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Dear Federal Employees Health Benefits Program Participant:

Welcome to the 2005 Open Season! By continuing to introduce pro-consumer
health care ideas, the Office of Personnel Management (OPM) team has
given you greater, cost effective choices. This year several national
and local health plans are offering new options, strengthening the
Federal Employees Health Benefits (FEHB) Program and highlighting once
again its unique and distinctive market-oriented features. I remain firm
in my belief that you, when fully informed as a Federal subscriber, are
in the best position to make the decisions that meet your needs and
those of your family. Plan brochures provide information to help
subscribers make these fully informed decisions. Please take the time to
review the plan's benefits, particularly Section 2, which explains plan
changes.

Exciting new features this year give you additional opportunities to
save and better manage your hard-earned dollars. For 2005, I am very
pleased and enthusiastic about the new High Deductible Health Plans
(HDHP) with a Health Savings Account (HSA) or Health Reimbursement
Arrangement (HRA) component. This combination of health plan and savings
vehicle provides a new opportunity to save and better manage your money.
If an HDHP/HSA is not for you and you are not retired, I encourage you
to consider a Flexible Spending Account (FSA) for health care. FSAs
allow you to reduce your out-of-pocket health care costs by 20 to more
than 40 percent by paying for certain health care expenses with tax-free
dollars, instead of after-tax dollars.

Since prevention remains a major factor in the cost of health care, last
year OPM launched the *HealthierFeds* campaign. Through this effort we
are encouraging Federal team members to take greater responsibility for
living a healthier lifestyle. The positive effect of a healthier life
style brings dividends for you and reduces the demands and costs within
the health care system. This campaign embraces four key "actions" that
can lead to a healthy America: be physically active every day, eat a
nutritious diet, seek out preventative screenings, and make healthy
lifestyle choices. Be sure to visit *HealthierFeds* at
[www.healthierfeds.opm.gov](http://www.healthierfeds.opm.gov/) for more
details on this important initiative. I also encourage you to visit the
Department of Health and Human Services website on Wellness and Safety,
[www.hhs.gov/safety/index.html](http://www.hhs.gov/safety/index.shtml),
which complements and broadens healthier lifestyle resources. The site
provides extensive information from health care experts and
organizations to support your personal interest in staying healthy.

The FEHB Program offers the Federal team the widest array of
cost-effective health care options and the information needed to make
the best choice for you and your family. You will find comprehensive
health plan information in this brochure, in the 2005 Guide to FEHB
Plans, and on the OPM Website at
[www.opm.gov/insure](http://www.opm.gov/insure). I hope you find these
resources useful, and thank you once again for your service to the
nation.

> Sincerely,
>
> Kay Coles James
>
> Director

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

**Privacy Practices**

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.

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

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

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

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

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

-   Where required by law.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-   Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice,
look at [www.opm.gov/insure](http://www.opm.gov/insure) on the Web. You
may also call 202-606-0745 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

Unites States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

Table of Contents

[Introduction 3](#introduction)

[Plain Language 3](#plain-language)

[Stop Health Care Fraud! 3](#stop-health-care-fraud)

[Preventing medical mistakes 3](#preventing-medical-mistakes)

[Section 1. Facts about this HMO plan
3](#section-1.-facts-about-this-hmo-plan)

[How we pay providers 3](#how-we-pay-providers)

[Your Rights 3](#your-rights)

[Service Area 3](#service-area)

[Section 2. How we change for 2005
3](#section-2.-how-we-change-for-2005)

[Program-wide changes 3](#program-wide-changes)

[Changes to this Plan 3](#changes-to-this-plan)

[Section 3. How you get care 3](#section-3.-how-you-get-care)

[Identification cards 3](#identification-cards)

[Where you get covered care 3](#where-you-get-covered-care)

[• Plan providers 3](#plan-providers)

[• Plan facilities 3](#plan-facilities)

[What you must do to get covered care
3](#what-you-must-do-to-get-covered-care)

[• Primary care 3](#primary-care)

[• Specialty care 3](#specialty-care)

[• Hospital care 3](#hospital-care)

[Circumstances beyond our control 3](#circumstances-beyond-our-control)

[Services requiring our prior approval
3](#services-requiring-our-prior-approval)

[Section 4. Your costs for covered services
3](#section-4.-your-costs-for-covered-services)

[Copayments 3](#copayments)

[Deductible 3](#deductible)

[Coinsurance 3](#coinsurance)

[Your catastrophic protection out-of-pocket maximum
3](#your-catastrophic-protection-out-of-pocket-maximum)

[Section 5. Benefits -- OVERVIEW *(See page 7 for how our benefits
changed this year and page 66 for a benefits summary.)*
3](#section-5.-benefits-overview-see-page-7-for-how-our-benefits-changed-this-year-and-page-54-for-a-benefits-summary.)

[Section 5(a) Medical services and supplies provided by physicians and
other health care professionals
3](#section-5a-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)

[Section 5(b) Surgical and anesthesia services provided by physicians
and other health care professionals
3](#section-5b-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)

[Section 5(c) Services provided by a hospital or other facility, and
ambulance services
3](#section-5c-services-provided-by-a-hospital-or-other-facility-and-ambulance-services)

[Section 5(d) Emergency services/accidents
3](#section-5d-emergency-servicesaccidents)

[Section 5(e) Mental health and substance abuse benefits
3](#section-5e-mental-health-and-substance-abuse-benefits)

[Section 5(f) Prescription drug benefits
3](#section-5f-prescription-drug-benefits)

[Section 5(g) Special features 3](#section-5g-special-features)

-   
-   

[Flexible benefits option 3](#flexible-benefits-option)[High risk
pregnancies 3](#high-risk-pregnancies)[Section 5(h) Dental benefits
3](#section-5h-dental-benefits)

[Section 6. General exclusions -- things we don't cover
3](#section-6.-general-exclusions-things-we-dont-cover)

[Section 7. Filing a claim for covered services
3](#section-7.-filing-a-claim-for-covered-services)

[Section 8. The disputed claims process
3](#section-8.-the-disputed-claims-process)

[Section 9. Coordinating benefits with other coverage
3](#section-9.-coordinating-benefits-with-other-coverage)

[When you have other health coverage
3](#when-you-have-other-health-coverage)

[What is Medicare? 3](#what-is-medicare)

[• Should I enroll in Medicare? 3](#should-i-enroll-in-medicare)

[• The Original Medicare Plan (Part A or Part B)
3](#the-original-medicare-plan-part-a-or-part-b)

[• Medicare Advantage 3](#medicare-advantage)

[TRICARE and CHAMPVA 3](#tricare-and-champva)

[Workers' Compensation 3](#workers-compensation)

[Medicaid 3](#medicaid)

[When other Government agencies are responsible for your care
3](#when-other-government-agencies-are-responsible-for-your-care)

[When others are responsible for injuries
3](#when-others-are-responsible-for-injuries)

[Section 10. Definitions of terms we use in this brochure
3](#section-10.-definitions-of-terms-we-use-in-this-brochure)

[Section 11. FEHB Facts 3](#section-11.-fehb-facts)

[Coverage information 3](#coverage-information)

[• No pre-existing condition limitation
3](#no-pre-existing-condition-limitation)

[• Where you can get information about enrolling in the FEHB Program
3](#where-you-can-get-information-about-enrolling-in-the-fehb-program)

[• Types of coverage available for you and your family
3](#types-of-coverage-available-for-you-and-your-family)

[• Children's Equity Act 3](#childrens-equity-act)

[• When benefits and premiums start
3](#when-benefits-and-premiums-start)

[• When you retire 3](#when-you-retire)

[When you lose benefits 3](#when-you-lose-benefits)

[• When FEHB coverage ends 3](#when-fehb-coverage-ends)

[• Spouse equity coverage 3](#spouse-equity-coverage)

[• Temporary Continuation of Coverage (TCC)
3](#temporary-continuation-of-coverage-tcc)

[• Converting to individual coverage
3](#converting-to-individual-coverage)

[• Getting a Certificate of Group Health Plan Coverage
3](#getting-a-certificate-of-group-health-plan-coverage)

[Two Federal Programs complement FEHB benefits
3](#section-12.-two-federal-programs-complement-fehb-benefits)

[The Federal Flexible Spending Account Program -- *FSAFEDS*
3](#the-federal-flexible-spending-account-program-fsafeds)

[The Federal Long Term Care Insurance Program
3](#the-federal-long-term-care-insurance-program)

[Index 3](#index)

[Summary of benefits for WINhealth Partners *-* 2005
3](#summary-of-benefits-for-winhealth-partners---2005)

[2005 Rate Information for WINhealth Partners
3](#rate-information-for-winhealth-partners)

# Introduction

This brochure describes the benefits of WINhealth Partners under our
contract (CS 2859) with the United States Office of Personnel
Management, as authorized by the Federal Employees Health Benefits law.
The address for WINhealth Partners administrative offices is:

WINhealth Partners

1200 East 20^th^ Street

Cheyenne, WY 82001

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

If you are enrolled in this Plan, you are entitled to the benefits
described in this brochure.

If you are enrolled in Self and Family coverage, each eligible family
member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2005, unless those
benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2005, and changes are summarized on
page 7. Rates are shown at the end of this brochure.

# Plain Language

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

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

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

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

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

# Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

    If the provider does not resolve the matter, call us at (307)
    638-7700 and explain the situation.

    If we do not resolve the issue:

-   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 or try to
    obtain services for someone who is not an eligible family member or
    who is no longer enrolled in the Plan.

# Preventing medical mistakes

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

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

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

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

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

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

-   Tell them about any drug allergies you have.

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

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

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

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

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

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

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

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

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

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

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

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

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

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

-   Ask your surgeon:

> Exactly what will you be doing?
>
> About how long will it take?
>
> What will happen after surgery?
>
> How can I expect to feel during recovery?

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

Want more information on patient safety?

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

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

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

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

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

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

# Section 1. Facts about this HMO plan

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

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

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

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

### How we pay providers

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

### Your Rights

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

-   WINhealth Partners meets State Licensing requirements

-   WINhealth Partners has been in existence for 9 years

-   WINhealth Partners is a not-for-profit organization

-   WINhealth Partners has initiated a thorough procedure for handling
    complaints and grievance

If you want more information about us, call (307) 638-7700, or write to
1200 East 20^th^ Street, Cheyenne, WY 82001. You may also contact us by
fax at (307) 638-7701 or visit our Web site at
[www.winhealthpartners.org](http://www.winhealthpartners.org/).

### Service Area

To enroll in this Plan, you must live in or work in our Service Area.
*Our service area is: Laramie, Carbon, Goshen, Big Horn, Uinta, Niobrara
and Park counties in Wyoming.*

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 out of our service area unless the services have prior plan
approval.

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

# Section 2. How we change for 2005

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

-   Section 9 - Coordinating benefits with other coverage

-   Section 12 -- Two new federal programs complement FEHB benefits

### Changes to this Plan

-   Your share of the non-Postal premium will decrease by 16% for Self
    Only or 16% for Family.

# Section 3. How you get care

+--------------------+-------------------------------------------------+
| ### Id             | We will send you an identification (ID) card    |
| entification cards | when you enroll. You should carry your ID card  |
|                    | with you at all times. You must show it         |
|                    | whenever you receive services from a Plan       |
|                    | provider, or fill a prescription at a Plan      |
|                    | pharmacy. Until you receive your ID card, use   |
|                    | your copy of the Health Benefits Election Form, |
|                    | SF-2809, your health benefits enrollment        |
|                    | confirmation (for annuitants), or your Employee |
|                    | Express confirmation letter.                    |
+--------------------+-------------------------------------------------+
|                    | If you do not receive your ID card within 30    |
|                    | days after the effective date of your           |
|                    | enrollment, or if you need replacement cards,   |
|                    | call us at (307) 638-7700 or write to us at     |
|                    | 1200 East 20^th^ Street, Suite A, Cheyenne, WY  |
|                    | 82001. You may also request replacement cards   |
|                    | through our Web site at                         |
|                    | [www.winhealthpa                                |
|                    | rtners.org](http://www.winhealthpartners.org/). |
+--------------------+-------------------------------------------------+
| ### Where yo       | You get care from "Plan providers" and "Plan    |
| u get covered care | facilities." You will only pay copayments,      |
|                    | deductibles, and/or coinsurance, and you will   |
|                    | not have to file claims.                        |
+--------------------+-------------------------------------------------+
| #                  | Plan providers are physicians and other health  |
| ### Plan providers | care professionals in our service area that we  |
|                    | contract with to provide covered services to    |
|                    | our members. We credential Plan providers       |
|                    | according to national standards.                |
|                    |                                                 |
|                    | We list Plan providers in the provider          |
|                    | directory, which we update periodically. The    |
|                    | list is also on our Web site.                   |
+--------------------+-------------------------------------------------+
| ##                 | Plan facilities are hospitals and other         |
| ## Plan facilities | 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 Web site.                   |
+--------------------+-------------------------------------------------+
| ###                | It depends on the type of care you need.        |
| What you must do t | WINhealth Partners utilizes an integrated       |
| o get covered care | health care delivery network that includes      |
|                    | Physicians, Hospitals, allied health and        |
|                    | ancillary service providers. You gain access to |
|                    | the network and its benefits by selecting a     |
|                    | contracted network Physician from the list of   |
|                    | participating Wyoming physicians. Your local    |
|                    | Physician will help coordinate your care within |
|                    | the WINhealth Partners network.                 |
|                    |                                                 |
|                    | > Our Participating Provider Directory lists    |
|                    | > those select Physicians, facilities, and      |
|                    | > ancillary service providers who participate   |
|                    | > in our HMO. WINhealth Partners does strongly  |
|                    | > encourage a long-term primary relationship    |
|                    | > with a Physician or Physicians who understand |
|                    | > the particular health needs of each patient.  |
+--------------------+-------------------------------------------------+
| #### Primary care  | Your primary care physician can be any          |
|                    | physician within the WINhealth Partners'        |
|                    | network of participating physicians. Your       |
|                    | primary care physician will provide most of     |
|                    | your health care. WINhealth Partners is an open |
|                    | access network. If you want to change primary   |
|                    | care physicians or if your primary care         |
|                    | physician leaves the Plan, you do not need to   |
|                    | notify us.                                      |
+--------------------+-------------------------------------------------+
| #                  | WINhealth Partners is an open access system.    |
| ### Specialty care | You may select any specialist physician within  |
|                    | WINhealth Partners' network of participating    |
|                    | physicians. You do not need a referral to see a |
|                    | participating specialist for needed care.       |
|                    |                                                 |
|                    | Here are some 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 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 and disabling         |
|                    |     condition and lose access to your           |
|                    |     specialist because we:                      |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   Terminate our contract with your specialist |
|                    |     for other than cause; or                    |
|                    |                                                 |
|                    | -   Drop out of the Federal Employees Health    |
|                    |     Benefits (FEHB) Program and you enroll in   |
|                    |     another FEHB program Plan; or               |
|                    |                                                 |
|                    | -   Reduce our service area and you enroll in   |
|                    |     another FEHB Plan,                          |
|                    |                                                 |
|                    | You may be able to continue seeing your         |
|                    | specialist for up to 90 days after you receive  |
|                    | notice of the change. Contact us, or if we drop |
|                    | out of the Program, contact your new plan.      |
|                    |                                                 |
|                    | If you are in the second or third trimester of  |
|                    | pregnancy and you lose access to your           |
|                    | specialist based on the above circumstances,    |
|                    | you can continue to see your specialist until   |
|                    | the end of your postpartum care, even if it is  |
|                    | beyond the 90 days.                             |
+--------------------+-------------------------------------------------+
| #### Hospital care | Your Plan primary care physician or specialist  |
|                    | will make necessary hospital arrangements and   |
|                    | supervise your care. This includes admission to |
|                    | a skilled nursing or other type of facility.    |
|                    |                                                 |
|                    | If you are in the hospital when your enrollment |
|                    | in our Plan begins, call our customer service   |
|                    | department immediately at (307) 638-7700. If    |
|                    | you are new to the FEHB Program, we will        |
|                    | arrange for you to receive care.                |
|                    |                                                 |
|                    | If you changed from another FEHB plan to us,    |
|                    | your former plan will pay for the hospital stay |
|                    | until:                                          |
|                    |                                                 |
|                    | -   You are discharged, not merely moved to an  |
|                    |     alternative care center; or                 |
|                    |                                                 |
|                    | -   The day your benefits from your former plan |
|                    |     run out; or                                 |
|                    |                                                 |
|                    | -   The 92^nd^ day after you become a member of |
|                    |     this Plan, whichever happens first.         |
|                    |                                                 |
|                    | These provisions apply only to the benefits of  |
|                    | the hospitalized person. If your plan           |
|                    | terminates participation in the FEHB Program in |
|                    | whole or in part, or if OPM orders an           |
|                    | enrollment change, this continuation of         |
|                    | coverage provision does not apply. In such      |
|                    | case, the hospitalized family member's benefits |
|                    | under the new plan begin on the effective date  |
|                    | of enrollment.                                  |
+--------------------+-------------------------------------------------+
| ### Circumstances  | Under certain extraordinary circumstances, such |
| beyond our control | 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. |
+--------------------+-------------------------------------------------+
| ### S              | Your WINhealth Partners' physician has          |
| ervices requiring  | authority to refer you for most services. For   |
| our prior approval | certain services, however, your physician must  |
|                    | obtain approval from us. Before giving          |
|                    | approval, we consider if the service is         |
|                    | covered, medically necessary, and follows       |
|                    | generally accepted medical practice.            |
|                    |                                                 |
|                    | We call this review and approval process        |
|                    | *preauthorization. Your physician must obtain   |
|                    | preauthorization for the following services:*   |
|                    |                                                 |
|                    | -   All transplants                             |
|                    |                                                 |
|                    | -   Durable medical equipment                   |
|                    |                                                 |
|                    | -   Orthopedic and prosthetic devices           |
|                    |                                                 |
|                    | -   Home health care                            |
|                    |                                                 |
|                    | -   Nursing home admission                      |
|                    |                                                 |
|                    | -   Infertility treatment                       |
|                    |                                                 |
|                    | -   Mental health/substance abuse               |
|                    |                                                 |
|                    | -   Magnetic resonance imaging (MRI), MRA and   |
|                    |     PET scan                                    |
|                    |                                                 |
|                    | -   CT scans                                    |
|                    |                                                 |
|                    | -   Any services outside of the WINhealth       |
|                    |     Partners provider network                   |
|                    |                                                 |
|                    | -   Diabetic nutritional counseling             |
|                    |                                                 |
|                    | -   Gastric bypass surgery                      |
|                    |                                                 |
|                    | -   Covered Dental Services                     |
|                    |                                                 |
|                    | -   Certain prescription drugs -- see preferred |
|                    |     drug list for details --                    |
|                    |                                                 |
|                    | -   Reconstructive surgery                      |
|                    |                                                 |
|                    | -   Non-emergent hospital admissions            |
|                    |                                                 |
|                    | -   Hospice                                     |
|                    |                                                 |
|                    | -   Podiatry                                    |
|                    |                                                 |
|                    | After your physician has obtained               |
|                    | preauthorization from us, a letter stating      |
|                    | whether the requested service has been approved |
|                    | will be sent to your physician and to you.      |
|                    | Services that are obtained without the required |
|                    | physician referral and preauthorization may not |
|                    | be covered.                                     |
+--------------------+-------------------------------------------------+

# Section 4. Your costs for covered services

You must share the costs 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 \$10 per office visit.     |
|                  |                                                   |
|                  | Administration to keep copay.                     |
+------------------+---------------------------------------------------+
| ### Deductible   | A deductible is a fixed expense you must incur    |
|                  | for certain covered services and supplies before  |
|                  | we start paying benefits for them. Copayments do  |
|                  | not count toward any deductible.                  |
|                  |                                                   |
|                  | *Deductible not applicable to this plan.*         |
|                  |                                                   |
|                  | Note: If you change plans during open season, you |
|                  | do not have to start a new deductible under your  |
|                  | old plan between January 1 and the effective date |
|                  | of your new plan. If you change plans at another  |
|                  | time during the year, you must begin a new        |
|                  | deductible under your new plan.                   |
|                  |                                                   |
|                  | And, if you change options in this Plan during    |
|                  | the year, we will credit the amount of covered    |
|                  | expenses already applied toward the deductible of |
|                  | your old option to the deductible of your new     |
|                  | option.                                           |
+------------------+---------------------------------------------------+
| ### Coinsurance  | Coinsurance is the percentage of our allowance    |
|                  | that you must pay for your care.                  |
|                  |                                                   |
|                  | Example: In our Plan, you pay 20% of our          |
|                  | allowance for durable medical equipment.          |
+------------------+---------------------------------------------------+
| ### You          | After your copayments and coinsurance total       |
| r catastrophic p | \$2,000 per person or \$4,000 per family          |
| rotection out-of | enrollment in any calendar year, you do not have  |
| -pocket maximum  | to pay any more for covered services. However,    |
|                  | copayments for the following services do not      |
|                  | count toward your catastrophic protection         |
|                  | out-of-pocket maximum, and you must continue to   |
|                  | pay copayments for these services:                |
|                  |                                                   |
|                  | 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 7 for how our benefits changed this year and page 54 for a benefits summary.)*

Note: This benefits section is divided into subsections. Please read the
important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at
(307) 638-7700 or at our Web site at
[www.winhealthpartners.org](http://www.xxx.xxx/).

a.  Medical services and supplies provided by physicians and other
    health care professionals 13-21

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

b.  Surgical and anesthesia services provided by physicians and other
    health care professionals 22-25

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

c.  Services provided by a hospital or other facility, and ambulance
    services 26-27

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

Section 5(d) Emergency services/accidents 28-29

> •Medical emergency
>
> •Ambulance

Section 5(e) Mental health and substance abuse benefits 30

> •Mental health and substance abuse benefits

Section 5(f) Prescription drug benefits 31-33

•Covered medicines and supplies

Section 5(g) Special features 34

> •Flexible benefits option
>
> •High risk pregnancies

Section 5(h) Dental benefits 35

•No benefits

•Accidental Injury Benefit

Summary of benefits for WINhealth Partners 54

•2005 Rate Information for WINhealth Partners

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

+---+---+-------------------------------------+---------------------+---+---+
|   | * | **Here are some important things    |                     | * |   |
|   | * | you should keep in mind about these |                     | * |   |
|   | I | benefits:**                         |                     | I |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Plan physicians must provide or |                     | * |   |
|   | * |     arrange your care.              |                     | * |   |
|   | P |                                     |                     | P |   |
|   | * | -   Be sure to read Section 4,      |                     | * |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   |   |     services*, for valuable         |                     |   |   |
|   | * |     information about how cost      |                     | * |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   | O |     Section 9 about coordinating    |                     | O |   |
|   | * |     benefits with other coverage,   |                     | * |   |
|   | * |     including with Medicare.        |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | R |                                     |                     | R |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | A |                                     |                     | A |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | N |                                     |                     | N |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| D |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
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| s |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$10 per office     |   |   |
| r |   |                                     | visit               |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
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| l |   |                                     |                     |   |   |
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| f |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| I |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| ' |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$10 per office     |   |   |
| r |   |                                     | visit               |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
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| T |   |                                     | Nothing.            |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     | \$100 per scan for  |   |   |
| t |   |                                     | MRI, CT scans, PET  |   |   |
| s |   |                                     | scans, Sleep        |   |   |
| , |   |                                     | Studies and other   |   |   |
| s |   |                                     | complex radiology   |   |   |
| u |   |                                     | scans.              |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | **You pay**         |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| R |   |                                     | \$10 per office     |   |   |
| o |   |                                     | visit               |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| R |   |                                     | \$10 per office     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
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| R |   |                                     | \$10 per office     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$10 per office     |   |   |
|   |   |                                     | visit               |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
|   |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | **You pay**         |   |   |
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| U |   |                                     | \$15 per office     |   |   |
| p |   |                                     | visit               |   |   |
| t |   |                                     |                     |   |   |
| o |   |                                     | \$25 per outpatient |   |   |
| t |   |                                     | visit               |   |   |
| w |   |                                     |                     |   |   |
| o |   |                                     | \$25 per visit      |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| U |   |                                     | \$25 per visit      |   |   |
| p |   |                                     |                     |   |   |
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| - |   |                                     | \$10 per office     |   |   |
|   |   |                                     | visit               |   |   |
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| * |   |                                     | *All charges.*      |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| R |   |                                     | 20% of our          |   |   |
| e |   |                                     | allowance           |   |   |
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| t |   |                                     | \$5,000 benefit     |   |   |
| a |   |                                     | maximum per year    |   |   |
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| * |   |                                     | *All charges.*      |   |   |
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| - |   |                                     | \$15 per office     |   |   |
|   |   |                                     | visit with a        |   |   |
|   |   |                                     | maximum annual      |   |   |
|   |   |                                     | benefit of \$500.   |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
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|   |   |                                     |                     |   |   |
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| * |   |                                     | **You pay**         |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
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| C |   |                                     | \$10 per office     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+

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

+---+---+------------------------------------+--------------------+---+---+
|   | * | **Here are some important things   |                    | * |   |
|   | * | you should keep in mind about      |                    | * |   |
|   | I | these benefits:**                  |                    | I |   |
|   | * |                                    |                    | * |   |
|   | * | -   Please remember that all       |                    | * |   |
|   |   |     benefits are subject to the    |                    |   |   |
|   | * |     definitions, limitations, and  |                    | * |   |
|   | * |     exclusions in this brochure    |                    | * |   |
|   | M |     and are payable only when we   |                    | M |   |
|   | * |     determine they are medically   |                    | * |   |
|   | * |     necessary.                     |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   Plan physicians must provide   |                    | * |   |
|   | * |     or arrange your care.          |                    | * |   |
|   | P |                                    |                    | P |   |
|   | * | -   Be sure to read Section 4,     |                    | * |   |
|   | * |     *Your costs for covered        |                    | * |   |
|   |   |     services*, for valuable        |                    |   |   |
|   | * |     information about how cost     |                    | * |   |
|   | * |     sharing works. Also read       |                    | * |   |
|   | O |     Section 9 about coordinating   |                    | O |   |
|   | * |     benefits with other coverage,  |                    | * |   |
|   | * |     including with Medicare.       |                    | * |   |
|   |   |                                    |                    |   |   |
|   | * | -   The amounts listed below are   |                    | * |   |
|   | * |     for the charges billed by a    |                    | * |   |
|   | R |     physician or other health care |                    | R |   |
|   | * |     professional for your surgical |                    | * |   |
|   | * |     care. Look in Section 5(c) for |                    | * |   |
|   |   |     charges associated with the    |                    |   |   |
|   | * |     facility (i.e. hospital,       |                    | * |   |
|   | * |     surgical center, etc.).        |                    | * |   |
|   | T |                                    |                    | T |   |
|   | * | -   YOUR PHYSICIAN MUST GET        |                    | * |   |
|   | * |     PRECERTIFICATION OF SOME       |                    | * |   |
|   |   |     SURGICAL PROCEDURES. Please    |                    |   |   |
|   | * |     refer to the precertification  |                    | * |   |
|   | * |     information shown in Section 3 |                    | * |   |
|   | A |     to be sure which services      |                    | A |   |
|   | * |     require precertification and   |                    | * |   |
|   | * |     identify which surgeries       |                    | * |   |
|   |   |     require precertification.      |                    |   |   |
|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
|   | N |                                    |                    | N |   |
|   | * |                                    |                    | * |   |
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|   | * |                                    |                    | * |   |
|   | * |                                    |                    | * |   |
+---+---+------------------------------------+--------------------+---+---+
| B |   |                                    | You pay            |   |   |
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+---+---+------------------------------------+--------------------+---+---+
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+---+---+------------------------------------+--------------------+---+---+

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

+---+---+-------------------------------------+---------------------+---+---+
|   | * | **Here are some important things    |                     | * |   |
|   | * | you should keep in mind about these |                     | * |   |
|   | I | benefits:**                         |                     | I |   |
|   | * |                                     |                     | * |   |
|   | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   Plan physicians must provide or |                     | * |   |
|   | * |     arrange your care and you must  |                     | * |   |
|   | P |     be hospitalized in a Plan       |                     | P |   |
|   | * |     facility.                       |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | -   Be sure to read Section 4,      |                     |   |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | * |     services* for valuable          |                     | * |   |
|   | O |     information about how cost      |                     | O |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   | * |     Section 9 about coordinating    |                     | * |   |
|   |   |     benefits with other coverage,   |                     |   |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | * |                                     |                     | * |   |
|   | R | -   The amounts listed below are    |                     | R |   |
|   | * |     for the charges billed by the   |                     | * |   |
|   | * |     facility (i.e., hospital or     |                     | * |   |
|   |   |     surgical center) or ambulance   |                     |   |   |
|   | * |     service for your surgery or     |                     | * |   |
|   | * |     care. Any costs associated with |                     | * |   |
|   | T |     the professional charge (i.e.,  |                     | T |   |
|   | * |     physicians, etc.) are in        |                     | * |   |
|   | * |     Sections 5(a) or (b).           |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   **YOUR PHYSICIAN MUST GET       |                     | * |   |
|   | * |     PRECERTIFICATION OF HOSPITAL    |                     | * |   |
|   | A |     STAYS.** Please refer to        |                     | A |   |
|   | * |     Section 3 to be sure which      |                     | * |   |
|   | * |     services require                |                     | * |   |
|   |   |     precertification.               |                     |   |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
|   | N |                                     |                     | N |   |
|   | * |                                     |                     | * |   |
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|   | * |                                     |                     | * |   |
|   | T |                                     |                     | T |   |
|   | * |                                     |                     | * |   |
|   | * |                                     |                     | * |   |
+---+---+-------------------------------------+---------------------+---+---+
| B |   |                                     | You pay             |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
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+---+---+-------------------------------------+---------------------+---+---+
| R |   |                                     | \$100 per admission |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
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| v |   |                                     |                     |   |   |
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| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| : |   |                                     |                     |   |   |
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| * |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
| - |   |                                     |                     |   |   |
| W |   |                                     |                     |   |   |
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| v |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
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| v |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
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| p |   |                                     |                     |   |   |
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| l |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
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| t |   |                                     |                     |   |   |
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| p |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| . |   |                                     |                     |   |   |
| W |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
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| s |   |                                     |                     |   |   |
| . |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
| N |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
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| B |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
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| r |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     | You pay             |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
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| x |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| / |   |                                     |                     |   |   |
| S |   |                                     |                     |   |   |
| k |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| S |   |                                     | Nothing             |   |   |
| k |   |                                     |                     |   |   |
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| l |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| ( |   |                                     |                     |   |   |
| S |   |                                     |                     |   |   |
| N |   |                                     |                     |   |   |
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| : |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
| N |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
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| v |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
| : |   |                                     |                     |   |   |
| C |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| H |   |                                     |                     |   |   |
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| p |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | Nothing             |   |   |
| C |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| 6 |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
| N |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
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| p |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| , |   |                                     |                     |   |   |
| h |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| k |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
| # |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| A |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$100 per trip;     |   |   |
|   |   |                                     | \$4,000 maximum     |   |   |
|   |   |                                     | benefit per trip.   |   |   |
|   |   |                                     |                     |   |   |
| L |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| p |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+

## Section 5(d) Emergency services/accidents

+---+---+-------------------------------------+---------------------+---+---+
| # | * | **Here are some important things to |                     | * |   |
| # | * | keep in mind about these            |                     | * |   |
| # | I | benefits:**                         |                     | I |   |
| # | * |                                     |                     | * |   |
| # | * | -   Please remember that all        |                     | * |   |
|   |   |     benefits are subject to the     |                     |   |   |
|   | * |     definitions, limitations, and   |                     | * |   |
|   | * |     exclusions in this brochure and |                     | * |   |
|   | M |     are payable only when we        |                     | M |   |
|   | * |     determine they are medically    |                     | * |   |
|   | * |     necessary.                      |                     | * |   |
|   |   |                                     |                     |   |   |
|   | * | -   We do not have a deductible.    |                     | * |   |
|   | * |                                     |                     | * |   |
|   | P | -   Be sure to read Section 4,      |                     | P |   |
|   | * |     *Your costs for covered         |                     | * |   |
|   | * |     services,* for valuable         |                     | * |   |
|   |   |     information about how cost      |                     |   |   |
|   | * |     sharing works. Also read        |                     | * |   |
|   | * |     Section 9 about coordinating    |                     | * |   |
|   | O |     benefits with other coverage,   |                     | O |   |
|   | * |     including with Medicare.        |                     | * |   |
|   | * |                                     |                     | * |   |
|   |   | #####                               |                     |   |   |
|   | * |                                     |                     | * |   |
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+---+---+-------------------------------------+---------------------+---+---+
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+---+---+-------------------------------------+---------------------+---+---+
|   |   |                                     |                     |   |   |
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| B |   |                                     | You pay             |   |   |
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| - |   |                                     | \$10 per visit      |   |   |
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|   |   |                                     | \$50 per emergency  |   |   |
|   |   |                                     | room visit          |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
| N |   |                                     |                     |   |   |
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| c |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| E |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| y |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
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| o |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
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| a |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| - |   |                                     | \$10 per visit      |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     | \$50 per emergency  |   |   |
|   |   |                                     | room visit          |   |   |
| E |   |                                     |                     |   |   |
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| d |   |                                     |                     |   |   |
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| n |   |                                     |                     |   |   |
| g |   |                                     |                     |   |   |
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|   |   |                                     |                     |   |   |
| d |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| t |   |                                     |                     |   |   |
| o |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| ' |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
|   |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| r |   |                                     |                     |   |   |
| v |   |                                     |                     |   |   |
| i |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| A |   |                                     |                     |   |   |
| m |   |                                     |                     |   |   |
| b |   |                                     |                     |   |   |
| u |   |                                     |                     |   |   |
| l |   |                                     |                     |   |   |
| a |   |                                     |                     |   |   |
| n |   |                                     |                     |   |   |
| c |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+
| P |   |                                     | \$100 per trip.     |   |   |
| r |   |                                     | Maximum benefit per |   |   |
| o |   |                                     | trip of \$4,000.    |   |   |
| f |   |                                     |                     |   |   |
| e |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
| s |   |                                     |                     |   |   |
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+---+---+-------------------------------------+---------------------+---+---+
| * |   |                                     | *All charges.*      |   |   |
| N |   |                                     |                     |   |   |
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| . |   |                                     |                     |   |   |
| * |   |                                     |                     |   |   |
+---+---+-------------------------------------+---------------------+---+---+

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

+---+---+-----------------------------------+----------------------+---+---+
|   | * | When you get our approval for     |                      | * |   |
|   | * | services and follow a treatment   |                      | * |   |
|   | I | plan we approve, cost-sharing and |                      | I |   |
|   | * | limitations for Plan mental       |                      | * |   |
|   | * | health and substance abuse        |                      | * |   |
|   |   | benefits will be no greater than  |                      |   |   |
|   | * | for similar benefits for other    |                      | * |   |
|   | * | illnesses and conditions.         |                      | * |   |
|   | M |                                   |                      | M |   |
|   | * | **Here are some important things  |                      | * |   |
|   | * | to keep in mind about these       |                      | * |   |
|   |   | benefits:**                       |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * | -   Please remember that all      |                      | * |   |
|   | P |     benefits are subject to the   |                      | P |   |
|   | * |     definitions, limitations, and |                      | * |   |
|   | * |     exclusions in this brochure   |                      | * |   |
|   |   |     and are payable only when we  |                      |   |   |
|   | * |     determine they are medically  |                      | * |   |
|   | * |     necessary.                    |                      | * |   |
|   | O |                                   |                      | O |   |
|   | * | -   Be sure to read Section 4,    |                      | * |   |
|   | * |     *Your costs for covered       |                      | * |   |
|   |   |     services*, for valuable       |                      |   |   |
|   | * |     information about how cost    |                      | * |   |
|   | * |     sharing works. Also read      |                      | * |   |
|   | R |     Section 9 about coordinating  |                      | R |   |
|   | * |     benefits with other coverage, |                      | * |   |
|   | * |     including with Medicare.      |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * | -   **YOU MUST GET                |                      | * |   |
|   | * |     PREAUTHORIZATION OF THESE     |                      | * |   |
|   | T |     SERVICES.** See the           |                      | T |   |
|   | * |     instructions after the        |                      | * |   |
|   | * |     benefits description below.   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | A |                                   |                      | A |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | N |                                   |                      | N |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   |   |                                   |                      |   |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
|   | T |                                   |                      | T |   |
|   | * |                                   |                      | * |   |
|   | * |                                   |                      | * |   |
+---+---+-----------------------------------+----------------------+---+---+
| B |   |                                   | You pay              |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| f |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| D |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| c |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
| # |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| M |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| h |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| h |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| d |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| u |   |                                   |                      |   |   |
| b |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
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| c |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| b |   |                                   |                      |   |   |
| u |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| b |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| f |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| A |   |                                   | Your cost sharing    |   |   |
| l |   |                                   | responsibilities are |   |   |
| l |   |                                   | no greater than for  |   |   |
| d |   |                                   | other illnesses or   |   |   |
| i |   |                                   | conditions.          |   |   |
| a |   |                                   |                      |   |   |
| g |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$10 per visit       |   |   |
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| s |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
| - |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
|   |   |                                   |                      |   |   |
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| c |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | \$100 per scan for   |   |   |
|   |   |                                   | MRI, CT scans, PET   |   |   |
|   |   |                                   | scans and other      |   |   |
|   |   |                                   | complex radiology    |   |   |
| D |   |                                   | scans.               |   |   |
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| s |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
+---+---+-----------------------------------+----------------------+---+---+
| - |   |                                   | Nothing              |   |   |
|   |   |                                   |                      |   |   |
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|   |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
| * |   |                                   | *All charges.*       |   |   |
| N |   |                                   |                      |   |   |
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| m |   |                                   |                      |   |   |
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| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| h |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| m |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| \ |   |                                   |                      |   |   |
| ' |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
| c |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
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| n |   |                                   |                      |   |   |
| i |   |                                   |                      |   |   |
| c |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
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| a |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
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| n |   |                                   |                      |   |   |
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| s |   |                                   |                      |   |   |
| s |   |                                   |                      |   |   |
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| P |   |                                   |                      |   |   |
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| w |   |                                   |                      |   |   |
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| l |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
| g |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| e |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| l |   |                                   |                      |   |   |
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| y |   |                                   |                      |   |   |
| n |   |                                   |                      |   |   |
| o |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
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| d |   |                                   |                      |   |   |
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| s |   |                                   |                      |   |   |
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| a |   |                                   |                      |   |   |
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| o |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
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| v |   |                                   |                      |   |   |
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| d |   |                                   |                      |   |   |
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| n |   |                                   |                      |   |   |
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| c |   |                                   |                      |   |   |
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| y |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| p |   |                                   |                      |   |   |
| r |   |                                   |                      |   |   |
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| a |   |                                   |                      |   |   |
| t |   |                                   |                      |   |   |
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| m |   |                                   |                      |   |   |
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| * |   |                                   |                      |   |   |
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| * |   |                                   |                      |   |   |
| * |   |                                   |                      |   |   |
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| t |   |                                   |                      |   |   |
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| z |   |                                   |                      |   |   |
| a |   |                                   |                      |   |   |
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| n |   |                                   |                      |   |   |
| * |   |                                   |                      |   |   |
| * |   |                                   |                      |   |   |
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| b |   |                                   |                      |   |   |
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| g |   |                                   |                      |   |   |
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| b |   |                                   |                      |   |   |
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| a |   |                                   |                      |   |   |
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+---+---+-----------------------------------+----------------------+---+---+
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+---+---+-----------------------------------+----------------------+---+---+

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

+---+---+--------------------------------------------------------+---+---+
|   | * | **Here are some important things to keep in mind about | * |   |
|   | * | these benefits:**                                      | * |   |
|   | I |                                                        | I |   |
|   | * | -   We cover prescribed drugs and medications, as      | * |   |
|   | * |     described in the chart beginning on the next page. | * |   |
|   |   |                                                        |   |   |
|   | * | -   All benefits are subject to the definitions,       | * |   |
|   | * |     limitations and exclusions in this brochure and    | * |   |
|   | M |     are payable only when we determine they are        | M |   |
|   | * |     medically necessary.                               | * |   |
|   | * |                                                        | * |   |
|   |   | -   Be sure to read Section 4, *Your costs for covered |   |   |
|   | * |     services,* for valuable information about how cost | * |   |
|   | * |     sharing works. Also read Section 9 about           | * |   |
|   | P |     coordinating benefits with other coverage,         | P |   |
|   | * |     including with Medicare.                           | * |   |
|   | * |                                                        | * |   |
|   |   |                                                        |   |   |
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+---+---+--------------------------------------------------------+---+---+
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+---+---+--------------------------------------------------------+---+---+

+------------------------------------------+---------------------------+
| **Benefit Description**                  | **You pay**               |
|                                          |                           |
|                                          | **After the calendar year |
|                                          | deductible...**           |
+------------------------------------------+---------------------------+
| ###### Covered medications and supplies  |                           |
+------------------------------------------+---------------------------+
| > We cover the following medications and | > \$50 Deductible         |
| > supplies prescribed by a Plan          | >                         |
| > physician and obtained from a Plan     | > \$10 per prescription   |
| > pharmacy or through our mail order     | > for generic             |
| > program:                               | >                         |
|                                          | > \$15 per prescription   |
| -   Drugs and medicines that by Federal  | > for preferred brand     |
|     law of the United States require a   | >                         |
|     physician's prescription for their   | > \$40 per prescription   |
|     purchase, except those listed as     | > for non-preferred drugs |
|     *Not covered*.                       | >                         |
|                                          | > 20% coinsurance for     |
| -   Insulin                              | > injectable medications  |
|                                          | > with \$5,000 out of     |
| -   Disposable needles and syringes for  | > pocket maximum          |
|     the administration of covered        | >                         |
|     medications                          | > *(Does not apply to:    |
|                                          | > Epinephrine, Insulin,   |
| -   Drugs for sexual dysfunction (see    | > Chemotherapy and        |
|     Prior authorization below)           | > allergens.)*            |
|                                          | >                         |
| ```{=html}                               | > Mail order drugs are    |
| <!-- -->                                 | > covered for 90-day      |
| ```                                      | > supply subject to the   |
| -   Contraceptive drugs and devices      | > following copayments:   |
|                                          | >                         |
| > Preauthorization Requirements:         | > No deductible           |
| >                                        | >                         |
| > Some prescription drugs need           | > \$20 member copayment   |
| > preauthorization before benefits will  | > for generic drugs       |
| > be available. A drug is authorized for | >                         |
| > the length of treatment not to exceed  | > \$30 member copayment   |
| > a one-year period of time. Call us at  | > for preferred brand     |
| > (307) 638-7700 when your physician     | > drugs                   |
| > prescribes these drugs to assure the   | >                         |
| > preauthorization is in place. Drugs    | > \$80 member copayment   |
| > needing Preauthorization by WINhealth  | > for non-preferred drugs |
| > Partners include:                      | >                         |
|                                          | > Note: If there is no    |
| -   Injectable medications               | > generic equivalent      |
|                                          | > available, you will     |
| -   Impotency Agents                     | > still have to pay the   |
|                                          | > brand name copay. If a  |
| -   Interferon/ Avonex and other like    | > generic is available    |
|     drugs                                | > but you buy a brand,    |
|                                          | > you will pay the        |
| -   Growth Hormones                      | > difference between the  |
|                                          | > brand and generic plus  |
| -   Accutane                             | > the brand name copay.   |
|                                          |                           |
| -   Drugs for adult acne                 |                           |
|                                          |                           |
| -   Drugs exceeding \$500 per month      |                           |
|                                          |                           |
| -   Prescriptions written by a           |                           |
|     non-participating provider except in |                           |
|     emergency situations                 |                           |
|                                          |                           |
| -   Differin Gel                         |                           |
|                                          |                           |
| -   Lamisil                              |                           |
|                                          |                           |
| -   Sporonox                             |                           |
|                                          |                           |
| -   Forteo                               |                           |
|                                          |                           |
| -   Clozaril                             |                           |
+------------------------------------------+---------------------------+
| *Not covered:*                           | *All charges.*            |
|                                          |                           |
| -   *Drugs and supplies for cosmetic     |                           |
|     purposes*                            |                           |
|                                          |                           |
| -   *Drugs to enhance athletic           |                           |
|     performance*                         |                           |
|                                          |                           |
| -   *Oral and injectable fertility       |                           |
|     drugs*                               |                           |
|                                          |                           |
| -   *Fertility drugs*                    |                           |
|                                          |                           |
| -   *Drugs obtained at a non-Plan        |                           |
|     pharmacy; except for out-of-area     |                           |
|     emergencies*                         |                           |
|                                          |                           |
| -   *Vitamins, nutrients and food        |                           |
|     supplements even if a physician      |                           |
|     prescribes or administers them*      |                           |
|                                          |                           |
| -   *Nonprescription medicines*          |                           |
|                                          |                           |
| -   *Prescription drugs when available   |                           |
|     without a prescription*              |                           |
|                                          |                           |
| -   *Smoking cessation drugs and         |                           |
|     medications, including nicotine      |                           |
|     patches.*                            |                           |
+------------------------------------------+---------------------------+

## **Section** 5(g) Special features

+----------------------+-----------------------------------------------+
| Feature              | Description                                   |
+----------------------+-----------------------------------------------+
| ##### Flex           | Under the flexible benefits option, we        |
| ible benefits option | determine the most effective way to provide   |
|                      | services.                                     |
|                      |                                               |
|                      | -   We may identify medically appropriate     |
|                      |     alternatives to traditional care and      |
|                      |     coordinate other benefits as a less       |
|                      |     costly alternative benefit.               |
|                      |                                               |
|                      | -   Alternative benefits are subject to our   |
|                      |     ongoing review.                           |
|                      |                                               |
|                      | -   By approving an alternative benefit, we   |
|                      |     cannot guarantee you will get it in the   |
|                      |     future.                                   |
|                      |                                               |
|                      | -   The decision to offer an alternative      |
|                      |     benefit is solely ours, and we may        |
|                      |     withdraw it at any time and resume        |
|                      |     regular contract benefits.                |
|                      |                                               |
|                      | -   Our decision to offer or withdraw         |
|                      |     alternative benefits is not subject to    |
|                      |     OPM review under the disputed claims      |
|                      |     process.                                  |
+----------------------+-----------------------------------------------+
| ##### H              | Our nurses will work with you through the     |
| igh risk pregnancies | course of your pregnancy to assure that you   |
|                      | get the necessary medical care. If you have a |
|                      | high risk pregnancy, call our medical         |
|                      | management department at (307) 638-7700.      |
+----------------------+-----------------------------------------------+

## **Section** 5(h) Dental benefits 

+---+---+------------------------------------+---------------------+---+---+
|   | * | **Here are some important things   |                     | * |   |
|   | * | to keep in mind about these        |                     | * |   |
|   | I | benefits:**                        |                     | I |   |
|   | * |                                    |                     | * |   |
|   | * | -   Please remember that all       |                     | * |   |
|   |   |     benefits are subject to the    |                     |   |   |
|   | * |     definitions, limitations, and  |                     | * |   |
|   | * |     exclusions in this brochure    |                     | * |   |
|   | M |     and are payable only when we   |                     | M |   |
|   | * |     determine they are medically   |                     | * |   |
|   | * |     necessary.                     |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * | -   Plan dentists must provide or  |                     | * |   |
|   | * |     arrange your care.             |                     | * |   |
|   | P |                                    |                     | 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    |                     | O |   |
|   | * |     patient. See Section 5(c) for  |                     | * |   |
|   | * |     inpatient hospital benefits.   |                     | * |   |
|   |   |     We do not cover the dental     |                     |   |   |
|   | * |     procedure unless it is         |                     | * |   |
|   | * |     described below.               |                     | * |   |
|   | R |                                    |                     | R |   |
|   | * | -   Be sure to read Section 4,     |                     | * |   |
|   | * |     *Your costs for covered        |                     | * |   |
|   |   |     services,* for valuable        |                     |   |   |
|   | * |     information about how cost     |                     | * |   |
|   | * |     sharing works. Also read       |                     | * |   |
|   | T |     Section 9 about coordinating   |                     | T |   |
|   | * |     benefits with other coverage,  |                     | * |   |
|   | * |     including with Medicare.       |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | A |                                    |                     | A |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | N |                                    |                     | N |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   |   |                                    |                     |   |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
|   | T |                                    |                     | T |   |
|   | * |                                    |                     | * |   |
|   | * |                                    |                     | * |   |
+===+===+====================================+=====================+===+===+
| # |   |                                    | You pay             |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| A |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| j |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| y |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| W |   |                                    | \$10 per office     |   |   |
| e |   |                                    | visit               |   |   |
| c |   |                                    |                     |   |   |
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| v |   |                                    |                     |   |   |
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| r |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
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| s |   |                                    |                     |   |   |
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| r |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
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| v |   |                                    |                     |   |   |
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| s |   |                                    |                     |   |   |
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| v |   |                                    |                     |   |   |
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| s |   |                                    |                     |   |   |
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| s |   |                                    |                     |   |   |
| u |   |                                    |                     |   |   |
| p |   |                                    |                     |   |   |
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| s |   |                                    |                     |   |   |
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| . |   |                                    |                     |   |   |
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| d |   |                                    |                     |   |   |
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| t |   |                                    |                     |   |   |
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| r |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| m |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| c |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
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| y |   |                                    |                     |   |   |
| . |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
| # |   |                                    |                     |   |   |
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|   |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
|   |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
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| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+
| * |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
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| a |   |                                    |                     |   |   |
| v |   |                                    |                     |   |   |
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| n |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| o |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| h |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| r |   |                                    |                     |   |   |
| d |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| a |   |                                    |                     |   |   |
| l |   |                                    |                     |   |   |
| b |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| n |   |                                    |                     |   |   |
| e |   |                                    |                     |   |   |
| f |   |                                    |                     |   |   |
| i |   |                                    |                     |   |   |
| t |   |                                    |                     |   |   |
| s |   |                                    |                     |   |   |
| . |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
| * |   |                                    |                     |   |   |
+---+---+------------------------------------+---------------------+---+---+

# 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 11.**

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 not medically necessary;

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

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

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

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

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

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

# Section 7. Filing a claim for covered services

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

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

+------------------+---------------------------------------------------+
| Medical and      | In most cases, providers and facilities file      |
| hospital         | claims for you. Physicians must file on the form  |
| benefits         | HCFA-1500, Health Insurance Claim Form. Your      |
|                  | facility will file on the UB-92 form. For claims  |
|                  | questions and assistance, call us at (307)        |
|                  | 638-7700.                                         |
|                  |                                                   |
|                  | When you must file a claim -- such as for         |
|                  | services you receive outside the Plan's service   |
|                  | area -- submit it on the HCFA-1500 or a claim     |
|                  | form that includes the information shown below.   |
|                  | Bills and receipts should be itemized and show:   |
|                  |                                                   |
|                  | -   Covered member's name and ID number;          |
|                  |                                                   |
|                  | -   Name and address of the physician or facility |
|                  |     that provided the service or supply;          |
|                  |                                                   |
|                  | -   Dates you received the services or supplies;  |
|                  |                                                   |
|                  | -   Diagnosis;                                    |
|                  |                                                   |
|                  | -   Type of each service or supply;               |
|                  |                                                   |
|                  | -   The charge for each service or supply;        |
|                  |                                                   |
|                  | -   A copy of the explanation of benefits,        |
|                  |     payments, or denial from any primary payer -- |
|                  |     such as the Medicare Summary Notice (MSN);    |
|                  |     and                                           |
|                  |                                                   |
|                  | -   Receipts, if you paid for your services.      |
|                  |                                                   |
|                  | **Submit your claims to: WINhealth Partners, PO   |
|                  | Box 652, Cheyenne, WY 82003**                     |
+------------------+---------------------------------------------------+
| Deadline for     | Send us all of the documents for your claim as    |
| filing your      | soon as possible. You must submit the claim by    |
| claim            | 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     | Please reply promptly when we ask for additional  |
| more information | 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/prior approval:

+----+-----------------------------------------------------------------+
| St | Description                                                     |
| ep |                                                                 |
+----+-----------------------------------------------------------------+
| 1  | Ask us in writing to reconsider our initial decision. You must: |
|    |                                                                 |
|    | a)  Write to us within 6 months from the date of our decision;  |
|    |     and                                                         |
|    |                                                                 |
|    | b)  Send your request to us at: PO Box 652, Cheyenne, WY 82003; |
|    |     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.           |
+----+-----------------------------------------------------------------+
| 2  | We have 30 days from the date we receive your request to:       |
|    |                                                                 |
|    | 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.                                                  |
+----+-----------------------------------------------------------------+
| 3  | You or your provider must send the information so that we       |
|    | receive it within 60 days of our request. We will then decide   |
|    | within 30 more days.                                            |
|    |                                                                 |
|    | If we do not receive the information within 60 days, we will    |
|    | decide within 30 days of the date the information was due. We   |
|    | will base our decision on the information we already have.      |
|    |                                                                 |
|    | We will write to you with our decision.                         |
+----+-----------------------------------------------------------------+
| 4  | If you do not agree with our decision, you may ask OPM to       |
|    | review it.                                                      |
+----+-----------------------------------------------------------------+
|    | You must write to OPM within:                                   |
|    |                                                                 |
|    | -   90 days after the date of our letter upholding our initial  |
|    |     decision; or                                                |
|    |                                                                 |
|    | -   120 days after you first wrote to us − if we did not answer |
|    |     that request in some way within 30 days; or                 |
|    |                                                                 |
|    | -   120 days after we asked for additional information.         |
+----+-----------------------------------------------------------------+
|    | Write to OPM at: United States Office of Personnel Management,  |
|    | Insurance Services Programs, Health Insurance Group 3, 1900 E   |
|    | Street, NW, Washington, DC 20415-3630.                          |
+----+-----------------------------------------------------------------+
|    |                                                                 |
+----+-----------------------------------------------------------------+
| T  |                                                                 |
| he |                                                                 |
| di |                                                                 |
| sp |                                                                 |
| ut |                                                                 |
| ed |                                                                 |
| cl |                                                                 |
| ai |                                                                 |
| ms |                                                                 |
| p  |                                                                 |
| ro |                                                                 |
| ce |                                                                 |
| ss |                                                                 |
| *  |                                                                 |
| (C |                                                                 |
| on |                                                                 |
| ti |                                                                 |
| nu |                                                                 |
| ed |                                                                 |
| )* |                                                                 |
+----+-----------------------------------------------------------------+
|    | 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    |
| *5 | information it collects from you and us to decide whether our   |
| ** | decision is correct. OPM will send you a final decision within  |
|    | 60 days. There are no other administrative appeals.             |
+----+-----------------------------------------------------------------+
|    | If you do not agree with OPM's decision, your only recourse is  |
|    | to sue. If you decide to sue, you must file the suit against    |
|    | OPM in Federal court by December 31 of the third year after the |
|    | year in which you received the disputed services, drugs, or     |
|    | supplies or from the year in which you were denied              |
|    | precertification or prior approval. This is the only deadline   |
|    | that may not be extended.                                       |
|    |                                                                 |
|    | OPM may disclose the information it collects during the review  |
|    | process to support their disputed claim decision. This          |
|    | information will become part of the court record.               |
+----+-----------------------------------------------------------------+
|    | You may not sue until you have completed the disputed claims    |
|    | process. Further, Federal law governs your lawsuit, benefits,   |
|    | and payment of benefits. The Federal court will base its review |
|    | on the record that was before OPM when OPM decided to uphold or |
|    | overturn our decision. You may recover only the amount of       |
|    | benefits in dispute.                                            |
+----+-----------------------------------------------------------------+

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

a)  We haven't responded yet to your initial request for care or
    preauthorization/prior approval, then call us at (307) 638-7700
    or (800) 868-7670 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

+------------------+---------------------------------------------------+
| ### Whe          | You must tell us if you or a covered family       |
| n you have other | member have coverage under another group health   |
|  health coverage | 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.                               |
+------------------+---------------------------------------------------+
| ### W            | Medicare is a Health Insurance Program for:       |
| hat is Medicare? |                                                   |
|                  | -   People 65 years of age or 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.                                        |
+------------------+---------------------------------------------------+
| #                | The decision to enroll in Medicare is yours. We   |
| ### Should I enr | encourage you to apply for Medicare benefits 3    |
| oll in Medicare? | months before you turn age 65. It's easy. Just    |
|                  | call the Social Security Administration toll-free |
|                  | number 1-800-772-1213 to set up an appointment to |
|                  | apply. If you do not apply for one or both Parts  |
|                  | of Medicare, you can still be covered under the   |
|                  | FEHB Program.                                     |
|                  |                                                   |
|                  | If you can get premium-free Part A coverage, we   |
|                  | advise you to enroll in it. Most Federal          |
|                  | employees and annuitants are entitled to Medicare |
|                  | Part A at age 65 **without cost**. When you don't |
|                  | have to pay premiums for Medicare Part A, it      |
|                  | makes good sense to obtain the coverage. It can   |
|                  | reduce your out-of-pocket expenses as well as     |
|                  | costs to the FEHB, which can help keep FEHB       |
|                  | premiums down.                                    |
|                  |                                                   |
|                  | Everyone is charged a premium for Medicare Part B |
|                  | coverage. The Social Security Administration can  |
|                  | provide you with premium and benefit information. |
|                  | Review the information and decide if it makes     |
|                  | sense for you to buy the Medicare Part B          |
|                  | coverage.                                         |
|                  |                                                   |
|                  | If you are eligible for Medicare, you may have    |
|                  | choices in how you get your health care. Medicare |
|                  | Advantage is the term used to describe the        |
|                  | various private health plan choices available to  |
|                  | Medicare beneficiaries. The information in the    |
|                  | next few pages shows how we coordinate benefits   |
|                  | with Medicare, depending on whether you are in    |
|                  | the Original Medicare Plan or a private Medicare  |
|                  | Advantage plan.                                   |
+------------------+---------------------------------------------------+
| ##               | The Original Medicare Plan (Original Medicare) is |
| ## The Original  | available everywhere in the United States. It is  |
| Medicare Plan (P | the way everyone used to get Medicare benefits    |
| art A or Part B) | and is the way most people get their Medicare     |
|                  | Part A and Part B benefits now. You may go to any |
|                  | doctor, specialist, or hospital that accepts      |
|                  | Medicare. The Original Medicare Plan pays its     |
|                  | share and you pay your share. Some things are not |
|                  | covered under Original Medicare, such as most     |
|                  | prescription drugs. (but coverage through private |
|                  | prescription drug plans will be available         |
|                  | starting in 2006).                                |
|                  |                                                   |
|                  | When you are enrolled in Original Medicare along  |
|                  | with this Plan, you still need to follow the      |
|                  | rules in this brochure for us to cover your care. |
+------------------+---------------------------------------------------+
|                  | **Claims process when you have the Original       |
|                  | Medicare Plan** -- You probably will never have   |
|                  | to file a claim form when you have both our Plan  |
|                  | and the Original Medicare Plan.                   |
|                  |                                                   |
|                  | -   When we are the primary payer, we process the |
|                  |     claim first.                                  |
|                  |                                                   |
|                  | -   When Original Medicare is the primary payer,  |
|                  |     Medicare processes your claim first. In most  |
|                  |     cases, your claim will be coordinated         |
|                  |     automatically and we will then provide        |
|                  |     secondary benefits for covered charges. You   |
|                  |     will not need to do anything. To find out if  |
|                  |     you need to do something to file your claim,  |
|                  |     call us at (307) 638-7700 or see our Web site |
|                  |     at                                            |
|                  |     [www.winhealt                                 |
|                  | hpartners.org](http://www.winhealthpartners.org/) |
|                  |                                                   |
|                  | **We do not waive any costs if the Original       |
|                  | Medicare Plan is your primary payer.**            |
+------------------+---------------------------------------------------+

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

+----------------------------------------------------+-------+--------+
| > **Primary Payer Chart**                          |       |        |
+----------------------------------------------------+-------+--------+
| **A. When you - or your covered spouse - are age   | **The |        |
| 65 or over and have Medicare and you...**          | pr    |        |
|                                                    | imary |        |
|                                                    | payer |        |
|                                                    | for   |        |
|                                                    | the   |        |
|                                                    | indiv |        |
|                                                    | idual |        |
|                                                    | with  |        |
|                                                    | Med   |        |
|                                                    | icare |        |
|                                                    | is    |        |
|                                                    | ...** |        |
+----------------------------------------------------+-------+--------+
|                                                    | **    | **This |
|                                                    | Medic | Plan** |
|                                                    | are** |        |
+----------------------------------------------------+-------+--------+
| > 1\) Have FEHB coverage on your own as an active  |       | ****  |
| > employee or through your spouse who is an active |       |        |
| > employee                                         |       |        |
+----------------------------------------------------+-------+--------+
| 2\) Have FEHB coverage on your own as an annuitant | **** |        |
| or through your spouse who is an annuitant         |       |        |
+----------------------------------------------------+-------+--------+
| > 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) and you are not covered under  |       |        |
| > FEHB through your spouse under #1 above          |       |        |
+----------------------------------------------------+-------+--------+
| 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) and   |       |        |
| > you are not covered under FEHB through your      |       |        |
| > spouse under #1 above                            |       |        |
+----------------------------------------------------+-------+--------+
| 1.  Are enrolled in Part B only, regardless of     | **** | ****  |
|     your employment status                         | for   | for    |
|                                                    | Part  | other  |
|                                                    | B     | se     |
|                                                    | ser   | rvices |
|                                                    | vices |        |
+----------------------------------------------------+-------+--------+
| 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...**      |       |        |
+----------------------------------------------------+-------+--------+
| 1)  Have Medicare solely based on end stage renal  |       | ****  |
|     disease (ESRD) and...                          |       |        |
|                                                    |       |        |
| -   It is within the first 30 months of            |       |        |
|     eligibility for or entitlement to Medicare due |       |        |
|     to ESRD (30-month coordination period)         |       |        |
+----------------------------------------------------+-------+--------+
| -   It is beyond the 30-month coordination period  | **** |        |
|     and you or a family member are still entitled  |       |        |
|     to Medicare due to ESRD                        |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Become eligible for Medicare due to ESRD while |       | **     |
|     already a Medicare beneficiary and**...**      |       | **for |
|                                                    |       | 30     |
| -   This Plan was the primary payer before         |       | -month |
|     eligibility due to ESRD                        |       | coordi |
|                                                    |       | nation |
|                                                    |       | period |
+----------------------------------------------------+-------+--------+
| -   Medicare was the primary payer before          | **** |        |
|     eligibility due to ESRD                        |       |        |
+----------------------------------------------------+-------+--------+
| **C. When either you or your spouse are eligible   |       |        |
| for Medicare solely due to disability and you...** |       |        |
+----------------------------------------------------+-------+--------+
| 1)  Have FEHB coverage on your own as an active    |       | ****  |
|     employee or through a family member who is an  |       |        |
|     active employee                                |       |        |
+----------------------------------------------------+-------+--------+
| 2)  Have FEHB coverage on your own as an annuitant | **** | []{    |
|     or through a family member who is an annuitant |       | .mark} |
+----------------------------------------------------+-------+--------+
| **D. When you or a covered family member are       | **** |        |
| covered under the FEHB Spouse Equity provision as  |       |        |
| a former spouse**                                  |       |        |
+----------------------------------------------------+-------+--------+

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

+--------------------+-------------------------------------------------+
| ####               | If you are eligible for Medicare, you may       |
| Medicare Advantage | choose to enroll in and get your Medicare       |
|                    | benefits from a Medicare Advantage plan. These  |
|                    | are private health care choices (like HMOs) in  |
|                    | some areas of the country. In most Medicare     |
|                    | Advantage plans, you can only go to doctors,    |
|                    | specialists, or hospitals that are part of the  |
|                    | plan. Medicare Advantage plans provide all the  |
|                    | benefits that Original Medicare covers. Some    |
|                    | cover extras, like prescription drugs. To learn |
|                    | more about enrolling in a Medicare Advantage    |
|                    | 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 Advantage plan, the |
|                    | following options are available to you:         |
|                    |                                                 |
|                    | **This Plan and another plan's Medicare         |
|                    | Advantage plan:** You may enroll in another     |
|                    | plan's Medicare Advantage plan and also remain  |
|                    | enrolled in our FEHB plan. We will still        |
|                    | provide benefits when your Medicare Advantage   |
|                    | plan is primary, even out of the Medicare       |
|                    | Advantage plan's network and/or service area,   |
|                    | (if you use our Plan providers), but we will    |
|                    | not waive any of our copayments, coinsurance or |
|                    | deductibles. If you enroll in a Medicare        |
|                    | Advantage plan, tell us. We will need to know   |
|                    | whether you are in the Original Medicare Plan   |
|                    | or in a Medicare Advantage plan so we can       |
|                    | correctly coordinate benefits with Medicare.    |
|                    |                                                 |
|                    | **This Plan and another plan\'s Medicare        |
|                    | Advantage plan:** You may enroll in another     |
|                    | plan's MedicareAdvantage plan and also remain   |
|                    | enrolled in our FEHB plan. We will still        |
|                    | provide benefits when your MedicareAdvantage    |
|                    | plan is primary, even out of the Medicare       |
|                    | Advantage plan\'s network and/or service area   |
|                    | (if you use our Plan providers), but we will    |
|                    | not waive any of our copayments, coinsurance,   |
|                    | or deductibles. If you enroll in a Medicare     |
|                    | Advantage plan, tell us. We will need to know   |
|                    | whether you are in the Original Medicare Plan   |
|                    | or in a Medicare Advantage plan so we can       |
|                    | correctly coordinate benefits with Medicare.    |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in a        |
|                    | Medicare Advantage plan:** If you are an        |
|                    | annuitant or former spouse, you can suspend     |
|                    | your FEHB coverage to enroll in a Medicare      |
|                    | Advantage plan, eliminating your FEHB premium.  |
|                    | (OPM does not contribute to your                |
|                    | MedicareAdvantage 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 Advantage plan\'s   |
|                    | service area.                                   |
+--------------------+-------------------------------------------------+
| ### T              | TRICARE is the health care program for eligible |
| RICARE and CHAMPVA | dependents of military persons, and retirees of |
|                    | the military. TRICARE includes the CHAMPUS      |
|                    | program. CHAMPVA provides health coverage to    |
|                    | disabled Veterans and their eligible            |
|                    | dependents. IF TRICARE or CHAMPVA and this Plan |
|                    | cover you, we pay first. See your TRICARE or    |
|                    | CHAMPVA Health Benefits Advisor if you have     |
|                    | questions about these programs.                 |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in TRICARE  |
|                    | or CHAMPVA:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these programs, eliminating    |
|                    | your FEHB premium. (OPM does not contribute to  |
|                    | any applicable plan premiums.) For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the       |
|                    | program.                                        |
+--------------------+-------------------------------------------------+
| ### Wor            | We do not cover services that:                  |
| kers' Compensation |                                                 |
|                    | -   You need because of a workplace-related     |
|                    |     illness or injury that the Office of        |
|                    |     Workers' Compensation Programs (OWCP) or a  |
|                    |     similar Federal or State agency determines  |
|                    |     they must provide; or                       |
|                    |                                                 |
|                    | -   OWCP or a similar agency pays for through a |
|                    |     third-party injury settlement or other      |
|                    |     similar proceeding that is based on a claim |
|                    |     you filed under OWCP or similar laws.       |
|                    |                                                 |
|                    | Once OWCP or similar agency pays its maximum    |
|                    | benefits for your treatment, we will cover your |
|                    | care.                                           |
+--------------------+-------------------------------------------------+
| ### Medicaid       | When you have this Plan and Medicaid, we pay    |
|                    | first.                                          |
|                    |                                                 |
|                    | **Suspended FEHB coverage to enroll in Medicaid |
|                    | or a similar State-sponsored program of medical |
|                    | assistance:** If you are an annuitant or former |
|                    | spouse, you can suspend your FEHB coverage to   |
|                    | enroll in one of these State programs,          |
|                    | eliminating your FEHB premium. For information  |
|                    | on suspending your FEHB enrollment, contact     |
|                    | your retirement office. If you later want to    |
|                    | re-enroll in the FEHB Program, generally you    |
|                    | may do so only at the next Open Season unless   |
|                    | you involuntarily lose coverage under the State |
|                    | program.                                        |
+--------------------+-------------------------------------------------+
| ### When o         | We do not cover services and supplies when a    |
| ther Government ag | local, State, or Federal government agency      |
| encies are respons | directly or indirectly pays for them.           |
| ible for your care |                                                 |
+--------------------+-------------------------------------------------+
| ### When           | When you receive money to compensate you for    |
|  others are respon | medical or hospital care for injuries or        |
| sible for injuries | 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. You may also be  |
|                  | responsible for additional amounts. See page 11.  |
+------------------+---------------------------------------------------+
| Copayment        | A copayment is a fixed amount of money you pay    |
|                  | when you receive covered services. See page 11.   |
+------------------+---------------------------------------------------+
| Covered services | Care we provide benefits for, as described in     |
|                  | this brochure.                                    |
+------------------+---------------------------------------------------+
| Custodial care   | Custodial Care is defined to be non-medically     |
|                  | necessary care that has been determined to be     |
|                  | primarily for your maintenance or care that has   |
|                  | been designed essentially to assist you in        |
|                  | meeting your activities of daily living.          |
|                  | Activities of daily living include, but are not   |
|                  | limited to, bathing, turning, dressing, walking,  |
|                  | taking oral medications, and feeding. Custodial   |
|                  | care that lasts 90 days or more is sometimes      |
|                  | known as Long Term Care.                          |
+------------------+---------------------------------------------------+
| Deductible       | A deductible is a fixed amount of covered         |
|                  | expenses you must incur for certain covered       |
|                  | services and supplies before we start paying      |
|                  | benefits for those services. See page 11.         |
+------------------+---------------------------------------------------+
| Experimental or  | Means medical, surgical or psychiatric            |
| investigational  | procedures, treatments, devices and               |
| services         | pharmacological regimes (including                |
|                  | investigational drugs and drug therapies), or     |
|                  | supplies where either (a) the service is not      |
|                  | recognized in accordance with generally accepted  |
|                  | medical standards as being safe and effective for |
|                  | treatment of condition in question regardless of  |
|                  | whether the service is authorized by law or used  |
|                  | in testing or other studies, or (b) the service   |
|                  | requires approval by a governmental authority and |
|                  | such authority has not been granted prior to the  |
|                  | service being rendered. WINhealth Partners, in    |
|                  | its discretion, shall have the sole authority to  |
|                  | determine from time to time which are considered  |
|                  | to be Experimental, Investigational, Unproven,    |
|                  | Unusual, or Not Customary Treatments, Procedures, |
|                  | Devices, Supplies, Equipment, and/or Drugs.       |
+------------------+---------------------------------------------------+
| Group health     | A body of subscribers who are eligible for health |
| coverage         | care insurance by virtue of some common           |
|                  | identifying attribute such as employment by an    |
|                  | employer, or membership in a union, association,  |
|                  | or other such organization who can purchase       |
|                  | health care insurance as a group. Generally, all  |
|                  | members of such a body of subscribers has similar |
|                  | exclusions, and have similar health care benefits |
|                  | or may receive a core benefit package, similar    |
|                  | exclusions, and have the ability to purchase      |
|                  | riders of additional areas of coverage such as    |
|                  | prescription drugs or eyeglasses.                 |
+------------------+---------------------------------------------------+
| Medical          | "Medical Necessity" means those Health Care       |
| necessity        | Services and supplies, as determined by WINhealth |
|                  | Partners on a case-by-case basis, that are        |
|                  | appropriate and necessary to meet the basic       |
|                  | health needs of the member.                       |
+------------------+---------------------------------------------------+
| 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. We determine our  |
|                  | > allowance using the prevailing fee schedule     |
|                  | > that was established for participating          |
|                  | > providers. Participating providers will accept  |
|                  | > the plan allowance as payment in full.          |
+------------------+---------------------------------------------------+
| Us/We            | Us and We refer to WINhealth Partners.            |
+------------------+---------------------------------------------------+
| You              | You refers to the enrollee and each covered       |
|                  | family member.                                    |
+------------------+---------------------------------------------------+

# Section 11. FEHB Facts

### Coverage information

+------------------+---------------------------------------------------+
| #### No p        | We will not refuse to cover the treatment of a    |
| re-existing cond | condition you had before you enrolled in this     |
| ition limitation | Plan solely because you had the condition before  |
|                  | you enrolled.                                     |
+------------------+---------------------------------------------------+
| #### W           | See                                               |
| here you can get | [www.opm.gov/insure](http://www.opm.gov/insure).  |
|  information abo | Also, your employing or retirement office can     |
| ut enrolling in  | answer your questions, and give you a *Guide to   |
| the FEHB Program | Federal Employees Health Benefits Plans,*         |
|                  | brochures for other plans, and other materials    |
|                  | you need to make an informed decision about your  |
|                  | FEHB coverage. These materials tell you:          |
|                  |                                                   |
|                  | -   When you may change your enrollment;          |
|                  |                                                   |
|                  | -   How you can cover your family members;        |
|                  |                                                   |
|                  | -   What happens when you transfer to another     |
|                  |     Federal agency, go on leave without pay,      |
|                  |     enter military service, or retire;            |
|                  |                                                   |
|                  | -   When your enrollment ends; and                |
|                  |                                                   |
|                  | -   When the next open season for enrollment      |
|                  |     begins.                                       |
|                  |                                                   |
|                  | We don't determine who is eligible for coverage   |
|                  | and, in most cases, cannot change your enrollment |
|                  | status without information from your employing or |
|                  | retirement office.                                |
+------------------+---------------------------------------------------+
| #### Typ         | Self Only coverage is for you alone. Self and     |
| es of coverage a | Family coverage is for you, your spouse, and your |
| vailable for you | unmarried dependent children under age 22,        |
|  and your family | 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 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.                                             |
+------------------+---------------------------------------------------+
| #### Child       | OPM has implemented the Federal Employees Health  |
| ren's Equity Act | Benefits Children's Equity Act of 2000. This law  |
|                  | mandates that you be enrolled for Self and Family |
|                  | coverage in the FEHB Program, if you are an       |
|                  | employee subject to a court or administrative     |
|                  | order requiring you to provide health benefits    |
|                  | for your child(ren).                              |
|                  |                                                   |
|                  | If this law applies to you, you must enroll for   |
|                  | Self and Family coverage in a health plan that    |
|                  | provides full benefits in the area where your     |
|                  | children live or provide documentation to your    |
|                  | employing office that you have obtained other     |
|                  | health benefits coverage for your children. If    |
|                  | you do not do so, your employing office will      |
|                  | enroll you involuntarily as follows:              |
|                  |                                                   |
|                  | -   If you have no FEHB coverage, your employing  |
|                  |     office will enroll you for Self and Family    |
|                  |     coverage in the Blue Cross and Blue Shield    |
|                  |     Service Benefit Plan's Basic Option;          |
|                  |                                                   |
|                  | -   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.                                      |
+------------------+---------------------------------------------------+
| ####             | The benefits in this brochure are effective       |
| When benefits an | January 1. If you joined this Plan during Open    |
| d premiums start | Season, your coverage begins on the first day of  |
|                  | your first pay period that starts on or after     |
|                  | January 1. If you changed plans or plan options   |
|                  | during Open Season and you receive care between   |
|                  | January 1 and the effective date of coverage      |
|                  | under your new plan or option, your claims will   |
|                  | be paid according to the 2005 benefits of your    |
|                  | old plan or option. However, if your old plan     |
|                  | left the FEHB Program at the end of the year, you |
|                  | are covered under that plan's 2004 benefits until |
|                  | the effective date of your coverage with your new |
|                  | plan. Annuitants' coverage and premiums begin on  |
|                  | January 1. If you joined at any other time during |
|                  | the year, your employing office will tell you the |
|                  | effective date of coverage.                       |
+------------------+---------------------------------------------------+
| ####             | When you retire, you can usually stay in the FEHB |
|  When you retire | 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 FE     | You will receive an additional 31 days of         |
| HB coverage ends | coverage, for no additional premium, when:        |
|                  |                                                   |
|                  | -   Your enrollment ends, unless you cancel your  |
|                  |     enrollment, or                                |
|                  |                                                   |
|                  | -   You are a family member no longer eligible    |
|                  |     for coverage.                                 |
|                  |                                                   |
|                  | You may be eligible for spouse equity coverage or |
|                  | Temporary Continuation of Coverage (TCC), or a    |
|                  | conversion policy (a non-FEHB individual policy.) |
+------------------+---------------------------------------------------+
| #### Spouse      | If you are divorced from a Federal employee or    |
|  equity coverage | annuitant, you may not continue to get benefits   |
|                  | under your former spouse's enrollment. This is    |
|                  | the case even when the court has ordered your     |
|                  | former spouse to provide health coverage to you.  |
|                  | But, you may be eligible for your own FEHB        |
|                  | coverage under the spouse equity law or Temporary |
|                  | Continuation of Coverage (TCC). If you are        |
|                  | recently divorced or are anticipating a divorce,  |
|                  | contact your ex-spouse's employing or retirement  |
|                  | office to get RI 70-5, the *Guide To Federal      |
|                  | Employees Health Benefits Plans for Temporary     |
|                  | Continuation of Coverage and Former Spouse        |
|                  | Enrollees,* or other information about your       |
|                  | coverage choices. You can also download the guide |
|                  | from OPM's Web site,                              |
|                  | [www.opm.gov/insure](http://www.opm.gov/insure).  |
+------------------+---------------------------------------------------+
| #### Temporar    | If you leave Federal service, or if you lose      |
| y Continuation o | coverage because you no longer qualify as a       |
| f Coverage (TCC) | family member, you may be eligible for Temporary  |
|                  | Continuation of Coverage (TCC). For example, you  |
|                  | can receive TCC if you are not able to continue   |
|                  | your FEHB enrollment after you retire, if you     |
|                  | lose your Federal job, if you are a covered       |
|                  | dependent child and you turn 22 or marry, etc.    |
|                  |                                                   |
|                  | You may not elect TCC if you are fired from your  |
|                  | Federal job due to gross misconduct.              |
|                  |                                                   |
|                  | **Enrolling in TCC.** Get the RI 79-27, which     |
|                  | describes TCC, and the RI 70-5, the *Guide to     |
|                  | Federal Employees Health Benefits Plans for       |
|                  | Temporary Continuation of Coverage and Former     |
|                  | Spouse Enrollees,* from your employing or         |
|                  | retirement office or from                         |
|                  | [www.opm.gov/insure](http://www.opm/gov/insure).  |
|                  | It explains what you have to do to enroll.        |
+------------------+---------------------------------------------------+
| #### C           | You may convert to a non-FEHB individual policy   |
| onverting to ind | if:                                               |
| ividual 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.          |
+------------------+---------------------------------------------------+
| #### Get         | The Health Insurance Portability and              |
| ting a Certifica | Accountability Act of 1996 (HIPAA) is a Federal   |
| te of Group Heal | law that offers limited Federal protections for   |
| th Plan Coverage | 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 at  |
|                  | [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 information about Federal and    |
|                  | State agencies you can contact for more           |
|                  | information.                                      |
+------------------+---------------------------------------------------+

# Section 12. Two Federal Programs complement FEHB benefits

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

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

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

+------------------+--------------------------------+--------+--------+
| -   What is an   | It is a tax-favored benefit    |        |        |
|     FSA?         | 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 FSAFEDS:            |        |        |
+------------------+--------------------------------+--------+--------+
| Health Care      | -   Covers eligible health     |        |        |
| Flexible         |     care expenses not          |        |        |
| Spending Account |     reimbursed by this Plan,   |        |        |
| (HCFSA)          |     or any other medical,      |        |        |
|                  |     dental, or vision care     |        |        |
|                  |     plan you or your           |        |        |
|                  |     dependents may have.       |        |        |
|                  |                                |        |        |
|                  | -   Eligible dependents for    |        |        |
|                  |     this account include       |        |        |
|                  |     anyone you claim on your   |        |        |
|                  |     Federal Income Tax return  |        |        |
|                  |     as a qualified dependent   |        |        |
|                  |     under the U.S. Internal    |        |        |
|                  |     Revenue Service (IRS)      |        |        |
|                  |     definition and/or with     |        |        |
|                  |     whom you jointly file your |        |        |
|                  |     Federal Income Tax return, |        |        |
|                  |     even if you don't have     |        |        |
|                  |     self and family health     |        |        |
|                  |     benefits coverage.         |        |        |
|                  |     ***Note:*** The IRS has a  |        |        |
|                  |     broader definition of a    |        |        |
|                  |     "family member" than is    |        |        |
|                  |     used under the FEHB        |        |        |
|                  |     Program to provide         |        |        |
|                  |     benefits by your FEHB      |        |        |
|                  |     Plan.                      |        |        |
|                  |                                |        |        |
|                  | -   The maximum annual amount  |        |        |
|                  |     that can be allotted for   |        |        |
|                  |     the HCFSA is \$4,000.      |        |        |
|                  |     *Note:* The Federal        |        |        |
|                  |     workforce includes a       |        |        |
|                  |     number of employees        |        |        |
|                  |     married to each other. If  |        |        |
|                  |     each spouse/employee is    |        |        |
|                  |     eligible for FEHB          |        |        |
|                  |     coverage, both may enroll  |        |        |
|                  |     for a HCFSA up to the      |        |        |
|                  |     maximum of \$4,000 each    |        |        |
|                  |     (\$8,000 total). Both are  |        |        |
|                  |     covered under each other's |        |        |
|                  |     HCFSA. The minimum annual  |        |        |
|                  |     amount is \$250.           |        |        |
+------------------+--------------------------------+--------+--------+
| Dependent Care   | -   Covers eligible dependent  |        |        |
| Flexible         |     care expenses incurred so  |        |        |
| Spending Account |     you, and your spouse, if   |        |        |
| (DCFSA)          |     married, can work, look    |        |        |
|                  |     for work, or attend school |        |        |
|                  |     full-time.                 |        |        |
|                  |                                |        |        |
|                  | -   Qualifying dependents for  |        |        |
|                  |     this account include your  |        |        |
|                  |     dependent children under   |        |        |
|                  |     age 13, or any person of   |        |        |
|                  |     any age whom you claim as  |        |        |
|                  |     a dependent on your        |        |        |
|                  |     Federal Income Tax return  |        |        |
|                  |     (and who is mentally or    |        |        |
|                  |     physically incapable of    |        |        |
|                  |     self care).                |        |        |
|                  |                                |        |        |
|                  | -   The maximum annual amount  |        |        |
|                  |     that can be allotted for   |        |        |
|                  |     the DCFSA is \$5,000. The  |        |        |
|                  |     minimum annual amount is   |        |        |
|                  |     \$250. *Note:* The IRS     |        |        |
|                  |     limits contributions to a  |        |        |
|                  |     DCFSA. For single          |        |        |
|                  |     taxpayers and taxpayers    |        |        |
|                  |     filing a joint return, the |        |        |
|                  |     maximum is \$5,000 per     |        |        |
|                  |     year. For taxpayers who    |        |        |
|                  |     file their taxes           |        |        |
|                  |     separately with a spouse,  |        |        |
|                  |     the maximum is \$2,500 per |        |        |
|                  |     year. The limit includes   |        |        |
|                  |     any child care subsidy you |        |        |
|                  |     may receive.               |        |        |
+------------------+--------------------------------+--------+--------+
| -   Enroll       | You **must make an election**  |        |        |
|     during Open  | to enroll in an FSA during the |        |        |
|     Season       | 2005 FEHB Open Season. Even if |        |        |
|                  | you enrolled during 2004, you  |        |        |
|                  | must make a new election to    |        |        |
|                  | continue participating in      |        |        |
|                  | 2005. Enrollment is easy!      |        |        |
|                  |                                |        |        |
|                  | -   **Online: visit            |        |        |
|                  |     [www.FSAFEDS               |        |        |
|                  | .com](http://www.FSAFEDS.com/) |        |        |
|                  |     and click on               |        |        |
|                  |     [Enroll]{.underline}.**    |        |        |
|                  |                                |        |        |
|                  | -   Telephone: call an FSAFEDS |        |        |
|                  |     Benefits Counselor         |        |        |
|                  |     toll-free at 1-877-FSAFEDS |        |        |
|                  |     (372-3337), Monday through |        |        |
|                  |     Friday, from 9 a.m. until  |        |        |
|                  |     9 p.m., Eastern Time. TTY: |        |        |
|                  |     1-800-952-0450.            |        |        |
+------------------+--------------------------------+--------+--------+
| What is SHPS?    | SHPS is a Third Party          |        |        |
|                  | Administrator hired by OPM to  |        |        |
|                  | manage the FSAFEDS Program.    |        |        |
|                  | SHPS is the largest FSA        |        |        |
|                  | administrator in the nation    |        |        |
|                  | and is responsible for the     |        |        |
|                  | enrollment, claims processing, |        |        |
|                  | customer service, and          |        |        |
|                  | day-to-day operations of       |        |        |
|                  | FSAFEDS.                       |        |        |
+------------------+--------------------------------+--------+--------+
| Who is eligible  | If you are a Federal employee  |        |        |
| to enroll?       | eligible for FEHB -- even if   |        |        |
|                  | you're not enrolled in FEHB -- |        |        |
|                  | you can choose to participate  |        |        |
|                  | in either, or both, of the     |        |        |
|                  | FSAs. *However, if you enroll  |        |        |
|                  | in a High Deductible Health    |        |        |
|                  | Plan (HDHP) with a Health      |        |        |
|                  | Savings Account (HSAA), you    |        |        |
|                  | are not eligible to            |        |        |
|                  | participate in an HCFSA*.      |        |        |
|                  |                                |        |        |
|                  | Almost all Federal employees   |        |        |
|                  | are eligible to enroll for a   |        |        |
|                  | DCFSA. The only exception is   |        |        |
|                  | intermittent (also called      |        |        |
|                  | "when actually employed"       |        |        |
|                  | \[WAE\]) employees expected to |        |        |
|                  | work fewer than 180 days       |        |        |
|                  | during the year.               |        |        |
|                  |                                |        |        |
|                  | *Note:* FSAFEDS is the FSA     |        |        |
|                  | Program established for all    |        |        |
|                  | Executive Branch employees and |        |        |
|                  | Legislative Branch employees   |        |        |
|                  | whose employers have signed on |        |        |
|                  | to participate. Under IRS law, |        |        |
|                  | FSAs are not available to      |        |        |
|                  | annuitants. Also, the U.S.     |        |        |
|                  | Postal Service and the         |        |        |
|                  | Judicial Branch, among others, |        |        |
|                  | have their own plans with      |        |        |
|                  | slightly different rules.      |        |        |
|                  | However, the advantages of     |        |        |
|                  | having an FSA are the same     |        |        |
|                  | regardless of the agency for   |        |        |
|                  | which you work.                |        |        |
+------------------+--------------------------------+--------+--------+
| -   How much     | Plan carefully when deciding   |        |        |
|     should I     | how much to contribute to an   |        |        |
|     contribute   | FSA. Because of the tax        |        |        |
|     to my FSA?   | benefits ~~of~~ an FSA         |        |        |
|                  | provides, the IRS places       |        |        |
|                  | strict guidelines on how the   |        |        |
|                  | money can be used. Under       |        |        |
|                  | current IRS tax rules, you are |        |        |
|                  | required to forfeit any money  |        |        |
|                  | for which you did not incur an |        |        |
|                  | eligible expense under your    |        |        |
|                  | FSA account(s) during the Plan |        |        |
|                  | Year. This is known as the     |        |        |
|                  | "use-it-or-lose-it" rule. You  |        |        |
|                  | will have until April 30,      |        |        |
|                  | following the end of the Plan  |        |        |
|                  | Year to submit claims for your |        |        |
|                  | eligible expenses incurred     |        |        |
|                  | from January 1 through         |        |        |
|                  | December 31. For example if    |        |        |
|                  | you enroll in FSAFEDS for the  |        |        |
|                  | 2005 Plan Year, you will have  |        |        |
|                  | until April 30, 2006 to submit |        |        |
|                  | claims for eligible expenses.  |        |        |
|                  |                                |        |        |
|                  | The FSAFEDS Calculator at      |        |        |
|                  | [www.FSAFEDS                   |        |        |
|                  | .com](http://www.fsafeds.com/) |        |        |
|                  | will help you plan your FSA    |        |        |
|                  | allocations and provide an     |        |        |
|                  | estimate of your tax savings   |        |        |
|                  | based on your individual       |        |        |
|                  | situation.                     |        |        |
+------------------+--------------------------------+--------+--------+
| -   What can my  | Every FEHB plan includes cost  |        |        |
|     HCFSA pay    | sharing features, such as      |        |        |
|     for?         | 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   |        |        |
|                  | 11 and detailed throughout     |        |        |
|                  | this brochure. Your HCFSA will |        |        |
|                  | reimburse you when those costs |        |        |
|                  | are for qualified medical care |        |        |
|                  | that you, your spouse and/or   |        |        |
|                  | your dependents receive that   |        |        |
|                  | is NOT covered or reimbursed   |        |        |
|                  | by this FEHB Plan or any other |        |        |
|                  | coverage that you have.        |        |        |
|                  |                                |        |        |
|                  | Under this Plan, typical       |        |        |
|                  | out-of-pocket expenses include |        |        |
|                  | copayments and coinsurance.    |        |        |
|                  |                                |        |        |
|                  | The IRS governs expenses       |        |        |
|                  | reimbursable by a HCFSA. See   |        |        |
|                  | Publication 502 for a          |        |        |
|                  | comprehensive list of          |        |        |
|                  | tax-deductible medical         |        |        |
|                  | expenses. ***Note:* While you  |        |        |
|                  | will see insurance premiums    |        |        |
|                  | listed in Publication 502,     |        |        |
|                  | they are NOT a reimbursable    |        |        |
|                  | expense for FSA purposes.**    |        |        |
|                  | Publication 502 can be found   |        |        |
|                  | on the IRS Web site at         |        |        |
|                  | [www.irs.gov/pub               |        |        |
|                  | /irs-pdf/p502.pdf](http://www. |        |        |
|                  | irs.gov/pub/irs-pdf/p502.pdf). |        |        |
|                  | The FSAFEDS Web site also has  |        |        |
|                  | a comprehensive list of        |        |        |
|                  | eligible expenses at           |        |        |
|                  | [www.FSAFE                     |        |        |
|                  | DS.com/fsafeds/eligibleexpense |        |        |
|                  | s.asp](http://www.FSAFEDS.com/ |        |        |
|                  | fsafeds/eligibleexpenses.asp). |        |        |
|                  | If you do not see your service |        |        |
|                  | or expense listed please call  |        |        |
|                  | an FSAFEDS Benefits Counselor  |        |        |
|                  | at 1-877-FSAFEDS (372-3337),   |        |        |
|                  | who will be able to answer     |        |        |
|                  | your specific questions.       |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax savings  | An FSA lets you allot money    |        |        |
|     with an FSA  | 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 be less. Without an FSA,  |        |        |
|                  | you would still pay for these  |        |        |
|                  | expenses, but you would do so  |        |        |
|                  | using money remaining in your  |        |        |
|                  | paycheck after Federal (and    |        |        |
|                  | often state and local) taxes   |        |        |
|                  | are deducted. The following    |        |        |
|                  | chart illustrates a typical    |        |        |
|                  | tax savings example:           |        |        |
+------------------+--------------------------------+--------+--------+
|                  | **Annual Tax Savings Example** | **With | **Wi   |
|                  |                                | FSA**  | thout\ |
|                  |                                |        | FSA**  |
+------------------+--------------------------------+--------+--------+
|                  | If your taxable income is:     | \$     | \$     |
|                  |                                | 50,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | And you deposit this amount    | \      | -\$0-  |
|                  | into an FSA:                   | $2,000 |        |
+------------------+--------------------------------+--------+--------+
|                  | Your taxable income is now:    | \$     | \$     |
|                  |                                | 48,000 | 50,000 |
+------------------+--------------------------------+--------+--------+
|                  | Subtract Federal & Social      | \$     | \$     |
|                  | Security taxes:                | 13,807 | 14,383 |
+------------------+--------------------------------+--------+--------+
|                  | If you spend after-tax dollars | -\$0-  | \      |
|                  | for expenses:                  |        | $2,000 |
+------------------+--------------------------------+--------+--------+
|                  | Your real spendable income is: | \$     | \$     |
|                  |                                | 34,193 | 33,617 |
+------------------+--------------------------------+--------+--------+
|                  | **Your tax savings:**          | **\    | **-    |
|                  |                                | $576** | \$0-** |
+------------------+--------------------------------+--------+--------+
|                  | **Note:** This example is      |        |        |
|                  | intended to demonstrate a      |        |        |
|                  | typical tax savings based on   |        |        |
|                  | 27% Federal and 7.65% FICA     |        |        |
|                  | taxes. Actual savings will     |        |        |
|                  | vary based upon the retirement |        |        |
|                  | system in which you are        |        |        |
|                  | enrolled (CSRS or FERS), your  |        |        |
|                  | state of residence, and your   |        |        |
|                  | individual tax situation. In   |        |        |
|                  | this example, the individual   |        |        |
|                  | received \$2,000 in services   |        |        |
|                  | for \$1,424, a discount of     |        |        |
|                  | almost 36%! You may also wish  |        |        |
|                  | to consult a tax professional  |        |        |
|                  | for more information on the    |        |        |
|                  | tax implications of an FSA.    |        |        |
+------------------+--------------------------------+--------+--------+
| -   Tax credits  | You *cannot* claim expenses on |        |        |
|     and          | your Federal Income Tax return |        |        |
|     deductions   | if you receive reimbursement   |        |        |
|                  | for them from your HCFSA or    |        |        |
|                  | DCFSA. Below are some          |        |        |
|                  | guidelines that may help you   |        |        |
|                  | decide whether to participate  |        |        |
|                  | in FSAFEDS.                    |        |        |
+------------------+--------------------------------+--------+--------+
| Health care      | The HCFSA is Federal Income    |        |        |
| expenses         | Tax-free from the first        |        |        |
|                  | dollar. In addition, you may   |        |        |
|                  | be reimbursed from your 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      |        |        |
|                  | shown above, 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 an HCFSA is also |        |        |
|                  | exempt from FICA taxes. This   |        |        |
|                  | exemption is not available on  |        |        |
|                  | your Federal Income Tax        |        |        |
|                  | return.                        |        |        |
+------------------+--------------------------------+--------+--------+
| Dependent care   | The DCFSA generally allows     |        |        |
| expenses         | many families to save more     |        |        |
|                  | than they would with the       |        |        |
|                  | Federal Tax Credit for         |        |        |
|                  | dependent care expenses. Note  |        |        |
|                  | that you may only be           |        |        |
|                  | reimbursed from the DCFSA up   |        |        |
|                  | to your current account        |        |        |
|                  | balance. If you file a claim   |        |        |
|                  | for more than your current     |        |        |
|                  | balance, it will be held until |        |        |
|                  | additional payroll allotments  |        |        |
|                  | have been added to your        |        |        |
|                  | account.                       |        |        |
|                  |                                |        |        |
|                  | Visit                          |        |        |
|                  | [www.fsafeds                   |        |        |
|                  | .com](http://www.fsafeds.com/) |        |        |
|                  | and download the [Dependent    |        |        |
|                  | Care Tax Credit                |        |        |
|                  | Worksheet]{.underline} from    |        |        |
|                  | the Forms and Literature page  |        |        |
|                  | to help you determine what is  |        |        |
|                  | best for your situation. You   |        |        |
|                  | may also wish to consult a tax |        |        |
|                  | professional for more details. |        |        |
+------------------+--------------------------------+--------+--------+
| -   Does it cost | No. Section 1127 of the        |        |        |
|     me anything  | National Defense Authorization |        |        |
|     to           | Act (Public Law 108-136)       |        |        |
|     participate  | requires agencies that offer   |        |        |
|     in FSAFEDS?  | FSAFEDS to employees to cover  |        |        |
|                  | the administrative fee(s) on   |        |        |
|                  | behalf of their employees.     |        |        |
|                  | However, remember that         |        |        |
|                  | participating in FSAFEDS can   |        |        |
|                  | cost you money if you don't    |        |        |
|                  | spend your entire account      |        |        |
|                  | balance by the end of the Plan |        |        |
|                  | Year, resulting in the         |        |        |
|                  | forfeiture of funds remaining  |        |        |
|                  | in your account (the IRS       |        |        |
|                  | "use-it-or-lose-it" rule).     |        |        |
+------------------+--------------------------------+--------+--------+
| -   Contact us   | To learn more or to enroll,    |        |        |
|                  | please visit the **FSAFEDS Web |        |        |
|                  | site** at                      |        |        |
|                  | [www.FSAFEDS.                  |        |        |
|                  | com](http://www.fsafeds.com/), |        |        |
|                  | or contact SHPS directly via   |        |        |
|                  | email or by phone. FSAFEDS     |        |        |
|                  | Benefits Counselors are        |        |        |
|                  | available Monday through       |        |        |
|                  | Friday, from 9:00 a.m. until   |        |        |
|                  | 9:00 p.m. Eastern Time.        |        |        |
|                  |                                |        |        |
|                  | -   E-mail: <FSAFEDS@shps.net> |        |        |
|                  |                                |        |        |
|                  | -   Telephone: 1-877-FSAFEDS   |        |        |
|                  |     (1-877-372-3337)           |        |        |
|                  |                                |        |        |
|                  | -   TTY: 1-800-952-0450        |        |        |
+------------------+--------------------------------+--------+--------+

### The Federal Long Term Care Insurance Program

+------------------+---------------------------------------------------+
| -   It's         | Why should you consider applying for coverage     |
|     important    | under the Federal Long Term Care Insurance        |
|     protection   | Program (FLTCIP)?                                 |
|                  |                                                   |
|                  | -   **FEHB plans do not cover the cost of long    |
|                  |     term care.** Also called "custodial care,"    |
|                  |     long term care is help you receive to perform |
|                  |     activities of daily living -- such as bathing |
|                  |     or dressing yourself - or supervision you     |
|                  |     receive because of a severe cognitive         |
|                  |     impairment. The need for long term care can   |
|                  |     strike anyone at any age and the cost of care |
|                  |     can be substantial.                           |
|                  |                                                   |
|                  | -   **The Federal Long Term Care Insurance        |
|                  |     Program can help protect you from the         |
|                  |     potentially high cost of long term care.**    |
|                  |     This coverage gives you options regarding the |
|                  |     type of care you receive and where you        |
|                  |     receive it. With FLTCIP coverage, you won't   |
|                  |     have to worry about relying on your loved     |
|                  |     ones to provide or pay for your care.         |
|                  |                                                   |
|                  | -   **It's to your advantage to apply sooner      |
|                  |     rather than later. In order to qualify for    |
|                  |     coverage under the FLTCIP,** you must apply   |
|                  |     and pass a medical screening (called          |
|                  |     underwriting). Certain medical conditions, or |
|                  |     combinations of 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 future       |
|                  |     change in your health disqualify you from     |
|                  |     obtaining coverage. Also, the younger you are |
|                  |     when you apply, the lower your premiums.      |
|                  |                                                   |
|                  | -   **You don't have to wait for an open season   |
|                  |     to apply.** The Federal Long Term Care        |
|                  |     Insurance Program accepts applications from   |
|                  |     eligible persons at any time. You will have   |
|                  |     to complete a full underwriting application,  |
|                  |     which asks a number of questions about your   |
|                  |     health. However, if you are a new or newly    |
|                  |     eligible employee, you (and your spouse, if   |
|                  |     applicable) have a limited opportunity to     |
|                  |     apply using the abbreviated underwriting      |
|                  |     application, which asks fewer questions.      |
|                  |     Newly married spouses of employees also have  |
|                  |     a limited opportunity to apply using          |
|                  |     abbreviated underwriting.                     |
|                  |                                                   |
|                  | -   **Qualified relatives are also eligible to    |
|                  |     apply.** Qualified relatives include spouses  |
|                  |     and adult children of employees and           |
|                  |     annuitants, and parents, parents-in-law, and  |
|                  |     stepparents of employees.                     |
+------------------+---------------------------------------------------+
| -   To find out  | Call 1-800-LTC-FEDS (1-800-582-3337) (TTY         |
|     more and to  | 1-800-843-3557) or visit                          |
|     request an   | [www.ltcfeds.com](http://www.ltcfeds.com/).       |
|     application  |                                                   |
+------------------+---------------------------------------------------+

# Index

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

Accidental injury 17, 22, 34

Allergy tests 16

Allogeneic (donor) bone marrow transplant 23

Ambulance 25, 26, 28

Anesthesia 5, 21

Autologous bone marrow transplant 16, 23

Biopsy 21

Blood and blood plasma 26

Casts 25, 26

Catastrophic protection out-of-pocket maximum 11, 53

**Changes for 2005** 7

Chemotherapy 16

Chiropractic 19

Cholesterol tests 14

Claims 8, 12, 36, 37, 41, 46, 48

Coinsurance 6, 8, 11, 36, 44, 49

Colorectal cancer screening 14

Congenital anomalies 21, 22

Contraceptive drugs and devices 15

Covered charges 40

Crutches 19

Deductible 6, 8, 11, 36, 49

Definitions 13, 21, 25, 27, 29, 30, 34, 44, 53

Dental care 34, 53

Diagnostic services 13, 25, 29, 53

Disputed claims review 33

Donor expenses 23

Dressings 25

Durable medical equipment 19

Educational classes and programs 20

Effective date of enrollment 9

Emergency 6, 27, 28, 35, 36, 53

Experimental or investigational 35

*Eyeglasses* 17

Family planning 15

Fecal occult blood test 14

Fraud 3, 4

General exclusions 35

General Exclusions 12

Hearing services 17

Home health services 19

Hospital 4, 5, 6, 8, 9, 18, 19, 21, 22, 23, 24, 25, 26, 28, 29, 34, 36,
40, 41, 43, 53

Immunizations 6, 14

Infertility 11, 15

Inpatient hospital benefits 36

Magnetic Resonance Imagings (MRIs) 13

Mammograms 13

Maternity benefits 15

Medicaid 43

Medically necessary 13, 15, 16, 21, 25, 27, 29, 30, 34, 35

Medicare 29, 39, 41

Original 40

Members

Associate 54

Family 45

Plan 8, 21

Mental Health/Substance Abuse Benefits 29

Newborn care 15

Nurse

Licensed Practical Nurse (LPN) 19

Nurse Anesthetist (NA) 25

Occupational therapy 17

Office visits 6, 11

Oral and maxillofacial surgical 22

Out-of-pocket expenses 39, 49

Oxygen 19, 25, 26

Pap test 13, 14

Physician 19, 21

Precertification 38

Prescription drugs 16, 36, 41, 53

Preventive care, adult 14

Preventive care, children 14

Preventive services 6

Prior approval 37, 38

Prosthetic devices 21

Psychologist 29

Radiation therapy 16

Room and board 25

Second surgical opinion 13

Skilled nursing facility care 9, 24, 26

Smoking cessation 20

Social worker 29

Speech therapy 17

Splints 25

Subrogation 43

Substance abuse 53

Surgery 5, 15, 17, 21

Anesthesia 26

Oral 22

Outpatient 26

Reconstructive 21, 22

Temporary Continuation of Coverage (TCC) 46

Transplants 16, 23

Treatment therapies 16

Vision care 53

Wheelchairs 19

Workers Compensation 42

X-rays 13, 25, 26

# Summary of benefits for WINhealth Partners *-* 2005

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

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

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

+----------------------------------------+-----------------------+----+
| **Benefits**                           | **You pay**           | ** |
|                                        |                       | Pa |
|                                        |                       | ge |
|                                        |                       | ** |
+----------------------------------------+-----------------------+----+
| Medical services provided by           | Office visit copay:   | 13 |
| physicians:                            | \$10                  |    |
|                                        |                       |    |
| -   Diagnostic and treatment services  | Diagnostic studies:   |    |
|     provided in the office             | \$100/test            |    |
+----------------------------------------+-----------------------+----+
| Services provided by a hospital:       | Nothing               | 25 |
|                                        |                       |    |
| -   Inpatient                          | \$50                  | 26 |
|                                        |                       |    |
| -   Outpatient                         |                       |    |
+----------------------------------------+-----------------------+----+
| Emergency benefits                     | \$50 per visit        | 28 |
|                                        |                       |    |
| -   In-area                            |                       | 28 |
|                                        |                       |    |
| -   Out-of-area                        |                       |    |
+----------------------------------------+-----------------------+----+
| Mental health and substance abuse      | Regular cost sharing  | 29 |
| treatment                              |                       |    |
+----------------------------------------+-----------------------+----+
| Prescription drugs                     | > \*Retail Pharmacy:  | 3  |
|                                        | >                     | 0- |
|                                        | > \$50 Deductible     | 32 |
|                                        | >                     |    |
|                                        | > \$10 generic        |    |
|                                        | > prescriptions       |    |
|                                        | >                     |    |
|                                        | > \$15 preferred      |    |
|                                        | > brand prescriptions |    |
|                                        | >                     |    |
|                                        | > \$40 non-preferred  |    |
|                                        | > brand prescriptions |    |
|                                        | >                     |    |
|                                        | > Mail Order (90-day  |    |
|                                        | > supply)             |    |
|                                        | >                     |    |
|                                        | > No deductible       |    |
|                                        | >                     |    |
|                                        | > \$20 generic        |    |
|                                        | >                     |    |
|                                        | > \$30 preferred      |    |
|                                        | > brand prescriptions |    |
|                                        | >                     |    |
|                                        | > \$80 non-preferred  |    |
|                                        | > brand prescriptions |    |
|                                        | >                     |    |
|                                        | > 20% coinsurance for |    |
|                                        | > injectables with a  |    |
|                                        | > \$5,000 out of      |    |
|                                        | > pocket maximum      |    |
+----------------------------------------+-----------------------+----+
| Dental care .                          | No benefit.           | 34 |
+----------------------------------------+-----------------------+----+
| Vision care .                          | No benefit.           | 17 |
+----------------------------------------+-----------------------+----+
| Special features: *None*               |                       | 33 |
+----------------------------------------+-----------------------+----+
| Protection against catastrophic costs  | \$2,000/Self Only or  | 11 |
|                                        | \$4,000/Family        |    |
| (your catastrophic protection          | enrollment per year   |    |
| out-of-pocket maximum)                 |                       |    |
|                                        | Some costs do not     |    |
|                                        | count toward this     |    |
|                                        | protection            |    |
+----------------------------------------+-----------------------+----+

# 2005 Rate Information for WINhealth Partners

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

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

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

+-------------+----------+--------------------------+-----------------+
| **Type**    | **Code** | ***Non-Postal Premium*** | ***Postal       |
|             |          |                          | Premium***      |
| **of**      |          | **                       |                 |
|             |          | [Biweekly]{.underline}** | **[Biweekly     |
| **E         |          | *                        | ]{.underline}** |
| nrollment** |          | *[Monthly]{.underline}** |                 |
|             |          |                          | **USPS Your**   |
|             |          | **Gov't Your Gov't       |                 |
|             |          | Your**                   | **Share Share** |
|             |          |                          |                 |
|             |          | **Share Share Share      |                 |
|             |          | Share**                  |                 |
+-------------+----------+--------------------------+-----------------+

**Location Information**

+-------------+----------+--------------------------+-----------------+
| **High      | **PV1**  | **\$125.54 \$41.85       | **\$148.56      |
| Option**    |          | \$272.01 \$90.67**       | \$18.83**       |
|             | **PV2**  |                          |                 |
| **Self      |          | **\$298.23 \$155.57      | **\$352.08      |
| Only**      |          | \$646.17 \$337.06**      | \$101.72**      |
|             |          |                          |                 |
| **High      |          |                          |                 |
| Option**    |          |                          |                 |
|             |          |                          |                 |
| **Self &    |          |                          |                 |
| Family**    |          |                          |                 |
+-------------+----------+--------------------------+-----------------+