Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, contact us as follows:

High Option: Call us at 800/222-APWU or write to us at P.O. Box 3279, Silver Spring, MD 20918 or through our Web site at www.apwuhp.com.

Consumer-driven Option: Call Definity Health at 866/833-3463 or request replacement cards through the Web site at www.definityhealth.com.

Where you get covered care

You can get care from any “covered provider” or “covered facility.” How much we pay – and you pay – depends on the type of covered provider or facility you use. If you use our preferred providers, you will pay less.

Covered providers

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

1. Doctor – A licensed doctor of medicine (M.D.), a licensed doctor of osteopathy (D.O.), a licensed doctor of podiatry (D.P.M.), or, for certain specified services covered by this Plan, a licensed dentist, licensed chiropractor, or licensed clinical psychologist practicing within the scope of the license.

2. Alternate Provider – Alternate providers are covered when performing certain specified services covered by this Plan and when such treatment is within the scope of the provider’s license. Alternate providers are limited to licensed physical occupational and speech therapists licensed physician’s assistants; Registered Nurses (R.N.); Licensed Practical Nurses (L.P.N.); Licensed Vocational Nurses (L.V.N.); and Certified Registered Nurse Anesthetists (C.R.N.A.).

3. Other covered providers include a qualified clinical psychologist, clinical social worker, optometrist, audiologist, nurse midwife nurse practitioner /clinical specialist, and nursing school administered clinic. For purposes of this FEHB brochure, the term “doctor” includes all of these providers when the services are performed within the scope of their license or certification.

Medically underserved areas. Note: We cover any licensed medical practitioner for any covered service performed within the scope of that license in states OPM determines are “medically underserved.” For 2005, the states are: Alabama, Alaska, Idaho, Kentucky, Louisiana, Mississippi, Missouri, Montana, New Mexico, North Dakota, South Carolina, South Dakota, Texas, and Wyoming.

Covered facilities

Covered facilities include:

Freestanding ambulatory facility

An out-of-hospital facility such as a medical, cancer, dialysis, or surgical center or clinic, and licensed outpatient facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations for treatment of substance abuse.

Covered facilities (continued)

Hospital

1. An institution which is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations, or

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

a) general inpatient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities, all of which must be provided on its premises or under its control, or

b) specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized provider of those facilities.

The term “hospital” shall not include a skilled nursing facility, a convalescent nursing home or institution or part thereof which 1) is used principally as a convalescent facility, rest facility, residential treatment center, nursing facility or facility for the aged or 2) furnishes primarily domiciliary or custodial care, including training in the routines of daily living.

What you must do to
get covered care

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

Transitional care

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

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

lose access to your PPO specialist because we terminate our contract with your specialist for other than cause,

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

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

Hospital care

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our High Option begins, call our customer service department immediately at 800/222-APWU. For the Consumer-driven Option, please call Definity Health at 866/833-3463.

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

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

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

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

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

How to Get Approval for…

Your hospital stay

Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won’t change our decision on medical necessity.

In most cases, your physician or hospital will take care of precertification. Because you are still responsible for ensuring that we are asked to precertify your care, you should always ask your physician or hospital whether they have contacted us.

Warning

We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any benefits.

How to precertify an
admission

High Option: You, your representative, your doctor, or your hospital must call Spectera/CARE at 800/580-8771 at least 48 hours before admission. In Minnesota, call PreferredOne at 800/451-9597 to precertify. These numbers are available 24 hours every day.

Consumer-driven Option: You, your representative, your doctor, or your hospital must call Definity Health at 866/333-4648 at least 48 hours before admission. This number is available 24 hours every day.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the doctor, or the hospital must telephone the above number 48 hours following the day of the emergency admission, even if you have been discharged from the hospital.

Provide the following information:

- Enrollee’s name and Plan identification number

- Patient’s name, birth date, and phone number

- Reason for hospitalization, proposed treatment, or surgery

- Name and phone number of admitting doctor

- Name of hospital or facility; and

- Number of planned days of confinement

We will then tell the doctor and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the hospital.

Maternity care

You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.

If your hospital stay
needs to be extended

High Option: If your hospital stay -- including for maternity care -- needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days by calling Spectera/CARE at 800/580-8771 or in Minnesota, call PreferredOne at 800/451-9597.

Consumer-driven Option: If your hospital stay – including for maternity care - needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days by calling Definity Health at 866/333-4648.

What happens when you
do not follow the precertification rules

If no one contacted us, we will decide whether the hospital stay was medically necessary.

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

If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.

If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.

When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then:

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

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

Exceptions

You do not need precertification in these cases:

You are admitted to a hospital outside the United States and Puerto Rico.

You have another group health insurance policy that is the primary payer for the hospital stay.

Your Medicare Part A is the primary payer for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payer and you do need precertification.

Radiology/Imaging Procedures Precertification

High Option: Radiology precertification is required prior to scheduling specific imaging procedures. We evaluate the medical necessity of your proposed procedure to ensure that the appropriate procedure is being requested for your condition. In most cases your physician will take care of the precertification. Because you are responsible for ensuring that precertification is done, you should ask your doctor to contact us.

The following outpatient radiology services require precertification:

CAT/CT – Computerized Axial Tomography

MRI – Magnetic Resonance Imaging

MRA – Magnetic Resonance Angiography

NC – Nuclear Cardiology

PET – Positron Emission Tomography

How to precertify a radiology/imaging procedure

For these outpatient studies; you, your representative or doctor must call MedSolutions before scheduling the procedure. The toll free number is 888/693-3298.

Provide the following information:

- Patient's name, Plan identification number, and birth date

- Requested procedure and clinical support for request

- Name and phone number of ordering provider

- Name of requested imaging facility

Exceptions

You do not need precertification in these cases:

You have another health insurance policy that is primary including Medicare Parts A&B or Part B Only

The procedure is performed outside the United States or Puerto Rico

You are inpatient hospital

The procedure is performed as an emergency

Warning

We will reduce our benefits for these procedures by $100 if no one contacts us for precertification. If the procedure is not medically necessary, we will not pay any benefits.

Other services

Some services require prior approval (High Option) and some require pre-notification (Consumer-driven Option):

High Option: Call Spectera/CARE at 800/580-8771 if you need any of the services listed below:

Consumer-driven Option: Call Definity Health at 866/333-4648 if you need any of the services listed below:

Prior approval/pre-notification is required for organ transplantation. Call before your first evaluation as a potential candidate.

Prior approval/pre-notification is required for surgical procedures which may be cosmetic in nature such as eyelid surgery (blepharoplasty) or varicose vein surgery (sclerotherapy).

Prior approval/pre-notification is required for recognized surgery for morbid obesity or for organic impotence.

Prior approval/pre-notification is required for home health care such as nursing visits, infusion therapy, growth hormone therapy (GHT), rehabilitative therapy (physical, occupational or speech therapy) and pulmonary rehabilitation programs.

Prior approval/pre-notification is required for durable medical equipment such as wheelchairs, oxygen equipment and supplies, artificial limbs and braces and for Retin A, Botox or drugs for organic impotence.

Prior approval is also required for mental health and substance abuse benefits, inpatient or outpatient, in-network or out-of-network. Under the High Option and the Consumer-driven Option, call ValueOptions at 888/700-7965.

Copayments

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

Example: Under the High Option, when you see your PPO physician you pay a copayment of $18 per visit.

Consumer-driven Option: There are no copayments under the Consumer-driven Option.

Deductible

Adeductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

High Option

If you use PPO providers, the calendar year deductible is $275 per person. Under a family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $550. If you use non-PPO providers, your calendar year deductible increases to a maximum of $500 per person ($1,000 per family). Whether or not you use PPO providers, your calendar year deductible will not exceed $500 per person ($1,000 per family).

We also have a separate deductible for mental health and substance abuse benefits. The in-network deductible is $275 per person. Under a family enrollment, this deductible is satisfied for all family members when the combined in-network covered expenses applied to this deductible for all family members reach $550. The out-of-network deductible is $750 per person each calendar year with no family maximum.

Note: If you change plans during Open Season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

And, if you change from Self and Family to Self Only, or from Self Only to Self and Family during the year, we will credit the amount of covered expenses already applied toward the deductible of your old enrollment to the deductible of your new enrollment. However, if you change from High Option to Consumer-driven Option, or from Consumer-driven Option to High Option, during the year, expenses incurred as of the effective date of the option change are subject to the benefit provisions of your new option.

Consumer-driven Option: There is no calendar year deductible under the Consumer-driven Option. Also, there is no separate deductible for mental health and substance abuse benefits under the Consumer-driven Option.

Coinsurance

High Option: Coinsurance is thepercentage of our allowance that you must pay for your care. Coinsurance doesn’t begin until you meet your deductible (High Option) or your Member Responsibility (Consumer-driven Option).

Example: You pay 30% of our allowance for office visits to a non-PPO physician.

Note: If your provider routinely waives (does not require you to pay) your copayments, deductibles, or coinsurance, the provider is misstating the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider’s fee by the amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives your 30% coinsurance, the actual charge is $70. We will pay $49 (70% of the actual charge of $70).

Consumer-driven Option: Coinsurance is the percentage of our allowance that you must pay for your care after you have used up your Personal Care Account (PCA) and paid your Member Responsibility.

Member Responsibility

High Option: Does not apply.

Consumer-driven Option: Your Member Responsibility is your bridge between your Personal Care Account (PCA) and your Traditional Health Coverage. After you have exhausted your PCA, you must pay your Member Responsibility before your Traditional Health Coverage begins. Your Member Responsibility is generally $600 for a Self Only enrollment or $1,200 for a Self and Family enrollment. Your Member Responsibility in subsequent years may be reduced by rolling over any unused portion of your Personal Care Account remaining at the end of the calendar year(s).

Differences between our allowance and the bill

High Option: Our “Plan allowance” is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in different ways, so their allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 11.

Often, the provider’s bill is more than a fee-for-service plan’s allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on the provider you use.

PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance or copayment.Here is an example about coinsurance: You see a PPO physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just -- 10% of our $100 allowance ($10). Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and his bill.

Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. When you use a non-PPO provider, you will pay your deductible and coinsurance -- plus any difference between our allowance and charges on the bill. Here is an example: You see a non-PPO physician who charges $150 and our allowance is again $100. Because you’ve met your deductible, you are responsible for your coinsurance, so you pay 30% of our $100 allowance ($30). Plus, because there is no agreement between the non-PPO physician and us, he can bill you for the $50 difference between our allowance and his bill.

The following table illustrates the examples of how much you have to pay out-of-pocket for services from a PPO physician vs. a non-PPO physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The table shows the amount you pay if you have met your calendar year deductible

Physician’s charge

$150

$150

Our allowance

We set it at:

100

We set it at:

100

We pay

90% of our allowance:

90

70% of our allowance:

70

You owe: Coinsurance

10% of our allowance:

10

30% of our allowance:

30

+Difference up to charge?

No:

0

Yes:

50

TOTAL YOU PAY

$10

$80

Consumer-driven Option:

PPO providers agree to accept our plan allowance so if you use a PPO Provider, you never have to worry about paying the difference between the plan allowance and the billed amount for covered services. If your covered expenses are being paid out of your Personal Care Account or if you are receiving in-network covered preventive services, the plan will pay 100%. If you have exhausted your Personal Care Account, you will be responsible for paying your Member Responsibility and also coinsurance under the Traditional Health Coverage.

Non PPO Providers: If you use a non-PPO provider, you will have to pay the difference between the plan allowance and the billed amount only if you use up your Personal Care Account for the year. Note that it usually makes sense to use PPO providers because it will make your Personal Care Account go much further since money left in your Personal Care Account can be rolled over to be used in the next year.

Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, copayments, and Member Responsibility

There is a limit to the amount you must pay out-of-pocket for coinsurance for the year for certain charges. When you have reached this limit, you pay no coinsurance for covered services for the remainder of the calendar year.

High Option:

PPO benefit: Your out-of-pocket maximum is $4,000 for either a Self Only or a Self and Family enrollment if you are using PPO providers. Only eligible expenses for PPO providers count toward this limit.

Non-PPO benefit: Your out-of-pocket maximum is $10,000 for either a Self Only or a Self and Family enrollment if you are using non-PPO providers. Eligible expenses for network providers also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers.

Out-of-pocket expenses for the purposes of this benefit are:

The 10% you pay for PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services

The 30% you pay for non-PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services; and

The copayment of $18 for outpatient visits to PPO physicians

The following cannot be included in the accumulation of out-of-pocket expenses:

Expenses in excess of our allowance or maximum benefit limitations

Expenses for out-of-network mental health or substance abuse

Any amounts you pay because benefits have been reduced for non-compliance with this Plan's cost containment requirements (see pages 11, 12, 13 and 14)

Covered expenses applied to the $275 or $500 calendar year deductibles

Covered expenses applied to the $275 deductible for in-network mental health or substance abuse care

The $300 per admission deductible for non-PPO Inpatient hospital charges

Expenses for prescription drugs

Expenses in excess of visit maximums for physical, occupational and speech therapy (see page 26)

Expenses incurred in excess of the $90 per day provided under home nursing care (see page 29); and

Expenses in excess of hospice care and preventive care maximums

Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, copayments, and Member Responsibility (continued)

Consumer-driven Option:

If you have exceeded your Personal Care Account and met your Member Responsibility the following would apply:

In-network benefit: Your out-of-pocket maximum is $4,500 for either a Self Only or a Self and Family enrollment if you are using network providers. Only eligible expenses for network providers count toward this limit.

Out-of-network benefit: Your out-of-pocket maximum is $9,000 for either a Self Only or a Self and Family enrollment if you are using out-of-network providers. Eligible expenses for network providers also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers.

Out-of-pocket expenses for the purposes of this benefit are:

The 15% you pay for in-network Inpatient and outpatient hospital charges, Surgical, Medical, Maternity and Emergency services under the Traditional Health Coverage

The 40% you pay for out-of-network Inpatient and outpatient hospital charges, Surgical, Medical, Maternity and Emergency services under the Traditional Health Coverage

The following cannot be included in the accumulation of out-of-pocket expenses:

Any expenses paid by the Plan under your Personal Care Account

Any expenses paid by the Plan under your In-network Preventive Care benefit

Any expenses you must pay under your Member Responsibility

Expenses in excess of our allowance or maximum benefit limitations or expenses not covered under the Traditional Health Coverage

Expenses for out-of-network mental health or substance abuse care

Expenses you pay for prescription drugs under your Traditional Health Coverage

Dental care or vision care expenses above the limitations provided under your Personal Care Account

Any amounts you pay because benefits have been reduced for non-compliance with this Plan’s cost containment requirements (see pages 11, 12, 13, 14 and 15)

Expenses in excess of hospice care maximums

Carryover

If you enrolled in our Plan during Open Season and your effective date is after January 1, your previous plan will be responsible for any medical care you received before your coverage in our Plan began. The old plan will pay your covered costs under this year’s benefits since benefit changes start on January 1. If you did not meet your out-of-pocket maximum under your old plan last year, your covered out-of-pocket expenses will be applied to that maximum. If you did meet that maximum, your old plan’s catastrophic protection benefit will continue to apply until your effective date in our Plan.

When Government facilities
bill us

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

If we overpay you

We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments. We will generally first seek recovery from the provider if we paid the provider directly, or from the person (covered family member, guardian, custodial parent, etc.) to whom we sent our payment.

If you…

are age 65 or over, and

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

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

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

Then, for your inpatient hospital care,

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

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

you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you; and

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

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

an amount set by Medicare and called the “Medicare approved amount,” or

the actual charge if it is lower than the Medicare approved amount.

Participates with Medicare or accepts Medicare assignment for the claim and is a member of our PPO network,

your deductibles, coinsurance, and copayments;

Participates with Medicare and is not in our PPO network,

your deductibles, coinsurance, copayments, and any balance up to the Medicare approved amount;

Does not participate with Medicare,

your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare approved amount

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

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

When you have the Original Medicare Plan
(Part A, Part B, or both)

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

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician accepts Medicare assignment for the claim.

High Option: If your physician accepts Medicare assignment, then you pay nothing for covered charges.

Consumer-driven Option: If your physician accepts Medicare assignment, then you pay nothing if you have unused benefits available under your Personal Care Account to pay the difference between the Medicare approved amount and Medicare’s payment. If your PCA is exhausted, you must pay either this full difference under your Member Responsibility or the lesser of your coinsurance or the full difference if your Member Responsibility has been met.

If your physician does not accept Medicare assignment, then you pay the difference between the "limiting charge" or the physician's charge (whichever is less) and our payment combined with Medicare’s payment.

It's important to know that a physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the “limiting charge.” The Medicare Summary Notice (MSN) that Medicare will send you will have more information about the limiting charge. If your physician tries to collect more than allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to your Medicare carrier who sent you the MSN form. Call us if you need further assistance.

Please see Section 10, Coordinating benefits with other coverage, for more information about how we coordinate benefits with Medicare.

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Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

The calendar year deductible is: PPO - $275 per person ($550 per family); Non-PPO - $500 per person ($1,000 per family). The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.

The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists, may not all be preferred providers. If they are not, they will be paid by this Plan as non-PPO providers. However, if surgical services are rendered at a PPO hospital or a PPO freestanding ambulatory facility by a PPO primary surgeon, we will pay the services of anesthesiologists who are not preferred providers at the PPO rate, based on Plan allowance.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

YOU MUST GET PRECERTIFICATION OF CERTAIN OUTPATIENT IMAGING PROCEDURES. FAILURE TO DO SO WILL RESULT IN A MINIMUM OF $100 PENALTY. Please refer to precertification information in Section 3 to be sure which procedures require precertification.

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Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it does not apply.

Professional services of physicians

In physician’s office

One annual routine gynecological visit for pap test for women age 18 or over – PPO only

PPO: $18 copayment (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Professional services of physicians

In an urgent care center

During a hospital stay

In a skilled nursing facility

Initial examination of a newborn child covered under a family enrollment

Second surgical opinion

At home

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Routine physical checkups and related tests

Non-PPO annual routine gynecological visits

All charges

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT and CT Scans/MRI/MRA/NC/PET (Outpatient requires precertification – See Section 3)

Ultrasound

Electrocardiogram and EEG

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Note: If your PPO provider uses a non-PPO lab or radiologist, we will pay non-PPO benefits for any lab and X-ray charges.

Not covered: Professional fees for automated lab tests

All charges

Routine screenings, limited to:

Total Blood Cholesterol – once annually

Fasting lipoprotein profile, once every 5 years for adults age 20 or over

Osteoporosis screening, once every two years, for women age 65 and older

Chlamydial infection

Colorectal Cancer Screening, including

- Fecal occult blood test, once annually, ages 40 and older

- Sigmoidoscopy, screening – every five years starting at age 50

- Colonoscopy, once every 10 years starting at age 50

- Double Contrast Barium Enema (DCBE), once every 5 years starting at age 50

Routine Prostate Specific Antigen (PSA) test – one annually for men age 40 and older

Routine pap test, one annually, women age 18 and older

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Routine mammograms– covered for women age 35 and older, as follows:

From age 35 through 39, one during this five year period

From age 40 through 64, one every calendar year

At age 65 and older, one every two consecutive calendar years

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Routine immunizations, limited to:

Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually

Pneumococcal vaccine, age 65 and older

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Adult immunizations other than those listed above

Office visit associated with preventive care other than one annual routine PPO gynecological visit for pap test for women age 18 or over

All charges

Childhood immunizations recommended by the American Academy of Pediatrics up to age 22

Examinations, limited to:

- Well-child care charges for physical examinations and laboratory tests through age 12

- Examination for amblyopia and strabismus-limited to one screening examination (age 2 through 6)

PPO: Nothing (No deductible)

Non-PPO: Any difference between the Plan allowance and the billed charge (No deductible)

PPO: Nothing (No deductible)

Non-PPO: Any difference between the Plan allowance and the billed charge and any amount above $250 per child (ages 0 through 3) each year and any amount above $150 per child (ages 4 through 12) each year (No deductible)

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see page 11 for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary, but you, your representative, your doctor, or your hospital must precertify.

We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self and Family enrollment. We cover circumcision of a covered newborn under Surgical benefits. See Surgery benefits (Section 5b).

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital Benefits (Section 5c) and Surgery Benefits (Section 5b).

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: Amniocentesis if for diagnosing multiple births

All charges

A range of voluntary family planning services, limited to:

Voluntary sterilization (See Surgical procedures Section 5(b))

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit.

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: Reversal of voluntary surgical sterilization and genetic counseling

All charges

Diagnosis and treatment of infertility, except as shown in Not covered.

PPO: 10% of the Plan allowance and any amount over $2,500

Non-PPO: 30% of the Plan allowance, any difference between our allowance and the billed amount and any amount over $2,500

Not covered:

Infertility services after voluntary sterilization

Assisted reproductive technology (ART) procedures, such as:

- artificial insemination (all procedures)

- in vitro fertilization

- embryo transfer and gamete intrafallopian transfer (GIFT)

- intravaginal insemination (IVI)

- intracervical insemination (ICI)

- intrauterine insemination (IUI)

Services and supplies related to ART procedures

Cost of donor sperm

Cost of donor egg

All charges

Testing and treatment, including materials (such as allergy serum)

Allergy injections

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: Provocative food testing and sublingual allergy desensitization

All charges

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on page 33.

Dialysis – hemodialysis and peritoneal dialysis

Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover IV/Infusion therapy and GHT when we preauthorize the treatment. Call Spectera/CARE at 800/580-8771 for preauthorization. Spectera/CARE will ask you to submit information that establishes that GHT is medically necessary. You should ask for preauthorization before you begin treatment. If you do not ask or if we determine GHT is not medically necessary, we will not cover GHT or related services and supplies. See Other services under How to get approval for... in Section 3.

Respiratory and inhalation therapies

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Physical therapy and occupational therapy provided by a licensed registered therapist up to a combined 60 visits per calendar year.

Note: Preauthorization of rehabilitative therapies is required. Call Spectera/CARE at 800/580-8771 for preauthorization.

Note: We only cover physical and occupational therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury and when a physician:

1) Orders the care

2) Identifies the specific professional skills the patient requires and the medical necessity for skilled services; and

3) Indicates the length of time the services are needed

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Maintenance therapies

Exercise programs

Physical and occupational therapies without preauthorization

All charges

Speech therapy where medically necessary and provided by a licensed therapist

Note: Preauthorization of speech therapy is required. Call Spectera/CARE at 800/580-8771 for preauthorization.

Note: Speech therapy is combined with 60 visits per year for the services of physical therapy and/or occupational therapy (see above).

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Audiologist to diagnose a hearing problem

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Hearing aids, testing and examinations for them

All charges

Internal (implant) ocular lenses and/or the first contact lenses required to correct an impairment caused by accident or illness. The services of an optometrist are limited to the testing, evaluation and fitting of the first contact lenses required to correct an impairment caused by accident or illness.

Note: See Preventive care, children for eye exams for children

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Eyeglasses or contact lenses and examinations for them

Eye exercises and visual training

Radial keratotomy and other refractive surgery

All charges

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes

See Orthopedic and prosthetic devices for information on podiatric shoe inserts

PPO: $18 copayment for the office visit (No deductible) plus 10% of the Plan allowance for other services performed during the visit

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above

Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges

Artificial limbs and eyes; stump hose

Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy

Leg, arm, neck and back braces

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See Section 5(b) for coverage of the surgery to insert the device.

Note: We recommend preauthorization of orthopedic and prosthetic devices. Call Spectera/CARE at 800/580-8771 for preauthorization.

Note: We will pay only for the cost of the standard item. Coverage for specialty items, such as bionics, is limited to the cost of the standard item.

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Orthopedic and corrective shoes

Arch supports

Foot orthotics

Heel pads and heel cups

Lumbosacral supports

Corsets, trusses, elastic stockings, support hose, and other supportive devices

All charges

Durable medical equipment (DME) is equipment and supplies that:

1) Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury)

2) Are medically necessary

3) Are primarily and customarily used only for a medical purpose

4) Are generally useful only to a person with an illness or injury

5) Are designed for prolonged use; and

6) Serve a specific therapeutic purpose in the treatment of an illness or injury

We cover rental or purchase, at our option, including repair and adjustment, of durable medical equipment, such as oxygen and dialysis equipment.

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Under this benefit, we also cover equipment such as:

Hospital beds

Wheelchairs

Ostomy supplies (including supplies purchased at a pharmacy)

Crutches; and

Walkers

Note: Call Spectera/CARE at 800/580-8771 as soon as your physician prescribes this equipment because prior approval is required. We arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Note: We will pay only for the cost of the standard item. Coverage for specialty equipment, such as all-terrain wheelchairs, is limited to the cost of the standard equipment.

(see above)

Not covered:

Whirlpool equipment

Sun and heat lamps

Light boxes

Heating pads

Exercise devices

Stair glides

Elevators

Air Purifiers

Computer “story boards,” “light talkers,” or other communication aids for communi