |
|                                                                       |
| ***(See page 10 for how our benefits changed this year and page 64    |
| for a benefits summary.)***                                           |
+-----------------------------------------------------------------------+

**NOTE**: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claims forms,
claims filing advice, or more information about our benefits, contact us
at 800-884-4901 or at our website
[www.firstcare.com](http://www.firstcare.com/).

(a) Medical services and supplies provided by physicians and other
    health care professionals 16-25

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

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals ......26-29

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

(c) Services provided by a hospital or other facility, and ambulance
    services 30-32

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

(d) Emergency services/accidents 33-35

-   Medical emergency  Ambulance

(e) Mental health and substance abuse benefits 36

(f) Prescription drug benefits 37-40

(g) Special features 41

-   Services for deaf and hearing impaired

-   Centers of excellence for transplants/heart surgery/etc.

(h) Dental benefits 42

Summary of benefits 64

+---+---+-----------------------------------------+---+-----------------+---+---+---+
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+---+---+-----------------------------------------+---+-----------------+---+---+---+
|   | # | **Here are some important things to     |   |                 | # |   |   |
|   | # | keep in mind about these benefits:**    |   |                 | # |   |   |
|   | # |                                         |   |                 | # |   |   |
|   | # | -   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.                          |   |                 | # |   |   |
|   |   |                                         |   |                 |   |   |   |
|   | I | -   Plan physicians must provide or     |   |                 | I |   |   |
|   |   |     arrange your care.                  |   |                 |   |   |   |
|   | * |                                         |   |                 | * |   |   |
|   | * | ```{=html}                              |   |                 | * |   |   |
|   | M | <!-- -->                                |   |                 | M |   |   |
|   | * | ```                                     |   |                 | * |   |   |
|   | * | -   Be sure to read Section 4, *Your    |   |                 | * |   |   |
|   |   |     costs for covered services,* for    |   |                 |   |   |   |
|   | * |     valuable information about how cost |   |                 | * |   |   |
|   | * |     sharing works. Also read Section 9  |   |                 | * |   |   |
|   | P |     about coordinating benefits with    |   |                 | P |   |   |
|   | * |     other coverage, including with      |   |                 | * |   |   |
|   | * |     Medicare.                           |   |                 | * |   |   |
|   |   |                                         |   |                 |   |   |   |
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+---+---+-----------------------------------------+---+-----------------+---+---+---+
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+---+---+-----------------------------------------+---+-----------------+---+---+---+
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+---+---+-----------------------------------------+---+-----------------+---+---+---+
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+---+---+-----------------------------------------+---+-----------------+---+---+---+
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| m |   |                                         |   |                 |   |   |   |
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|   |   |                                         |   |                 |   |   |   |
| a |   |                                         |   |                 |   |   |   |
| n |   |                                         |   |                 |   |   |   |
| d |   |                                         |   |                 |   |   |   |
|   |   |                                         |   |                 |   |   |   |
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|   |   |                                         |   |                 |   |   |   |
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| G |   |                                         |   |                 |   |   |   |
+---+---+-----------------------------------------+---+-----------------+---+---+---+

+-----------------------------------------------+----------------------+
| ##### Preventive care, adult                  | > **You pay**        |
+-----------------------------------------------+----------------------+
| > Routine screenings, such as:                | > Nothing if you     |
|                                               | > receive these      |
| -   Fasting lipoprotein profile (total        | > services during    |
|     cholesterol, LDL, HDL and triglycerides)  | > your office visit. |
|     -- once every 3 years for adults age 20   |                      |
|     or over;                                  |                      |
|                                               |                      |
| ```{=html}                                    |                      |
| <!-- -->                                      |                      |
| ```                                           |                      |
| -   Colorectal Cancer Screening, including:   |                      |
|                                               |                      |
|     -   Fecal occult blood test               |                      |
|                                               |                      |
|     -   Sigmoidoscopy, screening -- every     |                      |
|         five years starting at age 50         |                      |
|                                               |                      |
|     -   Colonoscopy -- once every 10 years at |                      |
|         age 50; or                            |                      |
|                                               |                      |
|     -   Double contrast barium enema (DCBE)   |                      |
|         -- once every 5-10 years at age 50;   |                      |
|                                               |                      |
| ```{=html}                                    |                      |
| <!-- -->                                      |                      |
| ```                                           |                      |
| -   Routine Prostate Specific Antigen (PSA)   |                      |
|     test -- one annually for men age 40 and   |                      |
|     older;                                    |                      |
|                                               |                      |
| -   Routine PAP test                          |                      |
|                                               |                      |
| -   Routine mammogram -- covered for women    |                      |
|     age 35 and older, as follows:             |                      |
|                                               |                      |
| ```{=html}                                    |                      |
| <!-- -->                                      |                      |
| ```                                           |                      |
| -   From age 35 to 39, one during this five   |                      |
|     year period                               |                      |
|                                               |                      |
| -   From age 40 through 64, one every         |                      |
|     calendar year                             |                      |
|                                               |                      |
| -   At age 65 and older, one every two        |                      |
|     consecutive calendar years                |                      |
|                                               |                      |
| ```{=html}                                    |                      |
| <!-- -->                                      |                      |
| ```                                           |                      |
| -   Bone mass measurement services for the    |                      |
|     detection of low bone mass and to         |                      |
|     determine the risk of osteoporosis.       |                      |
|                                               |                      |
| -   Routine immunizations according to        |                      |
|     generally accepted medical practice       |                      |
|     standards and the U.S. Public Health      |                      |
|     Service for people in the United States,  |                      |
|     including immunizations for travel        |                      |
|     outside the United States.                |                      |
|                                               |                      |
| ```{=html}                                    |                      |
| <!-- -->                                      |                      |
| ```                                           |                      |
| -   Annual influenza vaccines                 |                      |
|                                               |                      |
| -   Pneumococcal vaccine, age 65 and over     |                      |
|                                               |                      |
| -   Tetanus-diphtheria (Td) booster -- once   |                      |
|     every 10 years, ages19 and over (except   |                      |
|     as provided for under Childhood           |                      |
|     immunizations)                            |                      |
|                                               |                      |
| > • Eye screenings, biennially, for members   |                      |
| > age 19 and older for the purpose of         |                      |
| > determining vision loss                     |                      |
| >                                             |                      |
| > • Hearing screenings, biennially, for       |                      |
| > members age 19 and older for the purpose of |                      |
| > determining hearing loss                    |                      |
|                                               |                      |
| -   Speech screenings, biennially, for        |                      |
|     members age 19 and older for the purpose  |                      |
|     of determining speech impairment          |                      |
+-----------------------------------------------+----------------------+
| > *Not Covered: Physical exams, health        | *All charges*        |
| > reports and/or treatments required for      |                      |
| > employment, insurance, school, camp,        |                      |
| > travel, flight clearance, sports or legal   |                      |
| > proceedings*                                |                      |
+-----------------------------------------------+----------------------+

+--------------------------------------------+---+---+---+-----------------+---+---+---+
| #####  Preventive care, children           | * |   |   |                 |   |   |   |
|                                            | * |   |   |                 |   |   |   |
|                                            | Y |   |   |                 |   |   |   |
|                                            | o |   |   |                 |   |   |   |
|                                            | u |   |   |                 |   |   |   |
|                                            | p |   |   |                 |   |   |   |
|                                            | a |   |   |                 |   |   |   |
|                                            | y |   |   |                 |   |   |   |
|                                            | * |   |   |                 |   |   |   |
|                                            | * |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| -   Childhood immunizations recommended by | N |   |   |                 |   |   |   |
|     the American Academy of Pediatrics and | o |   |   |                 |   |   |   |
|     those required by the Texas Department | t |   |   |                 |   |   |   |
|     of Health                              | h |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | n |   |   |                 |   |   |   |
|                                            | g |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| ######## Well-c                            | # |   |   |                 |   |   |   |
| hild care charges for routine examinations | # |   |   |                 |   |   |   |
| , immunizations and care (through age 22). | # |   |   |                 |   |   |   |
|                                            | # |   |   |                 |   |   |   |
|                                            | # |   |   |                 |   |   |   |
|                                            | # |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | \ |   |   |                 |   |   |   |
|                                            | $ |   |   |                 |   |   |   |
|                                            | 1 |   |   |                 |   |   |   |
|                                            | 5 |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | p |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | o |   |   |                 |   |   |   |
|                                            | f |   |   |                 |   |   |   |
|                                            | f |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | c |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | v |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | s |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | t |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | t |   |   |                 |   |   |   |
|                                            | o |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | y |   |   |                 |   |   |   |
|                                            | o |   |   |                 |   |   |   |
|                                            | u |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | p |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | m |   |   |                 |   |   |   |
|                                            | a |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
|                                            | y |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | c |   |   |                 |   |   |   |
|                                            | a |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | p |   |   |                 |   |   |   |
|                                            | h |   |   |                 |   |   |   |
|                                            | y |   |   |                 |   |   |   |
|                                            | s |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | c |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | a |   |   |                 |   |   |   |
|                                            | n |   |   |                 |   |   |   |
|                                            | ; |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | \ |   |   |                 |   |   |   |
|                                            | $ |   |   |                 |   |   |   |
|                                            | 2 |   |   |                 |   |   |   |
|                                            | 5 |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | t |   |   |                 |   |   |   |
|                                            | o |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | a |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            | s |   |   |                 |   |   |   |
|                                            | p |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | c |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | a |   |   |                 |   |   |   |
|                                            | l |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | s |   |   |                 |   |   |   |
|                                            | t |   |   |                 |   |   |   |
|                                            | . |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| -   Examinations, such as:                 | N |   |   |                 |   |   |   |
|                                            | o |   |   |                 |   |   |   |
| > \- Eye screenings, annually, through age | t |   |   |                 |   |   |   |
| > 18 to determine vision loss.             | h |   |   |                 |   |   |   |
| >                                          | i |   |   |                 |   |   |   |
| > \- Ear screenings, annually, through age | n |   |   |                 |   |   |   |
| > 18 to determine hearing loss.            | g |   |   |                 |   |   |   |
| >                                          | i |   |   |                 |   |   |   |
| > \- Speech screenings, annually, through  | f |   |   |                 |   |   |   |
| > age 18 to determine speech impairment    | y |   |   |                 |   |   |   |
|                                            | o |   |   |                 |   |   |   |
|                                            | u |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | c |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | v |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | t |   |   |                 |   |   |   |
|                                            | h |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | s |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | s |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
|                                            | v |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | c |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | s |   |   |                 |   |   |   |
|                                            | d |   |   |                 |   |   |   |
|                                            | u |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | n |   |   |                 |   |   |   |
|                                            | g |   |   |                 |   |   |   |
|                                            | y |   |   |                 |   |   |   |
|                                            | o |   |   |                 |   |   |   |
|                                            | u |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
|                                            | o |   |   |                 |   |   |   |
|                                            | f |   |   |                 |   |   |   |
|                                            | f |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | c |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | v |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | s |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | t |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| ######## Maternity care                    |   |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| > Complete maternity (obstetrical) care,   | N |   |   |                 |   |   |   |
| > such as:                                 | o |   |   |                 |   |   |   |
|                                            | t |   |   |                 |   |   |   |
| -   Prenatal care                          | h |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
| ```{=html}                                 | n |   |   |                 |   |   |   |
| <!-- -->                                   | g |   |   |                 |   |   |   |
| ```                                        | f |   |   |                 |   |   |   |
| -   Delivery                               | o |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
| -   Postnatal care                         | p |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
| > Note: Here are some things to keep in    | e |   |   |                 |   |   |   |
| > mind:                                    | - |   |   |                 |   |   |   |
|                                            | a |   |   |                 |   |   |   |
| -   Your physician will pre-authorize your | n |   |   |                 |   |   |   |
|     normal delivery; see page 13 for other | d |   |   |                 |   |   |   |
|     circumstances, such as extended stays  | p |   |   |                 |   |   |   |
|     for you or your baby.                  | o |   |   |                 |   |   |   |
|                                            | s |   |   |                 |   |   |   |
| -   You may remain in the hospital up to   | t |   |   |                 |   |   |   |
|     48 hours after a regular delivery and  | - |   |   |                 |   |   |   |
|     96 hours after a cesarean delivery. We | n |   |   |                 |   |   |   |
|     will extend your inpatient stay if     | a |   |   |                 |   |   |   |
|     medically necessary.                   | t |   |   |                 |   |   |   |
|                                            | a |   |   |                 |   |   |   |
| ```{=html}                                 | l |   |   |                 |   |   |   |
| <!-- -->                                   | c |   |   |                 |   |   |   |
| ```                                        | a |   |   |                 |   |   |   |
| -   We cover routine nursery care of the   | r |   |   |                 |   |   |   |
|     newborn child during the covered       | e |   |   |                 |   |   |   |
|     portion of the mother's maternity      | ; |   |   |                 |   |   |   |
|     stay. We will cover other care of an   | \ |   |   |                 |   |   |   |
|     infant who requires non-routine        | $ |   |   |                 |   |   |   |
|     treatment only if we cover the infant  | 1 |   |   |                 |   |   |   |
|     under a Self and Family enrollment.    | 0 |   |   |                 |   |   |   |
|                                            | 0 |   |   |                 |   |   |   |
| ```{=html}                                 | i |   |   |                 |   |   |   |
| <!-- -->                                   | n |   |   |                 |   |   |   |
| ```                                        | p |   |   |                 |   |   |   |
| -   We pay hospitalization and surgeon     | a |   |   |                 |   |   |   |
|     services (delivery) the same as for    | t |   |   |                 |   |   |   |
|     illness and injury. See Hospital       | i |   |   |                 |   |   |   |
|     benefits (Section 5c) and Surgery      | e |   |   |                 |   |   |   |
|     benefits (Section 5b)*.*               | n |   |   |                 |   |   |   |
|                                            | t |   |   |                 |   |   |   |
|                                            | c |   |   |                 |   |   |   |
|                                            | o |   |   |                 |   |   |   |
|                                            | p |   |   |                 |   |   |   |
|                                            | a |   |   |                 |   |   |   |
|                                            | y |   |   |                 |   |   |   |
|                                            | a |   |   |                 |   |   |   |
|                                            | p |   |   |                 |   |   |   |
|                                            | p |   |   |                 |   |   |   |
|                                            | l |   |   |                 |   |   |   |
|                                            | i |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | s |   |   |                 |   |   |   |
|                                            | . |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| -   *Not covered: Sonograms to determine   | * |   |   |                 |   |   |   |
|     fetal sex*                             | A |   |   |                 |   |   |   |
|                                            | l |   |   |                 |   |   |   |
|                                            | l |   |   |                 |   |   |   |
|                                            | c |   |   |                 |   |   |   |
|                                            | h |   |   |                 |   |   |   |
|                                            | a |   |   |                 |   |   |   |
|                                            | r |   |   |                 |   |   |   |
|                                            | g |   |   |                 |   |   |   |
|                                            | e |   |   |                 |   |   |   |
|                                            | s |   |   |                 |   |   |   |
|                                            | * |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| ######## Family planning                   |   | * |   |                 |   |   |   |
|                                            |   | * |   |                 |   |   |   |
|                                            |   | Y |   |                 |   |   |   |
|                                            |   | o |   |                 |   |   |   |
|                                            |   | u |   |                 |   |   |   |
|                                            |   | p |   |                 |   |   |   |
|                                            |   | a |   |                 |   |   |   |
|                                            |   | y |   |                 |   |   |   |
|                                            |   | * |   |                 |   |   |   |
|                                            |   | * |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| > A range of voluntary family planning     |   | \ |   |                 |   |   |   |
| > services, limited to:                    |   | $ |   |                 |   |   |   |
|                                            |   | 1 |   |                 |   |   |   |
| -   Voluntary sterilization (See Surgical  |   | 5 |   |                 |   |   |   |
|     procedures, Section 5 (b))             |   | p |   |                 |   |   |   |
|                                            |   | e |   |                 |   |   |   |
| -   Surgically implanted contraceptives    |   | r |   |                 |   |   |   |
|     (such as, Norplant).                   |   | v |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
| -   Injectable contraceptive drugs (such   |   | s |   |                 |   |   |   |
|     as, Depo Provera)                      |   | i |   |                 |   |   |   |
|                                            |   | t |   |                 |   |   |   |
| -   Diaphragms                             |   | t |   |                 |   |   |   |
|                                            |   | o |   |                 |   |   |   |
| -   Intrauterine devices (IUDs)            |   | y |   |                 |   |   |   |
|                                            |   | o |   |                 |   |   |   |
| > Note: We cover oral contraceptives under |   | u |   |                 |   |   |   |
| > the prescription drug benefit. There is  |   | r |   |                 |   |   |   |
| > no charge when Norplant is implanted     |   | p |   |                 |   |   |   |
| > during a covered hospitalization. We     |   | r |   |                 |   |   |   |
| > will not refund any portion of the       |   | i |   |                 |   |   |   |
| > coinsurance if the implanted             |   | m |   |                 |   |   |   |
| > time-release medication is removed       |   | a |   |                 |   |   |   |
| > before the end of its expected life.     |   | r |   |                 |   |   |   |
|                                            |   | y |   |                 |   |   |   |
|                                            |   | c |   |                 |   |   |   |
|                                            |   | a |   |                 |   |   |   |
|                                            |   | r |   |                 |   |   |   |
|                                            |   | e |   |                 |   |   |   |
|                                            |   | p |   |                 |   |   |   |
|                                            |   | h |   |                 |   |   |   |
|                                            |   | y |   |                 |   |   |   |
|                                            |   | s |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | c |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | a |   |                 |   |   |   |
|                                            |   | n |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            |   | \ |   |                 |   |   |   |
|                                            |   | $ |   |                 |   |   |   |
|                                            |   | 2 |   |                 |   |   |   |
|                                            |   | 5 |   |                 |   |   |   |
|                                            |   | p |   |                 |   |   |   |
|                                            |   | e |   |                 |   |   |   |
|                                            |   | r |   |                 |   |   |   |
|                                            |   | v |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | s |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | t |   |                 |   |   |   |
|                                            |   | t |   |                 |   |   |   |
|                                            |   | o |   |                 |   |   |   |
|                                            |   | a |   |                 |   |   |   |
|                                            |   | s |   |                 |   |   |   |
|                                            |   | p |   |                 |   |   |   |
|                                            |   | e |   |                 |   |   |   |
|                                            |   | c |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | a |   |                 |   |   |   |
|                                            |   | l |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | s |   |                 |   |   |   |
|                                            |   | t |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            |   | 2 |   |                 |   |   |   |
|                                            |   | 0 |   |                 |   |   |   |
|                                            |   | % |   |                 |   |   |   |
|                                            |   | o |   |                 |   |   |   |
|                                            |   | f |   |                 |   |   |   |
|                                            |   | c |   |                 |   |   |   |
|                                            |   | h |   |                 |   |   |   |
|                                            |   | a |   |                 |   |   |   |
|                                            |   | r |   |                 |   |   |   |
|                                            |   | g |   |                 |   |   |   |
|                                            |   | e |   |                 |   |   |   |
|                                            |   | s |   |                 |   |   |   |
|                                            |   | f |   |                 |   |   |   |
|                                            |   | o |   |                 |   |   |   |
|                                            |   | r |   |                 |   |   |   |
|                                            |   | a |   |                 |   |   |   |
|                                            |   | l |   |                 |   |   |   |
|                                            |   | l |   |                 |   |   |   |
|                                            |   | s |   |                 |   |   |   |
|                                            |   | e |   |                 |   |   |   |
|                                            |   | r |   |                 |   |   |   |
|                                            |   | v |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | c |   |                 |   |   |   |
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|                                            |   | r |   |                 |   |   |   |
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|                                            |   | i |   |                 |   |   |   |
|                                            |   | a |   |                 |   |   |   |
|                                            |   | t |   |                 |   |   |   |
|                                            |   | e |   |                 |   |   |   |
|                                            |   | o |   |                 |   |   |   |
|                                            |   | f |   |                 |   |   |   |
|                                            |   | f |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | c |   |                 |   |   |   |
|                                            |   | e |   |                 |   |   |   |
|                                            |   | v |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | s |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | t |   |                 |   |   |   |
|                                            |   | c |   |                 |   |   |   |
|                                            |   | o |   |                 |   |   |   |
|                                            |   | p |   |                 |   |   |   |
|                                            |   | a |   |                 |   |   |   |
|                                            |   | y |   |                 |   |   |   |
|                                            |   | m |   |                 |   |   |   |
|                                            |   | e |   |                 |   |   |   |
|                                            |   | n |   |                 |   |   |   |
|                                            |   | t |   |                 |   |   |   |
|                                            |   | , |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | f |   |                 |   |   |   |
|                                            |   | a |   |                 |   |   |   |
|                                            |   | p |   |                 |   |   |   |
|                                            |   | p |   |                 |   |   |   |
|                                            |   | l |   |                 |   |   |   |
|                                            |   | i |   |                 |   |   |   |
|                                            |   | c |   |                 |   |   |   |
|                                            |   | a |   |                 |   |   |   |
|                                            |   | b |   |                 |   |   |   |
|                                            |   | l |   |                 |   |   |   |
|                                            |   | e |   |                 |   |   |   |
|                                            |   | . |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| > *Not covered: reversal of voluntary      |   |   | > |                 |   |   |   |
| > surgical sterilization, genetic          |   |   |   |                 |   |   |   |
| > counseling and testing, except for       |   |   | * |                 |   |   |   |
| > medically necessary prenatal genetic     |   |   | A |                 |   |   |   |
| > testing.*                                |   |   | l |                 |   |   |   |
|                                            |   |   | l |                 |   |   |   |
|                                            |   |   | > |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            |   |   | c |                 |   |   |   |
|                                            |   |   | h |                 |   |   |   |
|                                            |   |   | a |                 |   |   |   |
|                                            |   |   | r |                 |   |   |   |
|                                            |   |   | g |                 |   |   |   |
|                                            |   |   | e |                 |   |   |   |
|                                            |   |   | s |                 |   |   |   |
|                                            |   |   | * |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| ######## Infertility services              |   |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| > Diagnosis and treatment of infertility,  |   |   | 5 |                 |   |   |   |
| > such as:                                 |   |   | 0 |                 |   |   |   |
|                                            |   |   | % |                 |   |   |   |
| -   Artificial insemination:               |   |   | o |                 |   |   |   |
|                                            |   |   | f |                 |   |   |   |
| > \- intravaginal insemination (IVI)       |   |   | c |                 |   |   |   |
| >                                          |   |   | h |                 |   |   |   |
| > \- intracervical insemination (ICI)      |   |   | a |                 |   |   |   |
| >                                          |   |   | r |                 |   |   |   |
| > \- intrauterine insemina­tion (IUI)       |   |   | g |                 |   |   |   |
|                                            |   |   | e |                 |   |   |   |
| -   Lab and x-ray services                 |   |   | s |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| > *Not Covered:*                           |   |   | > |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
| -   *Assisted reproductive technology      |   |   | * |                 |   |   |   |
|     (ART) procedures, such as:*            |   |   | A |                 |   |   |   |
|                                            |   |   | l |                 |   |   |   |
| > *- In vitro fertilization*               |   |   | l |                 |   |   |   |
| >                                          |   |   | > |                 |   |   |   |
| > *- Fertility drugs*                      |   |   |   |                 |   |   |   |
| >                                          |   |   | c |                 |   |   |   |
| > *- Embryo transfer, gamete GIFT and      |   |   | h |                 |   |   |   |
| > zygote ZIFT*                             |   |   | a |                 |   |   |   |
| >                                          |   |   | r |                 |   |   |   |
| > *- Zygote transfer*                      |   |   | g |                 |   |   |   |
|                                            |   |   | e |                 |   |   |   |
| -   *Services and supplies related to      |   |   | s |                 |   |   |   |
|     excluded ART procedures*               |   |   | * |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
| -   *Surrogate parenting fees*             |   |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
| -   *Cost of donor sperm*                  |   |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
| -   *Cost of donor egg*                    |   |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| > **Allergy care**                         |   |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| -   Testing and treatment                  |   |   | \ |                 |   |   |   |
|                                            |   |   | $ |                 |   |   |   |
|                                            |   |   | 2 |                 |   |   |   |
|                                            |   |   | 5 |                 |   |   |   |
|                                            |   |   | p |                 |   |   |   |
|                                            |   |   | e |                 |   |   |   |
|                                            |   |   | r |                 |   |   |   |
|                                            |   |   | o |                 |   |   |   |
|                                            |   |   | f |                 |   |   |   |
|                                            |   |   | f |                 |   |   |   |
|                                            |   |   | i |                 |   |   |   |
|                                            |   |   | c |                 |   |   |   |
|                                            |   |   | e |                 |   |   |   |
|                                            |   |   | v |                 |   |   |   |
|                                            |   |   | i |                 |   |   |   |
|                                            |   |   | s |                 |   |   |   |
|                                            |   |   | i |                 |   |   |   |
|                                            |   |   | t |                 |   |   |   |
|                                            |   |   | t |                 |   |   |   |
|                                            |   |   | o |                 |   |   |   |
|                                            |   |   | a |                 |   |   |   |
|                                            |   |   | s |                 |   |   |   |
|                                            |   |   | p |                 |   |   |   |
|                                            |   |   | e |                 |   |   |   |
|                                            |   |   | c |                 |   |   |   |
|                                            |   |   | i |                 |   |   |   |
|                                            |   |   | a |                 |   |   |   |
|                                            |   |   | l |                 |   |   |   |
|                                            |   |   | i |                 |   |   |   |
|                                            |   |   | s |                 |   |   |   |
|                                            |   |   | t |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| -   Allergy injection, when administered   |   |   | 5 |                 |   |   |   |
|     without an office visit.               |   |   | 0 |                 |   |   |   |
|                                            |   |   | % |                 |   |   |   |
|                                            |   |   | o |                 |   |   |   |
|                                            |   |   | f |                 |   |   |   |
|                                            |   |   | c |                 |   |   |   |
|                                            |   |   | h |                 |   |   |   |
|                                            |   |   | a |                 |   |   |   |
|                                            |   |   | r |                 |   |   |   |
|                                            |   |   | g |                 |   |   |   |
|                                            |   |   | e |                 |   |   |   |
|                                            |   |   | s |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| -   Allergy serum                          |   |   | N |                 |   |   |   |
|                                            |   |   | o |                 |   |   |   |
|                                            |   |   | t |                 |   |   |   |
|                                            |   |   | h |                 |   |   |   |
|                                            |   |   | i |                 |   |   |   |
|                                            |   |   | n |                 |   |   |   |
|                                            |   |   | g |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| > *Not covered: provocative food testing   |   |   | > |                 |   |   |   |
| > and sublingual allergy desensitization*  |   |   |   |                 |   |   |   |
|                                            |   |   | * |                 |   |   |   |
|                                            |   |   | A |                 |   |   |   |
|                                            |   |   | l |                 |   |   |   |
|                                            |   |   | l |                 |   |   |   |
|                                            |   |   | > |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
|                                            |   |   | c |                 |   |   |   |
|                                            |   |   | h |                 |   |   |   |
|                                            |   |   | a |                 |   |   |   |
|                                            |   |   | r |                 |   |   |   |
|                                            |   |   | g |                 |   |   |   |
|                                            |   |   | e |                 |   |   |   |
|                                            |   |   | s |                 |   |   |   |
|                                            |   |   | * |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| ######## Treatment therapies               |   |   |   | **You pay**     |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| -   Chemotherapy and radiation therapy     |   |   |   | > \$15 copay    |   |   |   |
|                                            |   |   |   | > per primary   |   |   |   |
| > Note: High dose chemotherapy in          |   |   |   | > care office   |   |   |   |
| > association with autologous bone marrow  |   |   |   | > visit; \$25   |   |   |   |
| > transplants is limited to those          |   |   |   | > copay per     |   |   |   |
| > transplants listed under Organ/Tissue    |   |   |   | > specialist    |   |   |   |
| > Transplants on page 28.                  |   |   |   | > office visit; |   |   |   |
|                                            |   |   |   | > \$50 copay    |   |   |   |
| -   Respiratory and inhalation therapy     |   |   |   | > per           |   |   |   |
|                                            |   |   |   | > outpatient    |   |   |   |
| -   Dialysis -- hemodialysis and           |   |   |   | > facility      |   |   |   |
|     peritoneal dialysis                    |   |   |   | > visit or      |   |   |   |
|                                            |   |   |   | > \$100 copay   |   |   |   |
| -   Intravenous (IV)/Infusion Therapy --   |   |   |   | > per inpatient |   |   |   |
|     Home IV and antibiotic therapy         |   |   |   | > admission.    |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| -   Growth hormone therapy (GHT) for       |   |   |   | Nothing         |   |   |   |
|     children with growth hormone           |   |   |   |                 |   |   |   |
|     deficiency disease.                    |   |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
| > We will only cover GHT and growth        |   |   |   |                 |   |   |   |
| > hormone when we authorize the treatment  |   |   |   |                 |   |   |   |
| > of documented growth hormone deficiency  |   |   |   |                 |   |   |   |
| > in children. We will ask your physician  |   |   |   |                 |   |   |   |
| > to submit information that establishes   |   |   |   |                 |   |   |   |
| > that the GHT is medically necessary.     |   |   |   |                 |   |   |   |
| > Your physician needs to authorize GHT    |   |   |   |                 |   |   |   |
| > before treatment begins; otherwise, we   |   |   |   |                 |   |   |   |
| > will only cover GHT services from the    |   |   |   |                 |   |   |   |
| > date your physician submits the          |   |   |   |                 |   |   |   |
| > information. If your physician does not  |   |   |   |                 |   |   |   |
| > ask or if we determine GHT is not        |   |   |   |                 |   |   |   |
| > medically necessary, we will not cover   |   |   |   |                 |   |   |   |
| > the GHT or related services and          |   |   |   |                 |   |   |   |
| > supplies. See *Services requiring our    |   |   |   |                 |   |   |   |
| > prior approval* in Section 3.            |   |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| > **Physical and occupational therapies**  |   |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| -   Physical therapy and occupational      |   |   |   | \$25 per office |   |   |   |
|     therapy services for each of the       |   |   |   | visit; \$50 per |   |   |   |
|     following:                             |   |   |   | outpatient      |   |   |   |
|                                            |   |   |   | visit; included |   |   |   |
| > \- Qualified physical therapists; and    |   |   |   | in the \$100    |   |   |   |
| >                                          |   |   |   | inpatient       |   |   |   |
| > \- Occupational therapists.              |   |   |   | admission       |   |   |   |
| >                                          |   |   |   | copay.          |   |   |   |
| > 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 must be provided   |   |   |   |                 |   |   |   |
| > at a Plan facility, and is covered for   |   |   |   |                 |   |   |   |
| > up to two months per condition, or for   |   |   |   |                 |   |   |   |
| > up to 60 days per condition per calendar |   |   |   |                 |   |   |   |
| > year, whichever is greater, if           |   |   |   |                 |   |   |   |
| > significant improvement can be expected  |   |   |   |                 |   |   |   |
| > within that time.                        |   |   |   |                 |   |   |   |
| >                                          |   |   |   |                 |   |   |   |
| > Note: Your coverage is limited to        |   |   |   |                 |   |   |   |
| > services that continue to meet or exceed |   |   |   |                 |   |   |   |
| > the treatment goals established for you. |   |   |   |                 |   |   |   |
| > For a physically disabled person,        |   |   |   |                 |   |   |   |
| > treatment goals may include maintenance  |   |   |   |                 |   |   |   |
| > of functioning or prevention of or       |   |   |   |                 |   |   |   |
| > slowing of other deterioration.          |   |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+
| > *Not covered:*                           |   |   |   | > *All charges* |   |   |   |
|                                            |   |   |   |                 |   |   |   |
| -   *long-term rehabilitative therapy*     |   |   |   |                 |   |   |   |
|                                            |   |   |   |                 |   |   |   |
| -   *exercise programs*                    |   |   |   |                 |   |   |   |
+--------------------------------------------+---+---+---+-----------------+---+---+---+

+----------------------------------------------+-----------------------+
| ######## Speech therapy                      | **You pay**           |
+----------------------------------------------+-----------------------+
| -   Speech therapy services provided by a    | > \$25 per office     |
|     speech therapist                         | > visit; \$50per      |
|                                              | > outpatient visit;   |
|                                              | > included in the     |
|                                              | > \$100 inpatient     |
|                                              | > admission copay.    |
+----------------------------------------------+-----------------------+
| > **Hearing services (testing, treatment,    |                       |
| > and supplies)**                            |                       |
+----------------------------------------------+-----------------------+
| -   Hearing screenings, annually, for        | \$15 per office visit |
|     children through age 18 (see *Preventive | to your primary care  |
|     care, children*)                         | physician             |
|                                              |                       |
| -   Hearing screenings, biennially, for      | \$25 per office visit |
|     members age 19 and older (see            | to a specialist       |
|     *Preventive care, adult*)                |                       |
+----------------------------------------------+-----------------------+
| -   Hearing aids                             | Nothing up to Plan    |
|                                              | maximum of \$500 per  |
| > Note: Must be medically necessary as       | ear once every 36     |
| > determined by a Plan physician, authorized | months; all charges   |
| > in advance by the Plan, and obtained from  | over \$500 per ear.   |
| > a Plan provider.                           |                       |
+----------------------------------------------+-----------------------+
| > *Not covered:*                             | > *All charges*       |
|                                              |                       |
| -   *Repair or replacement of hearing aids   |                       |
|     due to normal wear and tear and loss or  |                       |
|     damage*                                  |                       |
+----------------------------------------------+-----------------------+
| > **Vision services (testing, treatment, and |                       |
| > supplies)**                                |                       |
+----------------------------------------------+-----------------------+
| -   Eye screenings, annually, for children   | Nothing if you        |
|     through age 18 to determine vision loss  | receive these         |
|     (see *Preventive care, children*)        | services during your  |
|                                              | primary care          |
| -   Eye screenings, biennially, for members  | physician office      |
|     age 19 and older to determine vision     | visit                 |
|     loss (see *Preventive care, adult*)      |                       |
+----------------------------------------------+-----------------------+
| > *Not Covered:*                             | > *All charges*       |
|                                              |                       |
| -   *Eyeglasses, frames, or contact lenses   |                       |
|     (including the fitting of contact        |                       |
|     lenses), except as necessary for the     |                       |
|     first pair of corrective lenses          |                       |
|     following cataract removal*              |                       |
|                                              |                       |
| -   *Eye exercises and orthoptics*           |                       |
|                                              |                       |
| -   *Radial keratotomy and other refractive  |                       |
|     surgery*                                 |                       |
|                                              |                       |
| -   *Refractions, including lens             |                       |
|     prescriptions, to determine the need for |                       |
|     glasses or contacts.*                    |                       |
+----------------------------------------------+-----------------------+

+------------------------------------------------+---------------------+
| ######## Foot care                             | **You pay**         |
+------------------------------------------------+---------------------+
| > Routine foot care when you are under active  | \$15 per visit to   |
| > treatment for a metabolic or peripheral      | your primary care   |
| > vascular disease, such as diabetes.          | physician           |
| >                                              |                     |
| > See Orthopedic and prosthetic devices for    | \$25 per visit to a |
| > information on podiatric shoe inserts.       | specialist          |
+------------------------------------------------+---------------------+
| > *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, |                     |
|     spurs, and of any instability, imbalance   |                     |
|     or subluxation of the foot (unless the     |                     |
|     treatment is by open cutting surgery.*     |                     |
+------------------------------------------------+---------------------+
| > **Orthopedic and prosthetic devices**        |                     |
+------------------------------------------------+---------------------+
| -   Artificial limbs and eyes; stump hose      | 20% of charges      |
|                                                |                     |
| -   Externally worn breast prostheses and      |                     |
|     surgical bras, including necessary         |                     |
|     replacements, following a mastectomy       |                     |
|                                                |                     |
| -   Corrective orthopedic appliances for       |                     |
|     non-dental treatment of temporomandibular  |                     |
|     joint (TMJ) pain dysfunction syndrome.     |                     |
|                                                |                     |
| -   Foot orthotics                             |                     |
|                                                |                     |
| -   Podiatric appliances for the prevention of |                     |
|     complications associated with diabetes.    |                     |
|                                                |                     |
| > • Braces (limb or back only)                 |                     |
+------------------------------------------------+---------------------+
| -   Internal prosthetic devices, such as       | Nothing             |
|     artificial joints, pacemakers, surgically  |                     |
|     implanted breast implant following         |                     |
|     mastectomy, and implanted lenses during    |                     |
|     cataract surgery. Note: See 5(b) for       |                     |
|     coverage of the surgery to insert the      |                     |
|     device.                                    |                     |
+------------------------------------------------+---------------------+
| > *Not Covered:*                               | *All charges*       |
|                                                |                     |
| -   *Orthopedic and corrective shoes*          |                     |
|                                                |                     |
| -   *Arch supports*                            |                     |
|                                                |                     |
| -   *Heel pads and heel cups*                  |                     |
|                                                |                     |
| -   *Lumbosacral supports*                     |                     |
|                                                |                     |
| -   *Corsets, trusses, elastic stockings,      |                     |
|     support hose, and other supportive         |                     |
|     devices*                                   |                     |
|                                                |                     |
| -   *Prosthetic repairs, maintenance or        |                     |
|     replacements, except for breast            |                     |
|     prostheses; and standard replacements      |                     |
|     needed because of physical growth by       |                     |
|     dependents under 18 years of age*.         |                     |
|                                                |                     |
| -   *Cochlear implanted device*                |                     |
|                                                |                     |
| -   *Wigs or prosthetic hair*                  |                     |
|                                                |                     |
| -   *Implanted neurological stimulators,       |                     |
|     including but not limited to spinal or     |                     |
|     dorsal column stimulators for relief of    |                     |
|     pain, Parkinson's, movement disorders or   |                     |
|     seizures.*                                 |                     |
+------------------------------------------------+---------------------+

+------------------------------------------------+---------------------+
| ######## Durable medical equipment (DME)       | **You pay**         |
+------------------------------------------------+---------------------+
| ######## Rental or purchase, at our option     | > 20% of charges    |
| , including repair and adjustment, of durable  |                     |
| medical equipment prescribed by your Plan phys |                     |
| ician, such as oxygen (see below) and dialysis |                     |
|  equipment. Under this benefit, we also cover: |                     |
|                                                |                     |
| -   Manual hospital beds                       |                     |
|                                                |                     |
| ```{=html}                                     |                     |
| <!-- -->                                       |                     |
| ```                                            |                     |
| -   Manual wheelchairs                         |                     |
|                                                |                     |
| ```{=html}                                     |                     |
| <!-- -->                                       |                     |
| ```                                            |                     |
| -   Crutches                                   |                     |
|                                                |                     |
| -   Canes                                      |                     |
|                                                |                     |
| -   Walkers                                    |                     |
|                                                |                     |
| -   Braces (limb or back only)                 |                     |
|                                                |                     |
| -   Traction devices                           |                     |
|                                                |                     |
| -   Nebulizers                                 |                     |
|                                                |                     |
| -   Indwelling urinary catheters               |                     |
|                                                |                     |
| -   C-PAP monitoring device (when there is a   |                     |
|     diagnosis of documented obstructive sleep  |                     |
|     apnea)                                     |                     |
|                                                |                     |
| ```{=html}                                     |                     |
| <!-- -->                                       |                     |
| ```                                            |                     |
| -   Oxygen, oxygen concentrators, rental of    |                     |
|     equipment for administration of oxygen,    |                     |
|     and mechanical equipment necessary for the |                     |
|     treatment of chronic or acute respiratory  |                     |
|     failure.                                   |                     |
|                                                |                     |
| > Note: Oxygen and equipment must be           |                     |
| > prescribed and directed by a Plan provider,  |                     |
| > and approved in advance by the Plan.         |                     |
|                                                |                     |
| -   Monitoring devices, such as apnea monitors |                     |
|     and uterine monitors for use in the home,  |                     |
|     when prescribed and directed by a Plan     |                     |
|     provider                                   |                     |
|                                                |                     |
| -   Ostomy supplies                            |                     |
|                                                |                     |
| -   Sterile dressing change kits, i.e.,        |                     |
|     tracheostomy suction and dressing kits,    |                     |
|     and central line dressing kits             |                     |
|                                                |                     |
| -   Note: DME must be pre-authorized, unless   |                     |
|     it is provided by your physician's office. |                     |
+------------------------------------------------+---------------------+
| > *Not covered:*                               | *All charges*       |
|                                                |                     |
| -   *Motorized, deluxe, and custom wheelchairs |                     |
|     and hospital beds; auto tilt chairs*       |                     |
|                                                |                     |
| ```{=html}                                     |                     |
| <!-- -->                                       |                     |
| ```                                            |                     |
| -   *Comfort or convenience items, such as     |                     |
|     bathtub chairs, whirlpool tubs, safety     |                     |
|     grab bars, stair gliders or elevators,     |                     |
|     over-the-bed tables, bed boards, saunas,   |                     |
|     and exercise equipment.*                   |                     |
|                                                |                     |
| -   *Environmental control equipment, such as  |                     |
|     air conditioners, purifiers, humidifiers,  |                     |
|     de-humidifiers, electrostatic machines and |                     |
|     heat lamps*                                |                     |
|                                                |                     |
| ```{=html}                                     |                     |
| <!-- -->                                       |                     |
| ```                                            |                     |
| -   *Institutional equipment, such as          |                     |
|     fluidized beds and diathermy machines.*    |                     |
|                                                |                     |
| -   *Consumable medical supplies, such as      |                     |
|     over-the-counter bandages, dressings and   |                     |
|     other disposable supplies and skin         |                     |
|     preparations.*                             |                     |
|                                                |                     |
| -   *Foam cervical collars.*                   |                     |
|                                                |                     |
| -   *Stethoscopes, sphygmomanometers, reading  |                     |
|     oximeters.*                                |                     |
+------------------------------------------------+---------------------+

*Durable medical equipment (DME) continued on next page*

+-------------------------------------------------+-------------------+---+
| #######                                         | **You pay**       |   |
| # Durable medical equipment (DME) *(Continued)* |                   |   |
+-------------------------------------------------+-------------------+---+
| -   *Hygienic or self help items or equipment.* | *All charges*     |   |
|                                                 |                   |   |
| -   *Sports cords.*                             |                   |   |
|                                                 |                   |   |
| -   *TENS units.*                               |                   |   |
|                                                 |                   |   |
| -   *Repair or replacement resulting from       |                   |   |
|     misuse or abuse*                            |                   |   |
+-------------------------------------------------+-------------------+---+
| ######## Diabetic Equipment and Supplies        |                   |   |
+-------------------------------------------------+-------------------+---+
| -   Equipment as follows:                       | 20% co-insurance  |   |
|                                                 |                   |   |
|     -   Blood glucose monitors, including       |                   |   |
|         monitors designed to be used by blind   |                   |   |
|         individuals                             |                   |   |
|                                                 |                   |   |
|     -   Insulin pumps and associated            |                   |   |
|         appurtenances                           |                   |   |
|                                                 |                   |   |
|     -   Insulin infusion devices                |                   |   |
|                                                 |                   |   |
|     -   Podiatric appliances for the prevention |                   |   |
|         of complications associated with        |                   |   |
|         diabetes                                |                   |   |
|                                                 |                   |   |
|     -   Injection aids                          |                   |   |
|                                                 |                   |   |
|     -   Insulin cartridges                      |                   |   |
|                                                 |                   |   |
|     -   Infusion sets                           |                   |   |
|                                                 |                   |   |
| ```{=html}                                      |                   |   |
| <!-- -->                                        |                   |   |
| ```                                             |                   |   |
| -   Supplies, including:                        |                   |   |
|                                                 |                   |   |
|     -   Test strips for blood glucose monitors  |                   |   |
|                                                 |                   |   |
|     -   Visual reading and urine test strips    |                   |   |
|                                                 |                   |   |
|     -   Lancets and lancet devices              |                   |   |
|                                                 |                   |   |
|     -   Injection aids                          |                   |   |
|                                                 |                   |   |
|     -   Syringes                                |                   |   |
|                                                 |                   |   |
|     -   Needles                                 |                   |   |
|                                                 |                   |   |
|     -   Glucose test tablets and test tape      |                   |   |
|                                                 |                   |   |
|     -   Benedict's solution or equivalent       |                   |   |
|                                                 |                   |   |
|     -   Acetone test tablets                    |                   |   |
+-------------------------------------------------+-------------------+---+
| -   *Note: Supplies limited to 30 day supply*   | > *All charges*   |   |
+-------------------------------------------------+-------------------+---+

+-------------------------------------------------+--------------------+
| ######## Home health services                   | **You pay**        |
+-------------------------------------------------+--------------------+
| -   Home health care visits ordered by a Plan   | > Nothing          |
|     physician and provided by a skilled home    |                    |
|     health care professional 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.*             |                    |
+-------------------------------------------------+--------------------+
| ######## Chiropractic                           |                    |
+-------------------------------------------------+--------------------+
| > No benefit                                    | > *All charges*    |
+-------------------------------------------------+--------------------+
| ######## Alternative treatments                 |                    |
+-------------------------------------------------+--------------------+
| ######                                          | > Nothing          |
| ## • Telemedicine to deliver health care, which |                    |
|  includes use of interactive audio, video, or o |                    |
| ther electronic media for diagnosis, consultati |                    |
| on, treatment, transfer of medical data, and me |                    |
| dical education, but excludes services performe |                    |
| d using a telephone or facsimile (FAX) machine. |                    |
+-------------------------------------------------+--------------------+
| ## Not covered:                                 | > *All charges*    |
|                                                 |                    |
| ######## *Naturopathic services*                |                    |
|                                                 |                    |
| ## Hypnotherapy                                 |                    |
|                                                 |                    |
| -   *Biofeedback*                               |                    |
|                                                 |                    |
| -   *Acupuncture*                               |                    |
|                                                 |                    |
| -   *Equine or Hippo therapy*                   |                    |
|                                                 |                    |
| -   *Massage therapy, unless associated with a  |                    |
|     physical therapy modality provided by a     |                    |
|     licensed physical therapist*                |                    |
+-------------------------------------------------+--------------------+
| #### **Educational classes and programs**       |                    |
+-------------------------------------------------+--------------------+
| > Coverage is limited to:                       | \$15 per office    |
|                                                 | visit to your      |
| -   Diabetes self-management training,          | primary care       |
|     including counseling and use of diabetic    | physician          |
|     equipment and supplies.                     |                    |
|                                                 | > \$25 per office  |
| -   Nutritional counseling for morbid obesity.  | > visit to a       |
|                                                 | > specialist       |
+-------------------------------------------------+--------------------+

+---+---+-------------------------------------------+------------+---+---+---+
| * |   |                                           |            |   |   |   |
| * |   |                                           |            |   |   |   |
| S |   |                                           |            |   |   |   |
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| t |   |                                           |            |   |   |   |
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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.                    |            |   |   |   |
|   | * |                                           |            | * |   |   |
|   | * | -   Be sure to read Section 4, *Your      |            | * |   |   |
|   | P |     costs for covered services,* for      |            | P |   |   |
|   | * |     valuable information about how cost   |            | * |   |   |
|   | * |     sharing works. Also read Section 9    |            | * |   |   |
|   |   |     about coordinating benefits with      |            |   |   |   |
|   | * |     other coverage, including with        |            | * |   |   |
|   | * |     Medicare.                             |            | * |   |   |
|   | O |                                           |            | O |   |   |
|   | * | -   The amounts listed below are for the  |            | * |   |   |
|   | * |     charges billed by a physician or      |            | * |   |   |
|   |   |     other health care professional for    |            |   |   |   |
|   | * |     your surgical care. Look in Section   |            | * |   |   |
|   | * |     5(c) for charges associated with the  |            | * |   |   |
|   | R |     facility (i.e., hospital, surgical    |            | R |   |   |
|   | * |     center, etc.).                        |            | * |   |   |
|   | * |                                           |            | * |   |   |
|   |   | -   YOUR PHYSICIAN MUST GET               |            |   |   |   |
|   | * |     PREAUTHORIZATION OF SOME SURGICAL     |            | * |   |   |
|   | * |     PROCEDURES. Please refer to the       |            | * |   |   |
|   | T |     preauthorization information shown in |            | T |   |   |
|   | * |     Section 3 to be sure which services   |            | * |   |   |
|   | * |     require preauthorization and identify |            | * |   |   |
|   |   |     which surgeries require               |            |   |   |   |
|   | * |     preauthorization.                     |            | * |   |   |
|   | * |                                           |            | * |   |   |
|   | A | -   Assistant surgeon services will be    |            | A |   |   |
|   | * |     covered for those surgeries which     |            | * |   |   |
|   | * |     require an assistant surgeon and when |            | * |   |   |
|   |   |     we pre-approve them.                  |            |   |   |   |
|   | * |                                           |            | * |   |   |
|   | * |                                           |            | * |   |   |
|   | N |                                           |            | N |   |   |
|   | * |                                           |            | * |   |   |
|   | * |                                           |            | * |   |   |
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|   | T |                                           |            | T |   |   |
|   | * |                                           |            | * |   |   |
|   | * |                                           |            | * |   |   |
+---+---+-------------------------------------------+------------+---+---+---+
| > |   |                                           | **You      |   |   |   |
|   |   |                                           | pay**      |   |   |   |
| * |   |                                           |            |   |   |   |
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+---+---+-------------------------------------------+------------+---+---+---+
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+---+---+-------------------------------------------+------------+---+---+---+
| > |   |                                           | \$15 when  |   |   |   |
|   |   |                                           | performed  |   |   |   |
| A |   |                                           | in primary |   |   |   |
| > |   |                                           | care       |   |   |   |
|   |   |                                           | office     |   |   |   |
| c |   |                                           |            |   |   |   |
| o |   |                                           | \$25 when  |   |   |   |
| m |   |                                           | performed  |   |   |   |
| p |   |                                           | in         |   |   |   |
| r |   |                                           | specialist |   |   |   |
| e |   |                                           | office     |   |   |   |
| h |   |                                           |            |   |   |   |
| e |   |                                           | \$50 when  |   |   |   |
| n |   |                                           | performed  |   |   |   |
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| i |   |                                           | outpatient |   |   |   |
| v |   |                                           | surgical   |   |   |   |
| e |   |                                           | facility   |   |   |   |
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|   |   |                                           | Included   |   |   |   |
| r |   |                                           | in the     |   |   |   |
| a |   |                                           | \$100      |   |   |   |
| n |   |                                           | inpatient  |   |   |   |
| g |   |                                           | admission  |   |   |   |
| e |   |                                           | copay      |   |   |   |
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| n |   |                                           |            |   |   |   |
| , |   |                                           |            |   |   |   |
|   |   |                                           |            |   |   |   |
|   |   |                                           |            |   |   |   |
|   |   |                                           |            |   |   |   |
|   |   |                                           |            |   |   |   |
| v |   |                                           |            |   |   |   |
| a |   |                                           |            |   |   |   |
| s |   |                                           |            |   |   |   |
| e |   |                                           |            |   |   |   |
| c |   |                                           |            |   |   |   |
| t |   |                                           |            |   |   |   |
| o |   |                                           |            |   |   |   |
| m |   |                                           |            |   |   |   |
| y |   |                                           |            |   |   |   |
| ) |   |                                           |            |   |   |   |
+---+---+-------------------------------------------+------------+---+---+---+

*Surgical procedures continued on next page*

+-------------------------------------------------+--------------------+
| > **Surgical procedures** *(Continued)*         | > **You pay**      |
+-------------------------------------------------+--------------------+
| > *Not Covered:*                                | > *All charges*    |
|                                                 |                    |
| -   *Reversal of voluntary sterilization*       |                    |
|                                                 |                    |
| -   *Any surgical procedures related to snoring |                    |
|     and sleep apnea*                            |                    |
|                                                 |                    |
| -   *Routine treatment of conditions of the     |                    |
|     foot; see Foot Care*                        |                    |
+-------------------------------------------------+--------------------+
| > **Reconstructive surgery**                    |                    |
+-------------------------------------------------+--------------------+
| -   Surgery to correct a functional defect      | \$15 when          |
|                                                 | performed in       |
| ```{=html}                                      | primary care       |
| <!-- -->                                        | office             |
| ```                                             |                    |
| -   Surgery to correct a condition caused by    | \$25 when          |
|     injury or illness if:                       | performed in       |
|                                                 | specialist office  |
| > \- the condition produced a major effect on   |                    |
| > the member's appearance, and                  | \$50 when          |
| >                                               | performed in       |
| > \- the condition can reasonably be expected   | outpatient         |
| > to be corrected by such surgery               | surgical facility  |
|                                                 |                    |
| -   Surgery to correct a condition that existed | > Included in the  |
|     at or from birth and is a significant       | > \$100 inpatient  |
|     deviation from the common form or norm.     | > admission copay  |
|     Examples of congenital anomalies are:       |                    |
|     protruding ear deformities; cleft lip;      |                    |
|     cleft palate; birth marks; webbed fingers;  |                    |
|     and webbed toes.                            |                    |
|                                                 |                    |
| ```{=html}                                      |                    |
| <!-- -->                                        |                    |
| ```                                             |                    |
| -   All stages of breast reconstruction surgery |                    |
|     following a mastectomy, such as:            |                    |
|                                                 |                    |
| > \- surgery to produce a symmetrical           |                    |
| > appearance on the other breast;               |                    |
| >                                               |                    |
| > \- treatment of any physical complications,   |                    |
| > such as lymphedemas;                          |                    |
| >                                               |                    |
| > \- breast prostheses and surgical bras and    |                    |
| > replacements (see Prosthetic 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 |                    |
|     (or any portion of a procedure) performed   |                    |
|     primarily to improve physical appearance    |                    |
|     through change in bodily form, except       |                    |
|     repair of accidental injury.*               |                    |
|                                                 |                    |
| ```{=html}                                      |                    |
| <!-- -->                                        |                    |
| ```                                             |                    |
| -   *Surgeries related to sex transformation*   |                    |
+-------------------------------------------------+--------------------+

+-------------------------------------------------+--------------------+
| > **Oral and maxillofacial surgery**            | > **You pay**      |
+-------------------------------------------------+--------------------+
| > Oral surgical procedures, limited to:         | \$15 when          |
|                                                 | performed in       |
| -   Reduction of fractures of the jaws or       | primary care       |
|     facial bones;                               | office             |
|                                                 |                    |
| -   Surgical correction of cleft lip, cleft     | \$25 when          |
|     palate or severe functional malocclusion;   | performed in       |
|                                                 | specialist office  |
| -   Removal of stones from salivary ducts;      |                    |
|                                                 | \$50 when          |
| -   Excision of leukoplakia or malignancies;    | performed in       |
|                                                 | outpatient         |
| -   Excision of cysts and incision of abscesses | surgical facility  |
|     when done as independent procedures; and    |                    |
|                                                 | > Included in the  |
| -   Treatment of temporomandibular joint (TMJ), | > \$100 inpatient  |
|     including surgical and non-surgical         | > admission copay  |
|     intervention, corrective orthopedic         |                    |
|     appliances and physical therapy and other   |                    |
|     surgical procedures that do not involve the |                    |
|     teeth or their supporting structures.       |                    |
+-------------------------------------------------+--------------------+
| > *Not Covered:*                                | > *All charges*    |
|                                                 |                    |
| -   *Oral implants and transplants*             |                    |
|                                                 |                    |
| -   *Procedures or related dental work that     |                    |
|     involve the teeth or their supporting       |                    |
|     structures (such as the periodontal         |                    |
|     membrane, gingiva, and alveolar bone)*      |                    |
+-------------------------------------------------+--------------------+
| > **Organ/tissue transplants**                  |                    |
+-------------------------------------------------+--------------------+
| > Limited to:                                   | Nothing            |
|                                                 |                    |
| -   Cornea                                      |                    |
|                                                 |                    |
| -   Heart                                       |                    |
|                                                 |                    |
| -   Heart/lung                                  |                    |
|                                                 |                    |
| -   Kidney                                      |                    |
|                                                 |                    |
| -   Kidney/Pancreas                             |                    |
|                                                 |                    |
| -   Liver                                       |                    |
|                                                 |                    |
| -   Lung: Single --Double                       |                    |
|                                                 |                    |
| -   Pancreas                                    |                    |
|                                                 |                    |
| -   Allogenic (donor) bone marrow transplants   |                    |
|                                                 |                    |
| -   Autologous bone marrow transplants          |                    |
|     (autologous stem cell and peripheral stem   |                    |
|     cell support) for the following conditions: |                    |
|     acute lymphocytic or non-lymphocytic        |                    |
|     leukemia; advanced Hodgkin\'s lymphoma;     |                    |
|     advanced non-Hodgkin\'s lymphoma; advanced  |                    |
|     neuroblastoma; breast cancer; multiple      |                    |
|     myeloma; epithelial ovarian cancer;         |                    |
|     testicular, mediastinal, retroperitoneal    |                    |
|     and ovarian germ cell tumors                |                    |
|                                                 |                    |
| -   Autologous tandem transplants for           |                    |
|     testicular cancer and other 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.         |                    |
+-------------------------------------------------+--------------------+

> *Organ/tissue transplants continued on next page*

+-------------------------------------------------+--------------------+
| > **Organ/tissue transplants** *(Continued)*    | > **You pay**      |
+-------------------------------------------------+--------------------+
| > Note: Immuno-suppressive medications          |                    |
| > necessary to prevent rejection of any         |                    |
| > transplanted organ listed above are covered   |                    |
| > subject to no copay while hospitalized. After |                    |
| > discharge, these medications are covered      |                    |
| > under the Prescription drug benefit and       |                    |
| > subject to the applicable prescription drug   |                    |
| > copay per 30-day supply. They are not         |                    |
| > available through the Mail Order Pharmacy.    |                    |
| >                                               |                    |
| > Note: All covered transplants must be         |                    |
| > evaluated by a nationally recognized medical  |                    |
| > facility designated by FIRSTCARE and they     |                    |
| > must agree that the proposed transplant is    |                    |
| > appropriate for the treatment of your         |                    |
| > condition. Also, they must agree to perform   |                    |
| > the transplant.                               |                    |
| >                                               |                    |
| > The FIRSTCARE Medical Director must approve   |                    |
| > all covered transplants. All related medical  |                    |
| > and hospital expenses of the donor are        |                    |
| > covered when the recipient is covered by this |                    |
| > Plan.                                         |                    |
+-------------------------------------------------+--------------------+
| > *Not covered:*                                | > *All charges*    |
| >                                               |                    |
| > • *Donor screening tests and donor search     |                    |
| > expenses, except those performed for the      |                    |
| > actual donor*                                 |                    |
|                                                 |                    |
| -   *Implants of artificial organs*             |                    |
|                                                 |                    |
| -   *Transplants not listed as covered*         |                    |
+-------------------------------------------------+--------------------+
| > **Anesthesia**                                |                    |
+-------------------------------------------------+--------------------+
| > Professional services provided in:            | Nothing            |
|                                                 |                    |
| -   Hospital (inpatient)                        |                    |
|                                                 |                    |
| ```{=html}                                      |                    |
| <!-- -->                                        |                    |
| ```                                             |                    |
| -   Hospital outpatient department              |                    |
|                                                 |                    |
| -   Skilled nursing facility                    |                    |
|                                                 |                    |
| -   Ambulatory surgical center                  |                    |
|                                                 |                    |
| ```{=html}                                      |                    |
| <!-- -->                                        |                    |
| ```                                             |                    |
| -   Office                                      |                    |
+-------------------------------------------------+--------------------+

+---+---+----------------------------------------+-------------+---+---+---+
| > |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
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| a |   |                                        |             |   |   |   |
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| u |   |                                        |             |   |   |   |
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| n |   |                                        |             |   |   |   |
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| > |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
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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         |             | * |   |   |
|   | M |     medically necessary.               |             | M |   |   |
|   | * |                                        |             | * |   |   |
|   | * | -   Plan physicians must provide or    |             | * |   |   |
|   |   |     arrange your care and you must be  |             |   |   |   |
|   | * |     hospitalized in a Plan facility.   |             | * |   |   |
|   | * |                                        |             | * |   |   |
|   | P | -   Be sure to read Section 4, *Your   |             | P |   |   |
|   | * |     costs for covered services,* for   |             | * |   |   |
|   | * |     valuable information about how     |             | * |   |   |
|   |   |     cost sharing works. Also read      |             |   |   |   |
|   | * |     Section 9 about coordinating       |             | * |   |   |
|   | * |     benefits with other coverage,      |             | * |   |   |
|   | O |     including with Medicare.           |             | O |   |   |
|   | * |                                        |             | * |   |   |
|   | * | -   The amounts listed below are for   |             | * |   |   |
|   |   |     the charges billed by the facility |             |   |   |   |
|   | * |     (i.e., hospital or surgical        |             | * |   |   |
|   | * |     center) or ambulance service for   |             | * |   |   |
|   | R |     your surgery or care. Any costs    |             | R |   |   |
|   | * |     associated with the professional   |             | * |   |   |
|   | * |     charge (i.e., physicians, etc.)    |             | * |   |   |
|   |   |     are covered in Sections 5(a) or    |             |   |   |   |
|   | * |     (b).                               |             | * |   |   |
|   | * |                                        |             | * |   |   |
|   | T | -   YOUR PHYSICIAN MUST GET            |             | T |   |   |
|   | * |     PREAUTHORIZATION OF HOSPITAL       |             | * |   |   |
|   | * |     STAYS. Please refer to the         |             | * |   |   |
|   |   |     preauthorization information shown |             |   |   |   |
|   | * |     in Section 3 to be sure which      |             | * |   |   |
|   | * |     services require preauthorization  |             | * |   |   |
|   | A |     and identify which surgeries       |             | A |   |   |
|   | * |     require preauthorization.          |             | * |   |   |
|   | * |                                        |             | * |   |   |
|   |   |                                        |             |   |   |   |
|   | * |                                        |             | * |   |   |
|   | * |                                        |             | * |   |   |
|   | N |                                        |             | N |   |   |
|   | * |                                        |             | * |   |   |
|   | * |                                        |             | * |   |   |
|   |   |                                        |             |   |   |   |
|   | * |                                        |             | * |   |   |
|   | * |                                        |             | * |   |   |
|   | T |                                        |             | T |   |   |
|   | * |                                        |             | * |   |   |
|   | * |                                        |             | * |   |   |
+---+---+----------------------------------------+-------------+---+---+---+
| > |   |                                        | **You pay** |   |   |   |
|   |   |                                        |             |   |   |   |
| * |   |                                        |             |   |   |   |
| * |   |                                        |             |   |   |   |
| B |   |                                        |             |   |   |   |
| e |   |                                        |             |   |   |   |
| n |   |                                        |             |   |   |   |
| e |   |                                        |             |   |   |   |
| f |   |                                        |             |   |   |   |
| i |   |                                        |             |   |   |   |
| t |   |                                        |             |   |   |   |
| > |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
| D |   |                                        |             |   |   |   |
| e |   |                                        |             |   |   |   |
| s |   |                                        |             |   |   |   |
| c |   |                                        |             |   |   |   |
| r |   |                                        |             |   |   |   |
| i |   |                                        |             |   |   |   |
| p |   |                                        |             |   |   |   |
| t |   |                                        |             |   |   |   |
| i |   |                                        |             |   |   |   |
| o |   |                                        |             |   |   |   |
| n |   |                                        |             |   |   |   |
| * |   |                                        |             |   |   |   |
| * |   |                                        |             |   |   |   |
+---+---+----------------------------------------+-------------+---+---+---+
| # |   |                                        | ########    |   |   |   |
| # |   |                                        |             |   |   |   |
| # |   |                                        |             |   |   |   |
| # |   |                                        |             |   |   |   |
| # |   |                                        |             |   |   |   |
| # |   |                                        |             |   |   |   |
| # |   |                                        |             |   |   |   |
| # |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
| I |   |                                        |             |   |   |   |
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| p |   |                                        |             |   |   |   |
| a |   |                                        |             |   |   |   |
| t |   |                                        |             |   |   |   |
| i |   |                                        |             |   |   |   |
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| n |   |                                        |             |   |   |   |
| t |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
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| o |   |                                        |             |   |   |   |
| s |   |                                        |             |   |   |   |
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| i |   |                                        |             |   |   |   |
| t |   |                                        |             |   |   |   |
| a |   |                                        |             |   |   |   |
| l |   |                                        |             |   |   |   |
+---+---+----------------------------------------+-------------+---+---+---+
| > |   |                                        | > \$100 per |   |   |   |
|   |   |                                        | > admission |   |   |   |
| R |   |                                        |             |   |   |   |
| o |   |                                        |             |   |   |   |
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|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
| f |   |                                        |             |   |   |   |
| o |   |                                        |             |   |   |   |
| r |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
| u |   |                                        |             |   |   |   |
| s |   |                                        |             |   |   |   |
| e |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
| a |   |                                        |             |   |   |   |
| t |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
|   |   |                                        |             |   |   |   |
| h |   |                                        |             |   |   |   |
| o |   |                                        |             |   |   |   |
| m |   |                                        |             |   |   |   |
| e |   |                                        |             |   |   |   |
| . |   |                                        |             |   |   |   |
+---+---+----------------------------------------+-------------+---+---+---+

*Inpatient hospital continued on next page*

+-------------------------------------------------+---------------------+
| ######## Inpatient hospital *(Continued)*       | ######## You pay    |
+-------------------------------------------------+---------------------+
| > *Not covered:*                                | > *All charges*     |
|                                                 |                     |
| -   *Custodial care, rest cures, domiciliary or |                     |
|     convalescent care*                          |                     |
|                                                 |                     |
| -   *Non-covered facilities, such as nursing    |                     |
|     homes, schools*                             |                     |
|                                                 |                     |
| -   *Personal comfort items, such as telephone, |                     |
|     television, barber services, guest meals    |                     |
|     and beds*                                   |                     |
|                                                 |                     |
| -   *Private nursing care*                      |                     |
|                                                 |                     |
| -   *Take-home drugs*                           |                     |
+-------------------------------------------------+---------------------+
| #### **Outp                                     | ####                |
| atient hospital or ambulatory surgical center** |                     |
+-------------------------------------------------+---------------------+
| -   Operating, recovery, and other treatment    | > \$50 per visit    |
|     rooms                                       |                     |
|                                                 |                     |
| #### Prescribed drugs and medicines             |                     |
|                                                 |                     |
| -   Diagnostic laboratory tests, X-rays, and    |                     |
|     pathology services                          |                     |
|                                                 |                     |
| -   Administration of blood, blood plasma, and  |                     |
|     other biologicals                           |                     |
|                                                 |                     |
| -   Blood and blood plasma                      |                     |
|                                                 |                     |
| -   Pre-surgical testing                        |                     |
|                                                 |                     |
| -   Dressings, casts, and sterile tray services |                     |
|                                                 |                     |
| -   Medical supplies, including oxygen          |                     |
|                                                 |                     |
| -   Anesthetics and anesthesia service          |                     |
|                                                 |                     |
| > NOTE: We cover hospital services and supplies |                     |
| > related to dental procedures when             |                     |
| > necessitated by a non-dental physical         |                     |
| > impairment. We do not cover the dental        |                     |
| > procedures.                                   |                     |
+-------------------------------------------------+---------------------+
| ######## Extended care                          | ########            |
| benefits/skilled nursing care facility benefits |                     |
+-------------------------------------------------+---------------------+
| > Extended care benefit:                        | > \$100 per         |
| >                                               | > admission         |
| > A comprehensive range of benefits to a        |                     |
| > maximum of 100 days per calendar year when    |                     |
| > full‑time skilled nursing care is necessary   |                     |
| > and confinement in a skilled nursing facility |                     |
| > is medically appropriate as determined by a   |                     |
| > Plan doctor and approved by the Plan.         |                     |
|                                                 |                     |
| -   Bed, board and general nursing care.        |                     |
|                                                 |                     |
| -   Drugs, biologicals, supplies, and equipment |                     |
|     ordinarily provided or arranged by the      |                     |
|     skilled nursing facility when prescribed by |                     |
|     a Plan doctor.                              |                     |
+-------------------------------------------------+---------------------+
| > *Not Covered:*                                | > *All charges*     |
|                                                 |                     |
| -   *Custodial care*                            |                     |
|                                                 |                     |
| -   *Rest cures*                                |                     |
|                                                 |                     |
| -   *Domiciliary or convalescent care*          |                     |
+-------------------------------------------------+---------------------+

+-------------------------------------------------+---------------------+
| #### **Hospice care**                           | #### **You pay**    |
+-------------------------------------------------+---------------------+
| We cover supportive and palliative care in the  | > Nothing           |
| home or a hospice facility                      |                     |
|                                                 |                     |
| Services include:                               |                     |
|                                                 |                     |
| > \- Inpatient and outpatient care, and         |                     |
| >                                               |                     |
| > \- Family counseling.                         |                     |
| >                                               |                     |
| > Note: A Plan physician must certify that the  |                     |
| > patient is in the terminal stages of illness, |                     |
| > with a life expectancy of approximately 6     |                     |
| > months or less.                               |                     |
+-------------------------------------------------+---------------------+
| > *Not covered:*                                | > *All charges*     |
|                                                 |                     |
| -   *Independent nursing*                       |                     |
|                                                 |                     |
| -   *Homemaker services*                        |                     |
+-------------------------------------------------+---------------------+
| ######## Ambulance                              | ########            |
+-------------------------------------------------+---------------------+
| -   Local professional ambulance service when   | > \$75 per trip     |
|     medically appropriate                       |                     |
+-------------------------------------------------+---------------------+

+----+---+----------------------------------------------------+---+----+
| #  |   |                                                    |   |    |
| ## |   |                                                    |   |    |
| ## |   |                                                    |   |    |
|  S |   |                                                    |   |    |
| ec |   |                                                    |   |    |
| ti |   |                                                    |   |    |
| on |   |                                                    |   |    |
|  5 |   |                                                    |   |    |
|  ( |   |                                                    |   |    |
| d) |   |                                                    |   |    |
| .  |   |                                                    |   |    |
| Em |   |                                                    |   |    |
| er |   |                                                    |   |    |
| ge |   |                                                    |   |    |
| nc |   |                                                    |   |    |
| y  |   |                                                    |   |    |
| se |   |                                                    |   |    |
| rv |   |                                                    |   |    |
| ic |   |                                                    |   |    |
| es |   |                                                    |   |    |
| /a |   |                                                    |   |    |
| cc |   |                                                    |   |    |
| id |   |                                                    |   |    |
| en |   |                                                    |   |    |
| ts |   |                                                    |   |    |
+----+---+----------------------------------------------------+---+----+
|    | # | **Here are some important things to keep in mind   | # | ## |
|    | # | about these benefits:**                            | # | ## |
|    | # |                                                    | # | #  |
|    | # | -   Please remember that all benefits are subject  | # |    |
|    | # |     to the definitions, limitations, and           | # |    |
|    | # |     exclusions in this brochure.                   | # |    |
|    | # |                                                    | # |    |
|    | # | -   Be sure to read Section 4, *Your costs for     | # |    |
|    | # |     covered services,* for valuable information    | # |    |
|    |   |     about how cost sharing works. Also read        |   |    |
|    | I |     Section 9 about coordinating benefits with     | I |    |
|    |   |     other coverage, including with Medicare.       |   |    |
|    | * |                                                    | * |    |
|    | * | -   Our Plan's allowance of Usual, Customary and   | * |    |
|    | M |     Reasonable (UCR) charges will apply to         | M |    |
|    | * |     emergency care received at any doctor's        | * |    |
|    | * |     office, outside our Plan's services area, for  | * |    |
|    |   |     the services rendered. (See next page and      |   |    |
|    | * |     Section 10 for the definition of our Plan's    | * |    |
|    | * |     allowance of UCR charges).                     | * |    |
|    | P |                                                    | P |    |
|    | * | #####                                              | * |    |
|    | * |                                                    | * |    |
|    |   |                                                    |   |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
|    | O |                                                    | O |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
|    |   |                                                    |   |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
|    | R |                                                    | R |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
|    |   |                                                    |   |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
|    | T |                                                    | T |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
|    |   |                                                    |   |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
|    | A |                                                    | A |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
|    |   |                                                    |   |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
|    | N |                                                    | N |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
|    |   |                                                    |   |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
|    | T |                                                    | T |    |
|    | * |                                                    | * |    |
|    | * |                                                    | * |    |
+----+---+----------------------------------------------------+---+----+
| >  |   |                                                    |   |    |
| ** |   |                                                    |   |    |
| Wh |   |                                                    |   |    |
| at |   |                                                    |   |    |
| >  |   |                                                    |   |    |
| is |   |                                                    |   |    |
| >  |   |                                                    |   |    |
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| >  |   |                                                    |   |    |
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| y? |   |                                                    |   |    |
| ** |   |                                                    |   |    |
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| >  |   |                                                    |   |    |
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| -- |   |                                                    |   |    |
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| th |   |                                                    |   |    |
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| >  |   |                                                    |   |    |
|  a |   |                                                    |   |    |
| ll |   |                                                    |   |    |
| >  |   |                                                    |   |    |
| ha |   |                                                    |   |    |
| ve |   |                                                    |   |    |
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| in |   |                                                    |   |    |
| >  |   |                                                    |   |    |
| co |   |                                                    |   |    |
| mm |   |                                                    |   |    |
| on |   |                                                    |   |    |
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| is |   |                                                    |   |    |
| >  |   |                                                    |   |    |
|  t |   |                                                    |   |    |
| he |   |                                                    |   |    |
| >  |   |                                                    |   |    |
| ne |   |                                                    |   |    |
| ed |   |                                                    |   |    |
| >  |   |                                                    |   |    |
|  f |   |                                                    |   |    |
| or |   |                                                    |   |    |
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|  q |   |                                                    |   |    |
| ui |   |                                                    |   |    |
| ck |   |                                                    |   |    |
| >  |   |                                                    |   |    |
|  a |   |                                                    |   |    |
| ct |   |                                                    |   |    |
| io |   |                                                    |   |    |
| n. |   |                                                    |   |    |
+----+---+----------------------------------------------------+---+----+
| >  |   |                                                    |   |    |
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| er |   |                                                    |   |    |
| ge |   |                                                    |   |    |
| nc |   |                                                    |   |    |
| y: |   |                                                    |   |    |
| ** |   |                                                    |   |    |
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| >  |   |                                                    |   |    |
|  * |   |                                                    |   |    |
| *E |   |                                                    |   |    |
| me |   |                                                    |   |    |
| rg |   |                                                    |   |    |
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| wi |   |                                                    |   |    |
| th |   |                                                    |   |    |
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| >  |   |                                                    |   |    |
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| ur |   |                                                    |   |    |
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|  s |   |                                                    |   |    |
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| in |   |                                                    |   |    |
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| me |   |                                                    |   |    |
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| en |   |                                                    |   |    |
| cy |   |                                                    |   |    |
| >  |   |                                                    |   |    |
| si |   |                                                    |   |    |
| tu |   |                                                    |   |    |
| at |   |                                                    |   |    |
| io |   |                                                    |   |    |
| n, |   |                                                    |   |    |
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| ca |   |                                                    |   |    |
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| yo |   |                                                    |   |    |
| ur |   |                                                    |   |    |
| >  |   |                                                    |   |    |
|  p |   |                                                    |   |    |
| ri |   |                                                    |   |    |
| ma |   |                                                    |   |    |
| ry |   |                                                    |   |    |
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| y. |   |                                                    |   |    |
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| >  |   |                                                    |   |    |
|  e |   |                                                    |   |    |
| xt |   |                                                    |   |    |
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| >  |   |                                                    |   |    |
| em |   |                                                    |   |    |
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| nc |   |                                                    |   |    |
| ie |   |                                                    |   |    |
| s, |   |                                                    |   |    |
| >  |   |                                                    |   |    |
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|  y |   |                                                    |   |    |
| ou |   |                                                    |   |    |
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| >  |   |                                                    |   |    |
| un |   |                                                    |   |    |
| ab |   |                                                    |   |    |
| le |   |                                                    |   |    |
| >  |   |                                                    |   |    |
| to |   |                                                    |   |    |
| >  |   |                                                    |   |    |
|  c |   |                                                    |   |    |
| on |   |                                                    |   |    |
| ta |   |                                                    |   |    |
| ct |   |                                                    |   |    |
| >  |   |                                                    |   |    |
| yo |   |                                                    |   |    |
| ur |   |                                                    |   |    |
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| to |   |                                                    |   |    |
| >  |   |                                                    |   |    |
|  t |   |                                                    |   |    |
| he |   |                                                    |   |    |
| >  |   |                                                    |   |    |
| ca |   |                                                    |   |    |
| re |   |                                                    |   |    |
| >  |   |                                                    |   |    |
| of |   |                                                    |   |    |
| >  |   |                                                    |   |    |
|  a |   |                                                    |   |    |
| >  |   |                                                    |   |    |
| Pl |   |                                                    |   |    |
| an |   |                                                    |   |    |
| >  |   |                                                    |   |    |
|  p |   |                                                    |   |    |
| ro |   |                                                    |   |    |
| vi |   |                                                    |   |    |
| de |   |                                                    |   |    |
| r. |   |                                                    |   |    |
+----+---+----------------------------------------------------+---+----+

+------------------------------------------------+---------------------+
| > **Emergencies outside our service area:**    |                     |
| >                                              |                     |
| > Benefits are available for any medically     |                     |
| > necessary health service that is immediately |                     |
| > required because of injury or unforeseen     |                     |
| > illness.                                     |                     |
| >                                              |                     |
| > If you need to be hospitalized, FIRSTCARE    |                     |
| > must be notified within 24 hours or on the   |                     |
| > first working day following your admission,  |                     |
| > unless it was not reasonably possible to     |                     |
| > notify Us within that time. If a Plan doctor |                     |
| > believes care can be better provided in a    |                     |
| > Plan hospital, you will be transferred when  |                     |
| > medically feasible with any ambulance        |                     |
| > charges covered in full.                     |                     |
|                                                |                     |
| Any follow-up care recommended by non-Plan     |                     |
| providers must be approved by the Plan or      |                     |
| provided by Plan providers.                    |                     |
+------------------------------------------------+---------------------+
| > **Benefit Description**                      | **You pay**         |
+------------------------------------------------+---------------------+
| > **Emergency within our service area**        |                     |
+------------------------------------------------+---------------------+
| -   Emergency care at a doctor\'s office       | \$15 per office     |
|                                                | visit to your       |
|                                                | primary care        |
|                                                | physician           |
|                                                |                     |
|                                                | \$25 per office     |
|                                                | visit to a          |
|                                                | specialist          |
+------------------------------------------------+---------------------+
| -   Emergency care at an urgent care center    | \$40 per visit      |
+------------------------------------------------+---------------------+
| -   Emergency care as an outpatient, including | \$100 per visit; if |
|     doctors\' services                         | admitted, the copay |
|                                                | is waived. However, |
|                                                | if admitted for an  |
|                                                | observation period  |
|                                                | of less than 24     |
|                                                | hours, the copay is |
|                                                | not waived.         |
+------------------------------------------------+---------------------+
| > *Not covered:*                               | *All charges*       |
|                                                |                     |
| -   *Elective care or non-emergency care*      |                     |
+------------------------------------------------+---------------------+
| ######## Emergency outside our service area    |                     |
+------------------------------------------------+---------------------+
| -   Emergency care at a doctor\'s office       | \$25 per office     |
|                                                | visit, plus all     |
|                                                | amounts over the    |
|                                                | Usual, Customary    |
|                                                | and Reasonable      |
|                                                | (UCR) charges for   |
|                                                | the services        |
|                                                | rendered.           |
+------------------------------------------------+---------------------+
| -   Emergency care at an urgent care center    | \$40 per visit      |
+------------------------------------------------+---------------------+
| -   Emergency care as an outpatient or         | \$100 per visit; if |
|     inpatient at a hospital, including         | admitted, the copay |
|     doctors\' services                         | is waived. However, |
|                                                | if admitted for an  |
|                                                | observation period  |
|                                                | of less than 24     |
|                                                | hours, the copay is |
|                                                | not waived.         |
+------------------------------------------------+---------------------+

*Emergency outside our service area continued next page*

+------------------------------------------------+---------------------+
| ######## Em                                    | > **You pay**       |
| ergency outside our service area *(Continued)* |                     |
+------------------------------------------------+---------------------+
| > *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*                              |                     |
|                                                |                     |
| -   *Charges for the normal delivery of a baby |                     |
|     (vaginal or cesarean section) outside our  |                     |
|     Plan\'s Service Area, if the delivery is   |                     |
|     within 30 days of your due date specified  |                     |
|     by your participating physician, except in |                     |
|     case of emergency; however, complications  |                     |
|     of pregnancy or premature delivery are     |                     |
|     covered.*                                  |                     |
+------------------------------------------------+---------------------+
| > **Ambulance**                                |                     |
+------------------------------------------------+---------------------+
| -   Professional ambulance service, including  | \$75 per trip       |
|     air ambulance, when medically appropriate. |                     |
|                                                |                     |
| > See 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     |   |              | M |   |
|   | * | > keep in mind about these benefits:**    |   |              | * |   |
|   | * | >                                         |   |              | * |   |
|   |   | > • All benefits are subject to the       |   |              |   |   |
|   | * | > definitions, limitations, and           |   |              | * |   |
|   | * | > exclusions in this brochure.            |   |              | * |   |
|   | 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 other  |   |              | * |   |
|   | O | > coverage, including with Medicare.      |   |              | O |   |
|   | * | >                                         |   |              | * |   |
|   | * | > • **YOU MUST GET PREAUTHORIZATION OF    |   |              | * |   |
|   |   | > THESE SERVICES.** See the instructions  |   |              |   |   |
|   | * | > after the benefits description below.   |   |              | * |   |
|   | * |                                           |   |              | * |   |
|   | R |                                           |   |              | R |   |
|   | * |                                           |   |              | * |   |
|   | * |                                           |   |              | * |   |
|   |   |                                           |   |              |   |   |
|   | * |                                           |   |              | * |   |
|   | * |                                           |   |              | * |   |
|   | T |                                           |   |              | T |   |
|   | * |                                           |   |              | * |   |
|   | * |                                           |   |              | * |   |
|   |   |                                           |   |              |   |   |
|   | * |                                           |   |              | * |   |
|   | * |                                           |   |              | * |   |
|   | 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 |   |                                           |   |              |   |   |
| * |   |                                           |   |              |   |   |
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+---+---+-------------------------------------------+---+--------------+---+---+
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| t |   |                                           |   |              |   |   |
|   |   |                                           |   |              |   |   |
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| a |   |                                           |   |              |   |   |
| n |   |                                           |   |              |   |   |
|   |   |                                           |   |              |   |   |
| i |   |                                           |   |              |   |   |
| n |   |                                           |   |              |   |   |
|   |   |                                           |   |              |   |   |
| f |   |                                           |   |              |   |   |
| a |   |                                           |   |              |   |   |
| v |   |                                           |   |              |   |   |
| o |   |                                           |   |              |   |   |
| r |   |                                           |   |              |   |   |
|   |   |                                           |   |              |   |   |
| o |   |                                           |   |              |   |   |
| f |   |                                           |   |              |   |   |
|   |   |                                           |   |              |   |   |
| a |   |                                           |   |              |   |   |
| n |   |                                           |   |              |   |   |
| o |   |                                           |   |              |   |   |
| t |   |                                           |   |              |   |   |
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| r |   |                                           |   |              |   |   |
| . |   |                                           |   |              |   |   |
+---+---+-------------------------------------------+---+--------------+---+---+

> **Preauthorization** To be eligible to receive these benefits you must
> obtain your treatment plan and follow all of our network authorization
> processes. These include:
>
> Mental health and substance abuse services are provided through these
> behavioral health benefit managers:

-   In the Amarillo and Lubbock regions (which includes
    Midland/Odessa) - Comprehensive Behavioral Care 800-541-3647

-   In the Central Texas area -- MHNet, Inc. -- 800-336-2030

> Your primary care physician may refer you, or you may contact the
> benefit manager for your region without a referral.
>
> **Limitation** If you do not obtain an approved treatment plan, we may
> limit your benefits.

+---+---+------------------------------------------+------------+---+---+
| * |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
| S |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| c |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| o |   |                                          |            |   |   |
| n |   |                                          |            |   |   |
| 5 |   |                                          |            |   |   |
| ( |   |                                          |            |   |   |
| f |   |                                          |            |   |   |
| ) |   |                                          |            |   |   |
| . |   |                                          |            |   |   |
| P |   |                                          |            |   |   |
| r |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| s |   |                                          |            |   |   |
| c |   |                                          |            |   |   |
| r |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| p |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| o |   |                                          |            |   |   |
| n |   |                                          |            |   |   |
| d |   |                                          |            |   |   |
| r |   |                                          |            |   |   |
| u |   |                                          |            |   |   |
| g |   |                                          |            |   |   |
| b |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| n |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| f |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| s |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
+---+---+------------------------------------------+------------+---+---+
|   | * | **Here are some important things to keep |            | * |   |
|   | * | in mind about these benefits:**          |            | * |   |
|   | I |                                          |            | I |   |
|   | * | -   We cover prescribed drugs and        |            | * |   |
|   | * |     medications, as described in the     |            | * |   |
|   |   |     chart beginning on the next page.    |            |   |   |
|   | * |                                          |            | * |   |
|   | * | -   All benefits are subject to the      |            | * |   |
|   | M |     definitions, limitations and         |            | M |   |
|   | * |     exclusions in this brochure and are  |            | * |   |
|   | * |     payable only when we determine they  |            | * |   |
|   |   |     are medically necessary.             |            |   |   |
|   | * |                                          |            | * |   |
|   | * | -   Be sure to read Section 4, *Your     |            | * |   |
|   | P |     costs for covered services,* for     |            | P |   |
|   | * |     valuable information about how cost  |            | * |   |
|   | * |     sharing works. Also read Section 9   |            | * |   |
|   |   |     about coordinating benefits with     |            |   |   |
|   | * |     other coverage, including with       |            | * |   |
|   | * |     Medicare.                            |            | * |   |
|   | O |                                          |            | O |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   |   |                                          |            |   |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   | R |                                          |            | R |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   |   |                                          |            |   |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   | T |                                          |            | T |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   |   |                                          |            |   |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   | A |                                          |            | A |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   |   |                                          |            |   |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   | N |                                          |            | N |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   |   |                                          |            |   |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
|   | T |                                          |            | T |   |
|   | * |                                          |            | * |   |
|   | * |                                          |            | * |   |
+---+---+------------------------------------------+------------+---+---+
|   |   | > **There are important features you     |            |   |   |
|   |   | > should be aware of.** These include:   |            |   |   |
|   |   |                                          |            |   |   |
|   |   | -   **Who can write your prescription.** |            |   |   |
|   |   |                                          |            |   |   |
|   |   | > A Plan physician or dentist, or an     |            |   |   |
|   |   | > out-of-Plan doctor when you have been  |            |   |   |
|   |   | > referred must write the prescription.  |            |   |   |
|   |   |                                          |            |   |   |
|   |   | -   **Where you can obtain them.**       |            |   |   |
|   |   |                                          |            |   |   |
|   |   | > \- **Retail Pharmacy**                 |            |   |   |
|   |   | >                                        |            |   |   |
|   |   | > You may fill your prescriptions at a   |            |   |   |
|   |   | > retail Plan pharmacy, or               |            |   |   |
|   |   | >                                        |            |   |   |
|   |   | > \- **Mail Order Pharmacy**             |            |   |   |
|   |   | >                                        |            |   |   |
|   |   | > You may obtain a medication for        |            |   |   |
|   |   | > chronic conditions through the Plan    |            |   |   |
|   |   | > mail order pharmacy. Medications for   |            |   |   |
|   |   | > chronic conditions are defined as      |            |   |   |
|   |   | > those that you have taken for at least |            |   |   |
|   |   | > six months. Our mail order pharmacy is |            |   |   |
|   |   | > Express Scripts 888-202-4560.          |            |   |   |
|   |   |                                          |            |   |   |
|   |   | -   **We use a Preferred Drug List       |            |   |   |
|   |   |     (PDL)**                              |            |   |   |
|   |   |                                          |            |   |   |
|   |   | > Our Preferred Drug List includes all   |            |   |   |
|   |   | > generic drugs and a comprehensive list |            |   |   |
|   |   | > of Preferred Name Brand drugs approved |            |   |   |
|   |   | > by our Pharmacy and Therapeutics (P&T) |            |   |   |
|   |   | > Committee, and used by Plan physicians |            |   |   |
|   |   | > to be dispensed through our Plan       |            |   |   |
|   |   | > pharmacies to meet patient needs at a  |            |   |   |
|   |   | > lower cost. You must use drugs         |            |   |   |
|   |   | > included on the Preferred Drug List to |            |   |   |
|   |   | > take advantage of the best combination |            |   |   |
|   |   | > of safety, effectiveness and cost      |            |   |   |
|   |   | > savings. Drugs not included in the PDL |            |   |   |
|   |   | > are called "non-Preferred" drugs and   |            |   |   |
|   |   | > you must pay a higher copayment for    |            |   |   |
|   |   | > these drugs. If you need to order a    |            |   |   |
|   |   | > Preferred Drug List or have any        |            |   |   |
|   |   | > questions, please call our Customer    |            |   |   |
|   |   | > Services Department at 800-884-4901 or |            |   |   |
|   |   | > visit our website at www.firstcare.com |            |   |   |
+---+---+------------------------------------------+------------+---+---+
|   |   | -   **These are the dispensing           |            |   |   |
|   |   |     limitations.**                       |            |   |   |
|   |   |                                          |            |   |   |
|   |   | > FIRSTCARE requires prior authorization |            |   |   |
|   |   | > and imposes dispensing limitations on  |            |   |   |
|   |   | > certain drugs, due to specific         |            |   |   |
|   |   | > therapeutic indications or             |            |   |   |
|   |   | > requirements for closer monitoring to  |            |   |   |
|   |   | > help insure appropriate dispensing.    |            |   |   |
|   |   | > The criteria used in administering     |            |   |   |
|   |   | > these programs follow FDA approved     |            |   |   |
|   |   | > dosing guidelines. For specific        |            |   |   |
|   |   | > information about your prescription    |            |   |   |
|   |   | > coverage, please consult a Customer    |            |   |   |
|   |   | > Services Representative at             |            |   |   |
|   |   | > 800-884-4901.                          |            |   |   |
|   |   | >                                        |            |   |   |
|   |   | > Prescriptions are limited to a 30-day  |            |   |   |
|   |   | > supply, except medications for chronic |            |   |   |
|   |   | > conditions that may be filled up to a  |            |   |   |
|   |   | > 90-day supply, but only when filled    |            |   |   |
|   |   | > through a Participating Mail Service   |            |   |   |
|   |   | > Pharmacy.                              |            |   |   |
|   |   | >                                        |            |   |   |
|   |   | > If you or your physician request a     |            |   |   |
|   |   | > Name Brand drug when a Generic         |            |   |   |
|   |   | > equivalent is available, you will be   |            |   |   |
|   |   | > responsible for the Generic Drug       |            |   |   |
|   |   | > Copayment plus the difference between  |            |   |   |
|   |   | > the cost of the Generic Drug and the   |            |   |   |
|   |   | > cost of the Name Brand Drug.           |            |   |   |
+---+---+------------------------------------------+------------+---+---+
|   |   | -   **Why use generic drugs?**           |            |   |   |
|   |   |                                          |            |   |   |
|   |   | > *Generic drugs* are lower-priced drugs |            |   |   |
|   |   | > that are pharmaceutically and          |            |   |   |
|   |   | > therapeutically equivalent in strength |            |   |   |
|   |   | > and dosage to the more expensive       |            |   |   |
|   |   | > original Name Brand product. The U.S.  |            |   |   |
|   |   | > Food and Drug Administration closely   |            |   |   |
|   |   | > regulates both generic and Name Brand  |            |   |   |
|   |   | > drugs to ensure they meet the same     |            |   |   |
|   |   | > standards for safety, purity, strength |            |   |   |
|   |   | > and effectiveness. Generic drugs are   |            |   |   |
|   |   | > less expensive for you -- and us --    |            |   |   |
|   |   | > and can reduce your out-of-pocket      |            |   |   |
|   |   | > expenses.                              |            |   |   |
|   |   |                                          |            |   |   |
|   |   | -   **When you have to file a claim.**   |            |   |   |
|   |   |                                          |            |   |   |
|   |   | > You may have to file a claim for       |            |   |   |
|   |   | > reimbursement if you are out of the    |            |   |   |
|   |   | > service area and have to pay for an    |            |   |   |
|   |   | > emergency prescription filled at an    |            |   |   |
|   |   | > out-of-network pharmacy. To obtain     |            |   |   |
|   |   | > these forms, call our Customer         |            |   |   |
|   |   | > Services Department at 800-884-4901.   |            |   |   |
|   |   |                                          |            |   |   |
|   |   | -   **What you should do if you are      |            |   |   |
|   |   |     called to active duty or in case of  |            |   |   |
|   |   |     a national emergency.**              |            |   |   |
|   |   |                                          |            |   |   |
|   |   | > FIRSTCARE will make special            |            |   |   |
|   |   | > arrangements for emergency supplies of |            |   |   |
|   |   | > medications for our members that are   |            |   |   |
|   |   | > called active duty or during a         |            |   |   |
|   |   | > national emergency. For information in |            |   |   |
|   |   | > obtaining this supply of medication,   |            |   |   |
|   |   | > call our Customer Services Department  |            |   |   |
|   |   | > at 800-884-4901.                       |            |   |   |
+---+---+------------------------------------------+------------+---+---+
| > |   |                                          | **You      |   |   |
|   |   |                                          | pay**      |   |   |
| * |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
| B |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| n |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| f |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| > |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
| D |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| s |   |                                          |            |   |   |
| c |   |                                          |            |   |   |
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| i |   |                                          |            |   |   |
| p |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| o |   |                                          |            |   |   |
| n |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
+---+---+------------------------------------------+------------+---+---+
| > |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
| C |   |                                          |            |   |   |
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|   |   |                                          |            |   |   |
| a |   |                                          |            |   |   |
| n |   |                                          |            |   |   |
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| > |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
| s |   |                                          |            |   |   |
| u |   |                                          |            |   |   |
| p |   |                                          |            |   |   |
| p |   |                                          |            |   |   |
| l |   |                                          |            |   |   |
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| s |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
| * |   |                                          |            |   |   |
+---+---+------------------------------------------+------------+---+---+
| > |   |                                          | *Retail    |   |   |
|   |   |                                          | Pharmacy*, |   |   |
| W |   |                                          | for a      |   |   |
| e |   |                                          | 30-day     |   |   |
| > |   |                                          | supply per |   |   |
|   |   |                                          | pr         |   |   |
| c |   |                                          | escription |   |   |
| o |   |                                          | unit or    |   |   |
| v |   |                                          | refill:    |   |   |
| e |   |                                          |            |   |   |
| r |   |                                          | > A \$10   |   |   |
| > |   |                                          | > copay    |   |   |
|   |   |                                          | > for      |   |   |
| t |   |                                          | > generic  |   |   |
| h |   |                                          | > drugs;   |   |   |
| e |   |                                          | >          |   |   |
| > |   |                                          | > A \$20   |   |   |
|   |   |                                          | > copay    |   |   |
| f |   |                                          | > for      |   |   |
| o |   |                                          | >          |   |   |
| l |   |                                          |  Preferred |   |   |
| l |   |                                          | > Name     |   |   |
| o |   |                                          | > Brand    |   |   |
| w |   |                                          | > drugs    |   |   |
| i |   |                                          | > when a   |   |   |
| n |   |                                          | > generic  |   |   |
| g |   |                                          | >          |   |   |
| > |   |                                          | equivalent |   |   |
|   |   |                                          | > is not   |   |   |
| m |   |                                          | >          |   |   |
| e |   |                                          | available; |   |   |
| d |   |                                          | >          |   |   |
| i |   |                                          | > A \$40   |   |   |
| c |   |                                          | > copay    |   |   |
| a |   |                                          | > for      |   |   |
| t |   |                                          | > non      |   |   |
| i |   |                                          | -Preferred |   |   |
| o |   |                                          | > drugs;   |   |   |
| n |   |                                          | > and      |   |   |
| s |   |                                          | >          |   |   |
| > |   |                                          | > A \$10   |   |   |
|   |   |                                          | > copay    |   |   |
| a |   |                                          | > for      |   |   |
| n |   |                                          | >          |   |   |
| d |   |                                          |  Preferred |   |   |
| > |   |                                          | > Name     |   |   |
|   |   |                                          | > Brand    |   |   |
| s |   |                                          | > drugs    |   |   |
| u |   |                                          | > when a   |   |   |
| p |   |                                          | > generic  |   |   |
| p |   |                                          | >          |   |   |
| l |   |                                          | equivalent |   |   |
| i |   |                                          | > is       |   |   |
| e |   |                                          | >          |   |   |
| s |   |                                          | available, |   |   |
| > |   |                                          | > plus the |   |   |
|   |   |                                          | >          |   |   |
| p |   |                                          | difference |   |   |
| r |   |                                          | > between  |   |   |
| e |   |                                          | > the cost |   |   |
| s |   |                                          | > of the   |   |   |
| c |   |                                          | > generic  |   |   |
| r |   |                                          | > drug and |   |   |
| i |   |                                          | > the cost |   |   |
| b |   |                                          | > of the   |   |   |
| e |   |                                          | >          |   |   |
| d |   |                                          |  Preferred |   |   |
| > |   |                                          | > Name     |   |   |
|   |   |                                          | > Brand    |   |   |
| b |   |                                          | > drug.    |   |   |
| y |   |                                          | >          |   |   |
| > |   |                                          | > *Mail    |   |   |
|   |   |                                          | > Order    |   |   |
| a |   |                                          | >          |   |   |
| > |   |                                          | Pharmacy,* |   |   |
|   |   |                                          | > for up   |   |   |
| P |   |                                          | > to a     |   |   |
| l |   |                                          | > 90-day   |   |   |
| a |   |                                          | > supply   |   |   |
| n |   |                                          | > per      |   |   |
| > |   |                                          | > pr       |   |   |
|   |   |                                          | escription |   |   |
| p |   |                                          | > unit or  |   |   |
| h |   |                                          | > refill:  |   |   |
| y |   |                                          | >          |   |   |
| s |   |                                          | > A \$20   |   |   |
| i |   |                                          | > copay    |   |   |
| c |   |                                          | > for      |   |   |
| i |   |                                          | > generic  |   |   |
| a |   |                                          | > drugs;   |   |   |
| n |   |                                          | >          |   |   |
| , |   |                                          | > A \$40   |   |   |
| > |   |                                          | > copay    |   |   |
|   |   |                                          | > for      |   |   |
| o |   |                                          | >          |   |   |
| r |   |                                          |  Preferred |   |   |
| > |   |                                          | > Name     |   |   |
|   |   |                                          | > Brand    |   |   |
| d |   |                                          | > drugs    |   |   |
| e |   |                                          | > when a   |   |   |
| n |   |                                          | > generic  |   |   |
| t |   |                                          | >          |   |   |
| i |   |                                          | equivalent |   |   |
| s |   |                                          | > is not   |   |   |
| t |   |                                          | >          |   |   |
| > |   |                                          | available; |   |   |
|   |   |                                          | >          |   |   |
| a |   |                                          | > A \$80   |   |   |
| n |   |                                          | > copay    |   |   |
| d |   |                                          | > for      |   |   |
| > |   |                                          | > non      |   |   |
|   |   |                                          | -Preferred |   |   |
| o |   |                                          | > drugs;   |   |   |
| b |   |                                          | > and      |   |   |
| t |   |                                          | >          |   |   |
| a |   |                                          | > A \$20   |   |   |
| i |   |                                          | > copay    |   |   |
| n |   |                                          | > for      |   |   |
| e |   |                                          | >          |   |   |
| d |   |                                          |  Preferred |   |   |
| > |   |                                          | > Name     |   |   |
|   |   |                                          | > Brand    |   |   |
| f |   |                                          | > drugs    |   |   |
| r |   |                                          | > when a   |   |   |
| o |   |                                          | > generic  |   |   |
| m |   |                                          | >          |   |   |
| > |   |                                          | equivalent |   |   |
|   |   |                                          | > is       |   |   |
| a |   |                                          | >          |   |   |
| > |   |                                          | available, |   |   |
|   |   |                                          | > plus the |   |   |
| P |   |                                          | >          |   |   |
| l |   |                                          | difference |   |   |
| a |   |                                          | > between  |   |   |
| n |   |                                          | > the cost |   |   |
| > |   |                                          | > of the   |   |   |
|   |   |                                          | > generic  |   |   |
| r |   |                                          | > drug and |   |   |
| e |   |                                          | > the cost |   |   |
| t |   |                                          | > of the   |   |   |
| a |   |                                          | >          |   |   |
| i |   |                                          |  Preferred |   |   |
| l |   |                                          | > Name     |   |   |
| > |   |                                          | > Brand    |   |   |
|   |   |                                          | > drug.    |   |   |
| p |   |                                          |            |   |   |
| h |   |                                          |            |   |   |
| a |   |                                          |            |   |   |
| r |   |                                          |            |   |   |
| m |   |                                          |            |   |   |
| a |   |                                          |            |   |   |
| c |   |                                          |            |   |   |
| y |   |                                          |            |   |   |
| > |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
| o |   |                                          |            |   |   |
| r |   |                                          |            |   |   |
| > |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| h |   |                                          |            |   |   |
| r |   |                                          |            |   |   |
| o |   |                                          |            |   |   |
| u |   |                                          |            |   |   |
| g |   |                                          |            |   |   |
| h |   |                                          |            |   |   |
| > |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
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|   |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
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| m |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| r |   |                                          |            |   |   |
| g |   |                                          |            |   |   |
| e |   |                                          |            |   |   |
| n |   |                                          |            |   |   |
| c |   |                                          |            |   |   |
| y |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
|   |   |                                          |            |   |   |
| k |   |                                          |            |   |   |
| i |   |                                          |            |   |   |
| t |   |                                          |            |   |   |
| s |   |                                          |            |   |   |
+---+---+------------------------------------------+------------+---+---+

*Covered medications and supplies continued on the next page*

+-------------------------------------------------+--------------------+
| > **Covered medications and supplies**          | > **You pay**      |
| > *(Continued)*                                 |                    |
+-------------------------------------------------+--------------------+
| -   Contraceptive drugs and devices, such as:   | 20% of all charges |
|                                                 |                    |
| > \- Diaphragms                                 |                    |
| >                                               |                    |
| > \- Intrauterine devices (IUDs)                |                    |
| >                                               |                    |
| > \- Implantable drugs, such as Norplant        |                    |
| >                                               |                    |
| > \- Injectable drugs, such as Depo Provera     |                    |
| >                                               |                    |
| > • Disposable needles and syringes for the     |                    |
| > administration of covered medications         |                    |
|                                                 |                    |
| -   Allergy syringes                            |                    |
+-------------------------------------------------+--------------------+
| > Here are some things to keep in mind about    |                    |
| > our prescription drug program:                |                    |
|                                                 |                    |
| -   A generic equivalent will be dispensed if   |                    |
|     it is available, unless your physician      |                    |
|     specifically requires a Name Brand. If you  |                    |
|     receive a Name Brand drug when a Federally  |                    |
|     approved generic drug is available, and     |                    |
|     your physician has not specified Dispense   |                    |
|     as Written for the Name Brand drug, you     |                    |
|     have to pay the Generic copay plus the      |                    |
|     difference in cost between the Name Brand   |                    |
|     and the Generic drug.                       |                    |
|                                                 |                    |
| -   Prescribing Generic drugs is encouraged.    |                    |
|     Prescribing Preferred Name Brand drugs is   |                    |
|     encouraged over non-Preferred Name Brand    |                    |
|     drugs.                                      |                    |
|                                                 |                    |
| -   A Generic (1^st^-tier) or Preferred Name    |                    |
|     Brand (2^nd^-tier) drug may not always be   |                    |
|     available or appropriate to treat a         |                    |
|     condition. In that case, a non-Preferred    |                    |
|     Name Brand drug is covered at the           |                    |
|     non-Preferred (3^rd^-tier) Copayment when   |                    |
|     used to treat a covered medical condition.  |                    |
|                                                 |                    |
| -   A non-Preferred drug is a prescription      |                    |
|     medication that is not in the Preferred     |                    |
|     Drug List. Non-Preferred drugs require a    |                    |
|     higher copayment.                           |                    |
|                                                 |                    |
| -   Prescriptions will not be refilled until    |                    |
|     70% of the prescription has been used.      |                    |
+-------------------------------------------------+--------------------+
| > *Not Covered:*                                | > *All charges*    |
|                                                 |                    |
| -   *Drugs and supplies for cosmetic purposes,  |                    |
|     including medications such as Lamisil or    |                    |
|     Sporanox for the treatment of uncomplicated |                    |
|     nail fungus, and drugs for hair growth or   |                    |
|     removal.*                                   |                    |
|                                                 |                    |
| -   *Vitamins, and nutritional substances that  |                    |
|     can be purchased without a prescription,    |                    |
|     except for pre-natal vitamins*              |                    |
|                                                 |                    |
| -   *Nonprescription medicines, except for the  |                    |
|     treatment of diabetes*                      |                    |
|                                                 |                    |
| -   *Drugs available without a prescription or  |                    |
|     for which there is a nonprescription        |                    |
|     equivalent available*                       |                    |
|                                                 |                    |
| -   *Drugs obtained at a non‑Plan pharmacy      |                    |
|     except for out‑of‑area emergencies*         |                    |
|                                                 |                    |
| -   *Medical supplies such as dressings and     |                    |
|     antiseptics*                                |                    |
|                                                 |                    |
| -   *Drugs to enhance athletic performance*     |                    |
|                                                 |                    |
| -   *Fertility drugs*                           |                    |
|                                                 |                    |
| -   *Smoking cessation drugs and medication,    |                    |
|     including nicotine patches*                 |                    |
+-------------------------------------------------+--------------------+

*Covered medications and supplies continued on the next page*

+--------------------------------------------------+-------------------+
| > **Covered medications and supplies**           | > **You pay**     |
| > *(Continued)*                                  |                   |
+--------------------------------------------------+-------------------+
| > *Not Covered (continued):*                     | > *All charges*   |
|                                                  |                   |
| -   *Drugs prescribed for weight loss and        |                   |
|     appetite suppressants, except for            |                   |
|     medications prescribed for morbid obesity*   |                   |
|                                                  |                   |
| ```{=html}                                       |                   |
| <!-- -->                                         |                   |
| ```                                              |                   |
| -   *Prescription refills in excess of the       |                   |
|     number specified by the Physician and any    |                   |
|     refill dispensed more than one year after    |                   |
|     the Physician\'s order*                      |                   |
|                                                  |                   |
| ```{=html}                                       |                   |
| <!-- -->                                         |                   |
| ```                                              |                   |
| -   *Any prescription drug for which the actual  |                   |
|     cost is less than the required copayment is  |                   |
|     not covered and you will be responsible for  |                   |
|     the cost of the drug*                        |                   |
|                                                  |                   |
| -   *Prescriptions or refills that replace lost, |                   |
|     stolen, spoiled, expired, spilled or are     |                   |
|     otherwise misplaced or mishandled by the     |                   |
|     Member.*                                     |                   |
+--------------------------------------------------+-------------------+

+-------------------------+--------------------------------------------+
| > Section 5 (g).        |                                            |
| > Special Features      |                                            |
+=========================+============================================+
| **Feature**             | > **Description**                          |
+-------------------------+--------------------------------------------+
| > **Services for deaf   | > **TDD LINE 800-562-5259**                |
| > and hearing           |                                            |
| > impaired**            |                                            |
+-------------------------+--------------------------------------------+
| > **Centers of          | > FIRSTCARE coordinates with nationally    |
| > excellence for        | > recognized medical facilities to         |
| > transplants/heart     | > evaluate the Member's case; to determine |
| > surgery/etc.**        | > that the proposed transplant or          |
|                         | > treatment is appropriate for the         |
|                         | > Member's condition; and to perform the   |
|                         | > transplant or treatment.                 |
+-------------------------+--------------------------------------------+

+----+---+------------------------------------------+--------------+---+---+
| *  |   |                                          |              |   |   |
| *S |   |                                          |              |   |   |
| ec |   |                                          |              |   |   |
| ti |   |                                          |              |   |   |
| on |   |                                          |              |   |   |
| 5  |   |                                          |              |   |   |
| (h |   |                                          |              |   |   |
| ). |   |                                          |              |   |   |
| De |   |                                          |              |   |   |
| nt |   |                                          |              |   |   |
| al |   |                                          |              |   |   |
| be |   |                                          |              |   |   |
| ne |   |                                          |              |   |   |
| fi |   |                                          |              |   |   |
| ts |   |                                          |              |   |   |
| ** |   |                                          |              |   |   |
+----+---+------------------------------------------+--------------+---+---+
|    | * | > When you get our approval for services |              | * |   |
|    | * | > and follow a treatment plan we         |              | * |   |
|    | I | > approve, cost-sharing and limitations  |              | I |   |
|    | * | > for Plan dental benefits will be no    |              | * |   |
|    | * | > greater than for similar benefits for  |              | * |   |
|    |   | > other illnesses and conditions.        |              |   |   |
|    | * | >                                        |              | * |   |
|    | * | > **Here are some important things to    |              | * |   |
|    | M | > keep in mind about these benefits:**   |              | M |   |
|    | * |                                          |              | * |   |
|    | * | • 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  |              | * |   |
|    | P | medically necessary.                     |              | P |   |
|    | * |                                          |              | * |   |
|    | * | -   We cover hospitalization for dental  |              | * |   |
|    |   |     procedures only when a non-dental    |              |   |   |
|    | * |     physical impairment exists which     |              | * |   |
|    | * |     makes hospitalization necessary to   |              | * |   |
|    | O |     safeguard the health of the patient. |              | O |   |
|    | * |     See Section 5 (c) for inpatient      |              | * |   |
|    | * |     hospital benefits. We do not cover   |              | * |   |
|    |   |     the dental procedure unless it is    |              |   |   |
|    | * |     described below.                     |              | * |   |
|    | * |                                          |              | * |   |
|    | R | > **Be sure to read Section 4, *Your     |              | R |   |
|    | * | > costs for covered services,* for       |              | * |   |
|    | * | > valuable information about how cost    |              | * |   |
|    |   | > sharing works. Also read Section 9     |              |   |   |
|    | * | > about coordinating benefits with other |              | * |   |
|    | * | > coverage, including with Medicare.**   |              | * |   |
|    | T |                                          |              | T |   |
|    | * |                                          |              | * |   |
|    | * |                                          |              | * |   |
|    |   |                                          |              |   |   |
|    | * |                                          |              | * |   |
|    | * |                                          |              | * |   |
|    | A |                                          |              | A |   |
|    | * |                                          |              | * |   |
|    | * |                                          |              | * |   |
|    |   |                                          |              |   |   |
|    | * |                                          |              | * |   |
|    | * |                                          |              | * |   |
|    | N |                                          |              | N |   |
|    | * |                                          |              | * |   |
|    | * |                                          |              | * |   |
|    |   |                                          |              |   |   |
|    | * |                                          |              | * |   |
|    | * |                                          |              | * |   |
|    | T |                                          |              | T |   |
|    | * |                                          |              | * |   |
|    | * |                                          |              | * |   |
+----+---+------------------------------------------+--------------+---+---+
| #  |   |                                          | > **You      |   |   |
| ## |   |                                          | > pay**      |   |   |
|  * |   |                                          |              |   |   |
| *A |   |                                          |              |   |   |
| cc |   |                                          |              |   |   |
| id |   |                                          |              |   |   |
| en |   |                                          |              |   |   |
| ta |   |                                          |              |   |   |
| l  |   |                                          |              |   |   |
| in |   |                                          |              |   |   |
| ju |   |                                          |              |   |   |
| ry |   |                                          |              |   |   |
|  b |   |                                          |              |   |   |
| en |   |                                          |              |   |   |
| ef |   |                                          |              |   |   |
| it |   |                                          |              |   |   |
| ** |   |                                          |              |   |   |
+----+---+------------------------------------------+--------------+---+---+
| >  |   |                                          | > *All       |   |   |
| No |   |                                          | > charges*   |   |   |
| >  |   |                                          |              |   |   |
|  b |   |                                          |              |   |   |
| en |   |                                          |              |   |   |
| ef |   |                                          |              |   |   |
| it |   |                                          |              |   |   |
+----+---+------------------------------------------+--------------+---+---+
| >  |   |                                          |              |   |   |
| ** |   |                                          |              |   |   |
| De |   |                                          |              |   |   |
| nt |   |                                          |              |   |   |
| al |   |                                          |              |   |   |
| >  |   |                                          |              |   |   |
| be |   |                                          |              |   |   |
| ne |   |                                          |              |   |   |
| fi |   |                                          |              |   |   |
| ts |   |                                          |              |   |   |
| ** |   |                                          |              |   |   |
+----+---+------------------------------------------+--------------+---+---+
| >  |   |                                          | > *All       |   |   |
| No |   |                                          | > charges*   |   |   |
| >  |   |                                          |              |   |   |
|  b |   |                                          |              |   |   |
| en |   |                                          |              |   |   |
| ef |   |                                          |              |   |   |
| it |   |                                          |              |   |   |
+----+---+------------------------------------------+--------------+---+---+

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

The exclusions in this section apply to all benefits. **Although we may
list a specific service as a benefit, we will not cover it unless your
Plan doctor determines it is medically necessary to prevent, diagnose,
or treat your illness, disease, injury, or condition** and we agree, as
discussed under *What Services Require Our Prior Approval* on page 13.

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;

```{=html}
<!-- -->
```
-   Services, drugs, or supplies related to sex transformations; or

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

-   Services, drugs, 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 fill your prescription drugs at Plan pharmacies, you will
not have to file claims. Just present your identification card and pay
your copayment or coinsurance.

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

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

**drug benefits** 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 800-884-4901.

When you must file a claim \-- such as for services you receive outside
of the 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;

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-   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: FIRSTCARE**

> **12940 N Highway 183**
>
> **Austin, Texas 78750**

**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 our Complaints and Appeals Department   |
|   |     at 12940 N. Highway 183, Austin Texas 78750; 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: Office of Personnel Management, Insurance       |
|   | Services Programs, Health Insurance Group 3, 1900 E Street, NW,  |
|   | Washington, DC 20415-3630.                                       |
+---+------------------------------------------------------------------+

***The Disputed Claims process*** (Continued)

+---+------------------------------------------------------------------+
|   | 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               |
|   | preauthorization. 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 our Customer Services
    Department at 800-884-4901 and we will expedite our review; or

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

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

-   **You may call OPM\'s Health Insurance Group 3 at 202-606-0737
    between 8 a.m. and 5 p.m. eastern time.**

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

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

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

When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as
the secondary payer. We, like other insurers, determine which coverage
is primary according to the National Association of Insurance
Commissioners\' guidelines.

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

When we are the secondary payer, we will determine our allowance. After
the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will not pay more than our allowance.

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

-   People 65 years of age and older.

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

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

Medicare has two parts:

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

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

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

> apply for Medicare benefits 3 months before you turn age 65. It's
> easy. Just call the Social Security Administration toll-free number
> 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 Original Medicare Plan** The Original Medicare Plan (Original
> Medicare) is a plan that is
>
> **(Part A or Part B)** available everywhere in the United States. It
> is the way everyone used to get Medicare benefits and is the way most
> people get their Medicare Part A and Part B benefits. You may go to
> any doctor, specialist, or hospital that accepts Medicare. The
> Original Medicare Plan pays its share and you pay your share. Some
> things are not covered under Original Medicare, like prescription
> drugs.
>
> When you are enrolled in Original Medicare along with this Plan, you
> still need to follow the rules in this brochure for us to cover your
> care. Your care must continue to be authorized by your Plan PCP, or
> pre-certified as required. We will not waive any of our copayments or
> coinsurance.
>
> **Claims process when you have the Original Medicare Plan \--** You
> probably will never have to file a claim form when you have both our
> Plan and the Original Medicare Plan.

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

-   When Original Medicare is the primary payer, Medicare processes your
    claim first. In most cases, your claims will be coordinated
    automatically and we will pay the balance of covered charges. You
    will not need to do anything. To find out if you need to do
    something about filing your claims, call us at 800-884-4901.

> **We do not waive any costs when you have Medicare.**

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

Medicare always makes the final determination as to whether they are
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...**          |   | Then |   |         |
|                                                    |   | the  |   |         |
|                                                    |   | pri  |   |         |
|                                                    |   | mary |   |         |
|                                                    |   | p    |   |         |
|                                                    |   | ayer |   |         |
|                                                    |   | for  |   |         |
|                                                    |   | the  |   |         |
|                                                    |   | in   |   |         |
|                                                    |   | divi |   |         |
|                                                    |   | dual |   |         |
|                                                    |   | with |   |         |
|                                                    |   | Medi |   |         |
|                                                    |   | care |   |         |
|                                                    |   | is.  |   |         |
|                                                    |   | ..** |   |         |
+----------------------------------------------------+---+------+---+---------+
|                                                    | * |      | * |         |
|                                                    | * |      | * |         |
|                                                    | M |      | T |         |
|                                                    | e |      | h |         |
|                                                    | d |      | i |         |
|                                                    | i |      | s |         |
|                                                    | c |      | P |         |
|                                                    | a |      | l |         |
|                                                    | r |      | a |         |
|                                                    | e |      | n |         |
|                                                    | * |      | * |         |
|                                                    | * |      | * |         |
+----------------------------------------------------+---+------+---+---------+
| 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     |   |     |   |  for   |
|     your employment status,                        |   | for  |   | other   |
|                                                    |   | Part |   | s       |
|                                                    |   | B    |   | ervices |
|                                                    |   | serv |   |         |
|                                                    |   | 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 sol                           |   |     |   |        |
| ely 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-months coordination period |   |      |   |         |
|     and you or a family member are still entitled  |   |      |   |         |
|     to Medicare due to ESRD                        |   |      |   |         |
+----------------------------------------------------+---+------+---+---------+
| 1)  Become eligible for Medicare due to ESRD while |   |     |   |        |
|     already a Medicare beneficiary and             |   |      |   |         |
|                                                    |   |      |   |         |
| -   This Plan was the primary payer before         |   |      |   |         |
|     eligibility due to ESRD                        |   |      |   |         |
|                                                    |   |      |   |         |
| -   Medicare was the primary payer before          |   |      |   |         |
|     eligibility due to ESRD                        |   |      |   |         |
+----------------------------------------------------+---+------+---+---------+
| > **C. When you or your spouse are eligible for    |   |      |   |         |
| > Medicare solely due to disability and you**      |   |      |   |         |
+----------------------------------------------------+---+------+---+---------+
| 1)  Are an active employee with the Federal        |   |     |   |        |
|     government and...                              |   |      |   |         |
|                                                    |   |      |   |         |
| -   You have FEHB coverage on your own or through  |   |      |   |         |
|     your spouse who is also an active employee     |   |      |   |         |
|                                                    |   |      |   |         |
| -   You have FEHB coverage through your spouse who |   |      |   |         |
|     is an annuitant                                |   |      |   |         |
+----------------------------------------------------+---+------+---+---------+
| 2)  Are an annuitant and...                        |   |     |   |        |
|                                                    |   |      |   |         |
| -   You have FEHB coverage on your own or through  |   |      |   |         |
|     your spouse who is also an annuitant           |   |      |   |         |
|                                                    |   |      |   |         |
| -   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
>
> \*\*Worker's Compensation is primary for claims related to your
> condition under Workers' Compensation
>
> Please note, if Medicare is primary and your Plan physician does not
> participate in Medicare, you will have to file a claim with Medicare.
> When you receive your Medicare Explanation of Benefits, you must send
> a copy to us at 12940 N. Highway 183, Austin, Texas 78750 so we can
> determine the secondary coverage.
>
> **• Medicare + Choice** If you are eligible for Medicare, you may
> choose to enroll in and get your Medicare benefits from a Medicare +
> Choice plan. These are health care choices (like HMOs) in some areas
> of the country. In most Medicare + Choice plans, you can only go to
> doctors, specialists, or hospitals that are part of the plan.
> Medicare + Choice plans provide all the benefits that Original
> Medicare covers. Some cover extras, like prescription drugs. To learn
> more about enrolling in a Medicare + Choice plan, contact Medicare at
> 1-800-MEDICARE (1-800-633-4227) or at
> [www.medicare.gov](http://www.medicare.gov/).
>
> If you enroll in a Medicare + Choice plan, the following options are
> available to you:
>
> **This Plan and another plan's Medicare + Choice plan:** You may
> enroll in another plan's Medicare + Choice plan and also remain
> enrolled in our FEHB plan. We will still provide benefits when your
> Medicare + Choice plan is primary, even out of the Medicare + Choice
> plan's network and/or service area (if you use our Plan providers),
> but we will not waive any of our copayments or coinsurance. If you
> enroll in a Medicare + Choice plan, tell us. We will need to know
> whether you are in the Original Medicare Plan or in a Medicare +
> Choice plan so we can correctly coordinate benefits with Medicare.
>
> **Suspended FEHB coverage to enroll in a Medicare + Choice plan:** If
> you are an annuitant or former spouse, you can suspend your FEHB
> coverage to enroll in a Medicare + Choice plan, eliminating your FEHB
> premium. (OPM does not contribute to your Medicare + Choice plan
> premium.) For information on suspending your FEHB enrollment, contact
> your retirement office. If you later want to re-enroll in the FEHB
> Program, generally you may do so only at the next open season unless
> you involuntarily lose coverage or move out of the Medicare + Choice
> plan's service area.

**TRICARE and CHAMPVA** TRICARE is the health care program for eligible
dependents of military persons, and retirees of the military. TRICARE
includes the CHAMPUS program. CHAMPVA provides health coverage to
disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA
and this Plan cover you, we pay first. See your TRICARE or CHAMPVA
Health Benefits Advisor if you have questions about these programs.

**Suspended FEHB coverage to enroll in TRICARE or CHAMPVA:** If you are
an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a one of these programs, eliminating your FEHB premium. (OPM
does not contribute to any applicable plan premiums.) For information on
suspending your FEHB enrollment, contact your retirement office. If you
later want to re-enroll in the FEHB Program, generally you may do so
only at the next Open Season unless you involuntarily lose coverage
under the program.

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

> • you need because of a workplace-related illness or injury that the
> Office of Workers' Compensation Programs (OWCP) or a similar Federal
> or State agency determines they must provide; or
>
> • 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 a 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 Government** We do not cover services and supplies when a
local, State, Federal

**agencies are responsible** Government agency directly or indirectly
pays for them

**for your care**

**When others are** When you receive money to compensate you for medical
or hospital

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

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

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

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

**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 care** Custodial care is care that:

-   Primarily helps with or supports daily living activities (such as,
    eating, dressing, and eliminating body wastes); or

-   Can be given by people other than trained medical personnel.

Care can be custodial even if it is prescribed by a physician or given
by trained medical personnel, and even if it involves artificial methods
such as feeding tubes or catheters.

Custodial care that lasts 90 days or more is sometimes known as Long
term care.

**Experimental or** Determining eligibility of coverage for a new
technology

investigational services requires evaluation of its health effects by
the Plan's Medical Advisory Committee, which consists of Medical
Directors from all of the Plan's regions and appropriate Ad Hoc
Specialists. A service or supply shall be considered to be experimental
or investigational as follows:

-   If the protocols or consent document of the entity prescribing or
    rendering the service or supply describes it as an alternative to
    more conventional therapies;

-   Authoritative medical or scientific literature published in the
    United States and written by experts in the field indicates that
    additional research is necessary before the service or supply could
    be classified as equally or more effective than conventional
    therapies;

-   Food and Drug Administration (FDA) approval is required in order for
    the service or supply to be lawfully marketed, and such approval has
    not been granted at the time the service or supply is prescribed or
    rendered; and

-   The prescribed service or supply is available to the member only
    through participation in FDA Phase I or Phase II clinical trials, or
    through FDA Phase III experimental or research clinical trials or
    corresponding trials sponsored by the National Cancer Institute.

**Group health coverage** Health coverage, such as FEHB, that is
provided through an employer group.

**Medical necessity** Medical necessity and/or medically necessary means
that the service must meet *all* of the following conditions:

-   The service is required for diagnosing, treating or preventing an
    illness or injury, or a medical condition such as pregnancy;

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-   If you are ill or injured, it is a service you need in order to
    improve your condition or to keep your condition from getting worse;

-   It is generally accepted as safe and effective under standard
    medical practice in your community; and

-   The service is provided in the most cost-efficient way, while still
    giving you an appropriate level of care.

> Not every service that fits this definition is covered under your
> Plan. Just because a physician or other health care provider has
> performed, prescribed or recommended a service does not mean it is a
> medical necessity and/or medically necessary or that it is covered
> under your Plan.

**Plan allowance** Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Plans determine their
allowances in different ways. Our Plan allowance is the amount our
contracted providers have agreed to accept as payment in full.

For emergency care received at any doctor's office, outside our Plan's
service area, our Plan's allowance is the amount FIRSTCARE has
determined to be the allowable prevailing charge for a particular
professional service in the geographical area in which the service is
performed.

**Usual, Reasonable and** The UCR charge is the amount we have
determined to be the

**Customary (UCR) charge** allowable prevailing charge for a particular
professional service in the geographical area in which the service is
provided.

**Us/We** Us and we refer to FIRSTCARE.

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

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

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

**Coverage Information**

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

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

**Where you can get information** See
[www.opm.gov/insure](http://www.opm.gov/insure). Also, your employing or
retirement

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

**FEHB Program** *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 available** Self Only coverage is for you alone.
Self and Family coverage

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

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

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

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

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

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

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

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

-   If you are enrolled in an HMO that does not serve the area where the
    children live, your employing office will change your enrollment to
    Self and Family in the Blue Cross and Blue Shield Service Benefit
    Plan's Basic Option.

> As long as the court/administrative order is in effect, and you have
> at least one child identified in the order who is still eligible under
> the FEHB Program, you cannot cancel your enrollment, change to Self
> Only, or change to a plan that doesn\'t serve the area in which your
> children live, unless you provide documentation that you have other
> coverage for the children. If the court/administrative order is still
> in effect when you retire, and you have at least one child still
> eligible for FEHB coverage, you must continue your FEHB coverage into
> retirement (if eligible) and cannot cancel your coverage, change to
> Self Only, or change to a plan that doesn't serve the area in which
> your children live as long as the court/administrative order is in
> effect. Contact your employing office for further information.

**When benefits and** The benefits in this brochure are effective on
January 1. If

**premiums start** 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. Annuitants' premiums begin on January 1. If you
joined at any other time during the year, your employing office will
tell you the effective date of coverage.

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

**When you lose benefits**

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

> • Your enrollment ends, unless you cancel your enrollment, or
>
> • You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation
of Coverage.

> **• Spouse equity coverage** If you are divorced from a Federal
> employee or annuitant, you

may not continue to get benefits under your former spouse's enrollment.
This is the case even when the court has ordered your former spouse to
supply health coverage to you. But, you may be eligible for your own
FEHB coverage under the spouse equity law or Temporary Continuation of
Coverage (TCC). If you are recently divorced or are anticipating a
divorce, contact your ex-spouse's employing or retirement office to get
RI 70-5, the *Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees*, or
other information about your coverage choices. You can also download the
guide from OPM's website, www.opm.gov/insure.

**• Temporary continuation** If you leave Federal service, or if you
lose coverage because

**of coverage (TCC)** you no longer qualify as a family member, you may
be eligible for Temporary Continuation of Coverage (TCC). For example,
you can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent
child and you turn 22 or marry, etc.

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

> **Enrolling in TCC** Get the RI 79-27, which describes TCC, and the RI
> 70-5, the *Guide to Federal Employees Health Benefits Plans for
> Temporary Continuation of Coverage and Former Spouse Enrollees,* from
> your employing or retirement office or from
> [www.opm.gov/insure](http://www.opm.gov/insure). It explains what you
> have to do to enroll.
>
> **• Converting to** You may convert to a non-FEHB individual policy
> if:

**individual coverage**

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

-   You decided not to receive coverage under TCC or the spouse equity
    law; or

-   You are not eligible for coverage under TCC or the spouse equity
    law.

If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who
is losing coverage, the employing or retirement office will **not**
notify you. You must apply in writing to us within 31 days after you are
no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we
will not impose a waiting period or limit your coverage due to
pre-existing conditions.

> **• Getting a Certificate of** The Health Insurance Portability and
> Accountability Act of 1996

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

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

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

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

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

-   **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.

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

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

+---------------------+------------------------------------------------+
| **Dependent Care**  | -   Covers eligible dependent care expenses    |
|                     |     incurred so you can work, or if you are    |
| **Flexible          |     married, so you and your spouse can work,  |
| Spending**          |     or your spouse can look for work or attend |
|                     |     school full-time.                          |
| **Account (DCFSA)** |                                                |
|                     | -   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 included any child care subsidy  |
|                     |     you may receive.                           |
+---------------------+------------------------------------------------+

+-----------------------+----------------------------------------------+
| -   **Enroll during   | You **must make an election** to enroll in   |
|     Open** **Season** | an FSA during the FEHB Open Season. Even if  |
|                       | you enrolled during Open Season for 2003,    |
| **What is SHPS?**     | you must make a new election to continue     |
|                       | participating in 2004. Enrollment is easy!   |
| **Who is eligible to  |                                              |
| enroll?**             | -   Enroll online anytime during Open Season |
|                       |     (November 10 through December 8, 2003)   |
| -   **How much should |     at **www.fsafeds.com**.                  |
|     I contribute to   |                                              |
|     my FSA?**         | -   Call the toll-free number 877-FSAFEDS    |
|                       |     (372-3337) Monday through Friday, from 9 |
| -   **What can my     |     a.m. until 9 p.m. eastern time and a     |
|     HCFSA pay for?**  |     FSAFEDS Benefit Counselor will help you  |
|                       |     enroll.                                  |
| -   **Tax savings     |                                              |
|     with an FSA**     | 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.            |
|                       |                                              |
|                       | 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 in intermittent |
|                       | (also called when actually employed \[WAE\]) |
|                       | employees expected to work less than 180     |
|                       | days during the year.                        |
|                       |                                              |
|                       | *Note:* FSAFEDS is the FSA Program           |
|                       | established for all Executive Branch         |
|                       | employees and Legislative Branch employees   |
|                       | whose employers signed on. Under IRS law,    |
|                       | FSAs are not available to annuitants. In     |
|                       | addition, the U.S. Postal Service and the    |
|                       | Judicial Branch, among others, are Federal   |
|                       | agencies that have their own plans with      |
|                       | slightly different rules, but the advantages |
|                       | of having an FSA are the same no matter what |
|                       | agency you work for.                         |
|                       |                                              |
|                       | Plan carefully when deciding how much to     |
|                       | contribute to an FSA. Because of the tax     |
|                       | benefits of an FSA, the IRS places strict    |
|                       | guidelines on them. You need to estimate how |
|                       | much you want to allocate to an FSA because  |
|                       | current IRS regulations require you forfeit  |
|                       | any funds remaining in your account(s) at    |
|                       | the end of the FSA plan year. This is        |
|                       | referred to as the "use it or lose it" rule. |
|                       | You will have until April 29, 2004 to submit |
|                       | claims for your eligible expenses incurred   |
|                       | during 2003 if you enrolled in FSAFEDS when  |
|                       | it was 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 Open Season.                          |
|                       |                                              |
|                       | The **FSAFEDS Calculator** at                |
|                       | www.fsafeds.com will help you plan your FSA  |
|                       | allocations and provide an estimate of your  |
|                       | tax savings based on your individual         |
|                       | situation.                                   |
|                       |                                              |
|                       | Every FEHB health plan includes cost sharing |
|                       | features, such as deductibles you must meet  |
|                       | before the Plan provides benefits,           |
|                       | coinsurance or copayments that you pay when  |
|                       | you and the Plan share costs, and medical    |
|                       | services and supplies that are not covered   |
|                       | by the Plan and for which you must pay.      |
|                       | These out-of-pocket costs are summarized on  |
|                       | page 64 and detailed throughout this         |
|                       | brochure. Your HCFSA will reimburse you for  |
|                       | such costs when they are for tax deductible  |
|                       | medical care for your and your dependents    |
|                       | that is NOT covered by this FEHB Plan or any |
|                       | other coverage that you have.                |
|                       |                                              |
|                       | Under FIRSTCARE, typical out-of-pocket       |
|                       | expenses include:                            |
|                       |                                              |
|                       | -   Copayment amounts for visits to the      |
|                       |     physician;                               |
|                       |                                              |
|                       | -   Copayment amounts for outpatient         |
|                       |     surgery; and                             |
|                       |                                              |
|                       | -   Copayment amount for hospitalization.    |
|                       |                                              |
|                       | Non-covered benefit expenses include:        |
|                       |                                              |
|                       | -   Vision refractive exams, eyeglasses, and |
|                       |     contact lenses;                          |
|                       |                                              |
|                       | -   Chiropractic treatment; and              |
|                       |                                              |
|                       | -   Radial keratotomy and other refractive   |
|                       |     surgery.                                 |
|                       |                                              |
|                       | The IRS governs expenses reimbursable by a   |
|                       | HCFSA. See Publication 502 for a             |
|                       | comprehensive list of tax-deductible medical |
|                       | expenses. **Note: While you will see         |
|                       | insurance premiums listed in Publication     |
|                       | 502, they are NOT a reimbursable expense for |
|                       | FSA purposes.** Publication 502 can be found |
|                       | on the IRS Web site at                       |
|                       | http://www.irs.gov/pub/irs-pdf/p502.pdf. If  |
|                       | you do not see your service or expense       |
|                       | listed in Publication 502, please call a     |
|                       | FSAFEDS Benefit Counselor at 877-FSAFEDS     |
|                       | (372-3337), who will be able to answer your  |
|                       | specific questions.                          |
|                       |                                              |
|                       | 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 chard      |
|                       | 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-**
  ----------------------------------------- -------------- --------------

+-----------------------+----------------------------------------------+
| -   **Tax credit and  | **Note:** This example is intended to        |
|     deductions**      | demonstrate a typical tax savings based on   |
|                       | 27% Federal and 7.65% FICA taxes. Actual     |
| **Health care         | savings will vary based upon which           |
| expenses**            | retirement system you are enrolled (CSRS or  |
|                       | FERS), as well as your individual tax        |
| **Dependent care      | situation. In this example, the individual   |
| expenses**            | received \$2,000 in services for \$1,424, a  |
|                       | discount of almost 36%! You may also wish to |
| -   **Does it cost me | consult a tax professional for more          |
|     anything to       | information on the tax implications of an    |
|     participate in    | FSA.                                         |
|     FSAFEDS?**        |                                              |
|                       | You *cannot* claim expenses on your Federal  |
| -   **Contact us**    | income tax return if you receive             |
|                       | reimbursement for them from your HCFSA or    |
|                       | DCFSA. Below are some guidelines that may    |
|                       | help you decide whether to participate in    |
|                       | FSAFEDS.                                     |
|                       |                                              |
|                       | 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.           |
|                       |                                              |
|                       | The DCRSA generally allows many families to  |
|                       | save more than they would with the Federal   |
|                       | tax credit for dependent care expenses. Note |
|                       | that you only may be reimbursed from the     |
|                       | DCFSA up to your current account balance. If |
|                       | you file a claim for more than your current  |
|                       | balance, it will be held until additional    |
|                       | payroll allotments have been added to your   |
|                       | account.                                     |
|                       |                                              |
|                       | Visit www.fsafeds.com and download the       |
|                       | Dependent Care Tax Credit Worksheet from the |
|                       | Quick Links box to help you determine what   |
|                       | is best for your situation. You may also     |
|                       | wish to consult a tax professional for more  |
|                       | details.                                     |
|                       |                                              |
|                       | Probably not. While there is an              |
|                       | administrative fee of \$4.00 per month for   |
|                       | an HCFSA and 1.5% of the annual election for |
|                       | a DCFSA, most agencies have elected to pay   |
|                       | these fees out of their share of employment  |
|                       | tax savings. To be sure, check the           |
|                       | FSAFEDS.com web site or call 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 play year and wind |
|                       | up forfeiting your end of the year account   |
|                       | balance, per the IRS "use it or lose it"     |
|                       | rule.                                        |
|                       |                                              |
|                       | To find out more or to enroll, please visit  |
|                       | the **FSAFEDS Web site** at                  |
|                       | **www.fsafeds.com**, or contact SHPS by      |
|                       | e-mail or by phone. SHPS Benefit Counselors  |
|                       | are available from 9:00 a.m. until 9:00 p.m. |
|                       | eastern time, Monday through Friday.         |
|                       |                                              |
|                       | -   E-mail: fsafeds@shps.net                 |
|                       |                                              |
|                       | -   Telephone: 877-FSAFEDS (372-3337)        |
|                       |                                              |
|                       | -   TTY: 800-952-0450 (for hearing impaired  |
|                       |     individuals that would like to utilize a |
|                       |     text messaging service)                  |
+-----------------------+----------------------------------------------+

**The Federal Long Term Care Insurance Program**

+-----------------------+----------------------------------------------+
| **It's important      | Here is why you should consider enrolling in |
| protection**          | the Federal Long Term Care Insurance         |
|                       | Program:                                     |
| **To find out more    |                                              |
| and to request an     | -   FEHB plans do not cover the cost of long |
| application**         |     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 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 your 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 the   |
|                       |     abbreviated underwriting. Qualified      |
|                       |     relatives are also eligible to apply     |
|                       |     with full underwriting.                  |
|                       |                                              |
|                       | Call 800-LTC-FEDS (800-582-3337) (TTY        |
|                       | 800-843-3557) or visit www.ltcfeds.com.      |
+-----------------------+----------------------------------------------+

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

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

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

**A**ccidental injury 27

Allergy tests 19

Allogeneic (donor) bone marrow

transplant 28

Alternative treatment 25

Ambulance 32

Anesthesia 29

Autologous bone marrow

transplant 28

**B**lood and blood plasma 30

Breast cancer screening 17

**C**asts 31

Catastrophic protection 14

Changes for 2004 10

Chemotherapy 20

Childbirth 18

Chiropractic 25

Cholesterol tests 17

Claims 44

Colorectal cancer screening 17

Congenital anomalies 26

Contraceptive devices and drugs 19

Coordination of benefits 47

Covered charges 16-42

Covered providers 11

Crutches 23

**D**eductible 14

Definitions 52

Dental care 42

Diabetic services 24

Diagnostic services 16

Dialysis 20

Disputed claims review 45

Donor expenses (transplants) 28

Dressings 31

Durable medical equipment

(DME) 23

**E**ducational classes and programs 25

Emergency 33

Experimental or investigational 52

Eyeglasses 21

**F**amily planning 19

Fecal occult blood test 17

**G**eneral Exclusions 43

**H**earing services 21

Home health services 25

Hospice care 32

Home nursing care 25

Hospital 30-31

**I**mmunizations 17

Infertility 19

In Hospital physician care 16

Inpatient Hospital Benefits 30

Insulin 38

**L**aboratory and pathological

services 16

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

Mail Order Prescription Drugs 37

Mammograms 17

Maternity Benefits 18

Medicaid 51

Medically necessary 53

Medicare 50

Mental Conditions/Substance Abuse Benefits 36

**N**ewborn care 18

Nurse Anesthetist 30

Nursery charges 18

**O**bstetrical care 18

Occupational therapy 20

Office visits 16

Oral and maxillofacial surgery 28

Orthopedic devices 22

Ostomy supplies 23

Out-of-pocket expenses 14

Outpatient facility care 31

Oxygen 23

**P**ap test 17

Physical examination 17

Physical therapy 20

Pre-admission testing 30

Preventive care, adult 17

Preventive care, children 18

Prescription drugs 37

Preventive services 17

Preauthorization 13

Prostate cancer screening 17

Prosthetic devices 22

**R**adiation therapy 20

Room and board 30

**S**econd surgical opinion 16

Skilled nursing facility care 31

Smoking cessation 39

Speech therapy 21

Splints 30

Sterilization procedures 19

Subrogation 51

Substance abuse 36

Surgery 26

-   Anesthesia 29

```{=html}
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```
-   Oral 28

-   Outpatient 31

-   Reconstructive 27

    Syringes 24, 39

    **T**emporary continuation of coverage 56

    Transplants 28

Treatment therapies 20

**U**sual, Reasonable and Customary (UCR) 53

**V**ision services 21

Well child care 18

Wheelchairs 23

Workers' compensation 51

**X**-rays 16

  -----------------------------------------------------------------------
  **Summary of benefits for FIRSTCARE -- 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.

```{=html}
<!-- -->
```
-   If you want to enroll or change your enrollment in this Plan, be
    sure to put the correct enrollment code from the cover on your
    enrollment form.

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

+-------------------------------------------+----------------------+---+
| **Benefits**                              | **You Pay**          | * |
|                                           |                      | * |
|                                           |                      | P |
|                                           |                      | a |
|                                           |                      | g |
|                                           |                      | e |
|                                           |                      | * |
|                                           |                      | * |
+-------------------------------------------+----------------------+---+
| Medical services provided by physicians:  | Office visit copay:  | > |
|                                           | \$15 primary care;   |   |
| -   Diagnostic and treatment services     | \$25 specialist      | 1 |
|     provided in the office                |                      | 6 |
+-------------------------------------------+----------------------+---+
| Services provided by a hospital:          | > \$100 per          | > |
|                                           | > admission          |   |
| -   Inpatient                             | >                    | 3 |
|                                           | > \$50 per visit     | 0 |
| -   Outpatient                            |                      | > |
|                                           |                      | > |
|                                           |                      |   |
|                                           |                      | 3 |
|                                           |                      | 1 |
+-------------------------------------------+----------------------+---+
| Emergency benefits:                       | \$100 per emergency  | > |
|                                           | room visit; waived   |   |
| -   In-area                               | if admitted          | 3 |
|                                           |                      | 4 |
| -   Out-of-area                           | > \$100 per          | > |
|                                           | > emergency room     | > |
|                                           | > visit; waived if   |   |
|                                           | > admitted.          | 3 |
|                                           |                      | 4 |
+-------------------------------------------+----------------------+---+
| > Mental health and substance abuse       | > Regular cost       | > |
| > treatment                               | > sharing            |   |
|                                           |                      | 3 |
|                                           |                      | 6 |
+-------------------------------------------+----------------------+---+
| Prescription                              | **Retail Pharmacy:** | > |
| drugs.........................            | \$10 copay for       |   |
| ......................................... | generic drugs; \$20  | 3 |
|                                           | copay for Preferred  | 7 |
| Retail Pharmacy: For up to a 30-day       | Name Brand drugs     |   |
| supply per prescription unit or refill    | when a generic is    |   |
|                                           | not available; \$40  |   |
| Mail Order Pharmacy: For up to a 90-day   | copay for            |   |
| supply per prescription unit or refill    | non-Preferred drugs; |   |
|                                           | and \$10 copay for   |   |
| Note: For additional details about your   | Preferred Name Brand |   |
| prescription benefit, please read Section | drugs when a generic |   |
| 5 (f).                                    | drug is available,   |   |
|                                           | plus difference in   |   |
|                                           | cost between the     |   |
|                                           | generic and          |   |
|                                           | Preferred Name Brand |   |
|                                           | drugs.               |   |
|                                           |                      |   |
|                                           | > **Mail Order       |   |
|                                           | > Pharmacy:** \$20   |   |
|                                           | > copay              |   |
|                                           | >                    |   |
|                                           | > for generic drugs; |   |
|                                           | > \$40 copay for     |   |
|                                           | >                    |   |
|                                           | > Preferred Name     |   |
|                                           | > Brand drugs when a |   |
|                                           | > generic is not     |   |
|                                           | > available; \$80    |   |
|                                           | > copay for          |   |
|                                           | > non-Preferred      |   |
|                                           | > drugs; and \$20    |   |
|                                           | > copay for          |   |
|                                           | > Preferred Name     |   |
|                                           | > Brand drugs when a |   |
|                                           | > generic drug is    |   |
|                                           | > available, plus    |   |
|                                           | > difference in cost |   |
|                                           | > between the        |   |
|                                           | > generic and        |   |
|                                           | > Preferred Name     |   |
|                                           | > Brand drugs.       |   |
+-------------------------------------------+----------------------+---+
| Dental Care                               | > No benefit.        | > |
|                                           |                      |   |
|                                           |                      | 4 |
|                                           |                      | 2 |
+-------------------------------------------+----------------------+---+
| Vision Care                               | > Nothing during     | > |
|                                           | > office visit.      |   |
|                                           |                      | 2 |
|                                           |                      | 1 |
+-------------------------------------------+----------------------+---+
| Special features: Services for deaf and   |                      | > |
| hearing impaired; Centers of excellence   |                      |   |
| for transplants/heart surgery/etc.        |                      | 4 |
|                                           |                      | 1 |
+-------------------------------------------+----------------------+---+
| Protection against catastrophic costs     | Nothing after 200%   | > |
|                                           | of annual            |   |
| (your catastrophic protection             | premium/Self Only or | 1 |
| out-of-pocket maximum)                    | 200% of annual       | 4 |
|                                           | premium/Family       |   |
|                                           | enrollment.          |   |
|                                           |                      |   |
|                                           | Some costs do not    |   |
|                                           | count toward this    |   |
|                                           | protection.          |   |
+-------------------------------------------+----------------------+---+

**2004 Rate Information for**

**FIRSTCARE**

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

**Postal rates** apply to career Postal Service employees. Most
employees should refer to the FEHB Guide for United States Postal
Service Employees, RI 70-2. Different postal rates apply and special
FEHB guides are published for Postal Service Nurses, RI 70-2B; and 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** |
+--------------+-----+-------+-------+-------+-------+-------+-------+

##### Central Texas 

  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------
  Self Only       **6U1**   **\$112.38**   **\$37.46**   **\$243.49**   **\$81.16**    **\$132.98**   **\$16.86**

  Self and Family **6U2**   **\$241.42**   **\$80.47**   **\$523.07**   **\$174.36**   **\$285.68**   **\$36.21**
  --------------- --------- -------------- ------------- -------------- -------------- -------------- -------------

West Texas

  --------------- --------- -------------- -------------- -------------- -------------- -------------- -------------
  Self Only       **CK1**   **\$121.40**   **\$67.69**    **\$263.03**   **\$146.67**   **\$143.32**   **\$45.77**

  Self and Family **CK2**   **\$277.09**   **\$129.08**   **\$600.36**   **\$279.68**   **\$327.12**   **\$79.05**
  --------------- --------- -------------- -------------- -------------- -------------- -------------- -------------