Sponsored and administered by: The Association

Who may enroll in this Plan: Members of the Association

Annuitants (retirees) who are members of the Association may enroll in this Plan.

Identification cards

We will send you an identification (ID) card. You should carry this card with you at all times. You must show your ID card whenever you receive services from a medical or dental provider, and to fill a prescription at a participating Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF2809, or your health benefits enrollment confirmation (for annuitants).

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

Where you get covered care

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

• Covered providers

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

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

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

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

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

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

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

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

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

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

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

Medically underserved areas: We cover any licensed medical practitioner, including chiropractors, for any covered service performed within the scope of that license in states OPM determines are "medically underserved." For 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

Hospital:

1. An institution that is accredited as a hospital under the hospital accredita­tion program of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); or
2. Any other institution that is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing service, and that is primarily engaged in providing:
   1. General patient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities, all of which facilities must be provided on its premises or under its control; or
   2. specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises, under its control, or through a written agree­ment with a hospital (as defined above) or with a specialized provider of those facilities.
3. For inpatient and outpatient treatment of mental health and substance abuse, the term hospital also includes a freestanding residential treatment center facility approved by the JCAHO.

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

• is used principally as a convalescent facility, rest facility, nursing facility or facility for the aged;
• furnishes primarily domiciliary or custodial care including training in the routines of daily living;
• or is operated as a school.

NursingSchool Administered Clinic: A clinic that is

1. licensed or certified in the state where the services are performed, and
2. provides ambulatory care in an outpatient setting—primarily in rural or inner city areas where there is a shortage of physicians. Services billed for by these clinics are considered outpatient ‘office' services rather than facility charges.

Skilled nursing facility: An institution, or that part of an institution that provides convalescent skilled nursing care 24 hours a day and is classified as a skilled nursing facility under Medicare.

Birthing Center: A licensed facility that is equipped and operated solely to provide prenatal care, to perform uncomplicated spontaneous deliveries and to provide immediate postpartum care.

Hospice: A facility that meets all of the following:

1. primarily provides inpatient hospice care to terminally ill persons;
2. is certified by Medicare as such, or is licensed or accredited as such by the jurisdiction it is in;
3. is supervised by a staff of M.D.s or D.O.s, at least one of whom must be on call at all times;
4. provides 24-hour-a-day nursing services under the direction of an R.N. and has a full-time administrator; and
5. provides an ongoing quality assurance program.

What you must do to get covered care

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

• Transitional care

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

• lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan, or
• lose access to your PPO specialist because we terminate our contract with your specialist for other than cause,

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

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

• Hospital care

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-634-0069.

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

• You are discharged, not merely moved to an alternative care center; or
• The day your benefits from your former plan run out; or
• The 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.

• Your hospital stay

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

Warning:

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

How to precertify an admission

• You, your representative, your physician, or your hospital must call us before the admission or care. The toll-free number is 1-800-634-0069.
• Provide the following information:
  • Enrollee's name and Plan identification number;
  • Patient's name, birth date, and phone number;
  • Reason for hospitalization, proposed treatment, or surgery;
  • Name and phone number of admitting physician;
  • Name of hospital or facility; and
  • Number of planned days of hospital stay.

• We will then tell your physician and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your physi­cian, and the hospital.
• If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, your physician, or your hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

Maternity care

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

If your hospital stay needs to be extended

If your hospital stay—including for maternity care—needs to be extended, you, your representative, your physician or the hospital must ask us to approve the additional days.

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 no one contacted us for specified services such as Hospice Care, Skilled Nursing Facility Care, Home Health Care, we will disqualify higher paid benefits.
• If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.
• When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then:
  • for the part of the admission that was medically necessary, we will pay inpatient benefits, but
  • for the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.

Exceptions

You do not need precertification in these cases:

• You are admitted to a hospital outside the United States.
• You have another group health insurance policy that is the primary payer for the hospital stay.
• Your Medicare Part A is the primary payer for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payer and you do need precertification.

• Other services

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

• Home health care (See Section 5(a))
• Hospice care (See Section 5(c))
• Skilled nursing facilities (See Section 5(c))
• Mental health and substance abuse treatment (See Section 5(e))
• Some prescription drugs (See Section 5(f))
• Organ/tissue transplants (See Section 5(b))

Copayments

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

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

Deductible

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

• The calendar year deductible is $300 per person. Under a family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $600.

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

Coinsurance

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

Example: You pay 10% coinsurance of our allowance for an X-ray.

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

For example, if your physician ordinarily charges $100 for a service but routinely waives your 10% coinsurance, the actual charge is $90. We will pay $81 (90% of the actual charge of $90).

Differences between our allowance and the bill

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 10.

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

When you live in the Plan's PPO area, you should use a PPO provider. The following two examples explain how we will handle your bill when you go to a PPO provider and when you go to a non-PPO provider. When you use a PPO provider, the amount you pay is much less.

• PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an example about coinsurance: You see a PPO physician who charges $350, but our allowance is $300. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just 10% of our $300 allowance ($30). Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and his bill. Follow these procedures when you use a PPO provider in order to receive PPO benefits:

• Verify with us that your address of record is in a PPO area;
• When you phone for an appointment, verify that the physician or facility is still a PPO provider and;
• Present your PPO ID card confirming your PPO participation in order to receive PPO benefits.

• Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. For instance,
  • When you reside in the PPO network area and use a non-PPO provider, you will pay your deductible and coinsurance—plus any difference between our allowance and charges on the bill. Here is an example: You see a non-PPO physician who charges $350 and our allowance is again $300. Because you've met your deductible, you are responsible for your coinsurance, so you pay 30% of our $300 allowance ($90). Plus, because there is no agreement between the non-PPO physician and us, he can bill you for the $50 difference between our allowance and his bill.
  • When you reside outside the PPO network area, you will pay your deductible and coinsurance - plus any difference between our allowance and charges on the bill. As in the example above, once you have met your deductible, you are responsible for your coinsurance. You will pay 15% of our allowance ($45) and the physician can bill you for the $50 difference between our allowance and his bill.

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

Physician's change

$350

$350

Our allowance

We set it at: $300

We set it at: $300

We pay

90% of our allowance: $270

70% of our allowance: $210

You owe: Coinsurance

10% of our allowance: $30

30% of our allowance: $90

+Difference up to charge?

No: 0

Yes: $50

TOTAL YOU PAY

$30

$140

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

For those benefits where coinsurance or deductibles apply, we pay 100% of the Plan allowance for the rest of the calendar year after your expenses total:

• PPO providers: $3,500—For you or any covered family member;
• Non-PPO providers: $7,000—For you or any covered family member;
• Out-of-network providers: $3,000—For you or any covered family member.
• Out-of-pocket expenses are:
• Your $300/$600 calendar year deductible;
• The percentage you pay for covered services after you have met your deduct­ibles;
• The percentage you pay for surgery, anesthesia and extended medical care after an accidental injury; and
• Your copayment for hospital stays.
• The following cannot be included in your out-of-pocket expenses:
• Expenses in excess of the Plan allowance or maximum benefit limitations;
• Non-covered services and supplies;
• Prescription drug copayments;
• Copayments, except for hospital admission copayments;
• Expenses for dental care including the 20% you pay for dental care after an accidental injury; or
• Any amounts you pay if benefits have been reduced because of noncompliance with our precertification, prior authorization or prior approval requirements

When Government facilities bill

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

If we overpay you

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

If you....

• are age 65 or over, and
• do not have Medicare Part A, Part B, or both; and
• have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and
• are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)

Then, for your inpatient hospital care,

• the law requires us to base our payment on an amount—the "equivalent Medicare amount"—set by Medicare's rules for what Medicare would pay, not on the actual charge;
• you are responsible for your applicable deductibles, coinsurance, or copayments you owe under this Plan;
• you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits; and
• the law prohibits a hospital from collecting more than the Medicare equivalent amount.

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

• an amount set by Medicare and called the "Medicare approved amount," or
• the actual charge if it is lower than the Medicare approved amount.

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

your deductibles, coinsurance, 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 A (Hospital insurance) and Medicare B (Medical insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital, that does not participate with Medicare and is not reimbursed by Medicare.

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

• If your physician accepts Medicare assignment, then you pay nothing for covered charges.
• If your physician does not accept Medicare assignment, then you pay the differ­ence between the "limiting charge" or the physician's charge (whichever is less) and our payment combined with Medicare's payment.

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

Please see Section 9, Coordinating Benefits With Other Coverage, for more information about how we coordinate benefits with Medicare.

IMPORTANT

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: $300 per person ($600 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.
• PPO benefits apply only when you reside in the PPO network area and use a PPO provider. When no PPO provider is available, non-PPO benefits apply. Out-of-network benefits apply when you reside outside the PPO network area.
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

IMPORTANT

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 (not including surgery)

• In physician's office
  • office visits
  • consultations (to include second surgical opinion)
  • injections

Note: Drugs provided by the physician are covered under Section 5(f).

Note: Supplies provided by the physician are covered under Section 5(a).

PPO: $10 copayment (No Deductible)

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

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

Professional services of physicians (not including surgery)

• In a hospital (Inpatient or Outpatient)
• In an urgent care center
• In a skilled nursing facility
• 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

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• Non-routine mammograms
• CAT Scans/MRI
• Ultrasound
• Electrocardiogram and EEG
• Sonograms

PPO: 10% of the Plan allowance

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

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount.

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.

Routine physical examination per person to include a history and physical, chest X-ray, urinalysis, blood tests, and EKG (electrocardiogram). Up to a maximum of $500 per calendar year.

PPO: Services in physician's office Nothing up to the $500 maximum and all charges in excess of the $500 maximum (No Deductible)

PPO: Services outside physician's office Nothing up to the $500 maximum and all charges in excess of the $500 maximum (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the $500 maximum

Out-of-Network: 15% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the $500 maximum (No Deductible)

The following are paid in addition to the routine physical $500 maximum:

• One annual cervical cancer screening (pap smear) for women age 18 and older. Note: if you see another physician for your pap smear, the office visit will be covered.
• One annual Prostate Specific Antigen (PSA) test (prostate cancer screening) for men age 40 and older.
• One annual fecal occult blood test (colorectal cancer screening) for members age 40 and older.
• One routine sigmoidoscopy every five years starting at age 50.

PPO: 10% of the Plan allowance (No Deductible)

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

Out-of-Network: 15% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Preventive care, adult - continued on next page

• One routine colonoscopy every ten years starting at age 50.
• One annual routine mammogram (breast cancer screening) for women age 35 and older.
• One non-fasting blood cholesterol test every three consecutive calendar years
• Chlamydial screening

Note: Your physician's bill must clearly state "Routine Physical Exam." If a medical diagnosis is provided on the bill, those services will be paid under the medical benefit.

PPO: 10% of the Plan allowance (No Deductible)

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

Out-of-Network: 15% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Routine immunizations, limited to:

• Tetanus-diphtheria (Td) booster once every 10 years, ages 22 and over
• Pneumococcal vaccine, annually, age 65 and over
• Influenza vaccine, annually

PPO: 10% of the Plan allowance

Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

• Childhood immunizations recommended by the American Academy of Pediatrics (to age 22)

PPO: Nothing (No Deductible)

Non-PPO: Only the difference between the Plan allowance and the billed amount (No Deductible)

Out-of-network: Only the difference between the Plan allowance and the billed amount (No Deductible)

• Well-child care charges for routine examinations and care (to age 2):
• One annual routine physical examination (over age 2 to age 22):

PPO: $10 copayment (No Deductible)

PPO: Services outside physician's office Nothing (No Deductible)

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

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount. (No Deductible)

Complete maternity (obstetrical) care such as:

• Prenatal care (to include laboratory tests)
• Amniocentesis
• Delivery
• Initial, routine examination of your newborn infant covered under your family enrollment
• Circumcision of your newborn infant
• Postnatal care
• One routine sonogram

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Note: Here are some things to keep in mind:

• You do not have to precertify your normal delivery; see page 9 for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended stay, if medically necessary but you, your representative, your physician or your hospital must precertify.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self and Family enrollment. If your baby stays in the hospital after your discharge and is covered under your Self and Family enrollment, you must pay a separate hospital stay copayment. See Section 5(c).
• Bassinet or nursery charges on which you and your baby are confined are considered your maternity expenses, not your baby's.
• Sonograms and other related tests that are not included in your routine prenatal or postnatal care are covered in Lab, X-ray, and other diagnostic tests, page 20

Not covered:

• Routine sonograms to determine fetal age, size or sex; or procedures, services, drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.

All charges

A range of voluntary family planning services, limited to:

• Voluntary sterilization (See Section 5(b) for surgical procedures)
• Surgically implanted contraceptives
• Fitting, inserting or removing intrauterine devices (such as diaphragms IUDs)

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Injection of contraceptive drugs (such as Depo-Provera)

Note: We cover FDA-approved prescription drugs and devices for birth con­trol in Section 5(f).

PPO: $10 copay (No Deductible)

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

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• Reversal of voluntary surgical sterilization, genetic counseling.

All charges

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

• Initial diagnostic tests and procedures done only to identify the cause of infertility
• Fertility drugs, hormone therapy and related services
• Medical or surgical procedures done to create or enhance fertility

Note: We will pay up to $5,000 per person per lifetime for covered infer tility services, including prescription drugs.

PPO: 10% of the Plan allowance and charges in excess of the $5,000 maximum

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and charges in excess of the $5,000 maximum

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount and charges in excess of the $5,000 maximum

Not covered:

• Infertility services after voluntary sterilization
• Assisted reproductive technology (ART) procedures, such as:
  • artificial insemination
  • invitro 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

Allergy testing, injections and treatment (including allergy serum)

PPO services in physician's office: $10 copayment (No Deductible)

PPO services outside physician's office: 10% of the Plan allowance

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

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• RAST tests
• Food tests
• End Point titration techniques
• Sublingual allergy desensitation
• Hair analysis

All charges

• Chemotherapy and radiation therapy (High dose chemotherapy in associ­ation with autologous bone marrow transplants is limited to those trans­plants listed in Section 5(b), Organ/tissue transplants.)
• Renal Dialysis
• Intravenous (IV)/Infusion Therapy Home IV and antibiotic therapy
• Respiratory and inhalation therapies
• Growth hormone therapy (GHT) (We only cover GHT when you obtain prior approval. Call 1-800-634-0069 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; other­wise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Other Services under How to get approval for...in Section 3.)

Note: We cover drugs administered for the therapies listed above in Section 5(f).

PPO: 10% of the Plan allowance

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

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

90 total combined outpatient physical, speech and occupational therapy visits per calendar year for the following:

Visits for the services of each of the following:

• physicians
• qualified physical therapists;
• speech therapists; and
• occupational therapists

Note: 90 total combined visits not to include inpatient physical, speech and occupational therapy. Which is covered under Section 5(c) hospital or facility coverage.

PPO: 10% of the Plan

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

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

Note: We only cover therapy when a physician:

• orders the care;
• identifies the specific professional skills you require and the medical necessity for skilled services; and
• indicates the length of time you need the services.

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

Note: Inpatient rehabilitative services are covered under Section 5(c)

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

All charges

First hearing aid and testing only when necessitated by accidental injury or intra-aural surgery.

Note: Services must be received within one year of the date of the accident or surgery.

PPO: 10% of the Plan allowance

Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Hearing aids, testing and examinations for them, except for accidental injury or intra-aural surgery.

All charges

One pair of eyeglasses or contact lenses per incident to correct an impairment directly caused by:

• Accidental ocular injury or
• Specifically ordered by the physician in connection with a diagnosis of:
  • Cataract
  • Keratoconus or
  • Glaucoma

Note: Services must be received within one year of the date of accident or surgery.

PPO: 10% of the Plan allowance

Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Eyeglasses or contact lenses and examinations for them, except for accidental injury and intraocular surgery
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Eye refractions

All charges

We do not provide benefits for routine foot care, such as:

• Treatment or removal of corns and calluses, or trimming of toenails
• Orthopedic shoes, orthotics and other supportive devices for the feet

All charges

• Orthopedic braces
• Artificial limbs and eyes to replace natural limbs and eyes; stump hose
• Externally worn breast prostheses and surgical bras including necessary replacements following a mastectomy
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy.

Note: See Section 5(b) for coverage of the surgery to insert the device and Section 5(c) for hospital or facility coverage.

PPO: 10% of the Plan allowance

Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

Wigs up to a $300 maximum while covered under this Plan, when required due to hair loss in connection with chemotherapy or radiation treatment

Nothing up to the lifetime maximum of $300 (No Deductible). All charges over the $300 lifetime maximum.

Not covered:

• Orthopedic and corrective shoes and other supportive devices for the feet
• Arch supports
• Foot orthotics
• Heel pads and heel cups
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Lumbosacral supports

All charges

Durable medical equipment (DME)

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.

PPO: 10% of the Plan allowance

Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

We cover purchase or rental up to the purchase price, at our option, including repair and adjustment, of durable medical equipment. Under this benefit, we also cover:

• Oxygen;
• Hospital beds;
• Dialysis equipment;
• Respirators;
• Wheelchairs, crutches, canes, walkers, casts;
• Cervical collars and traction kits; and
• Splints and trusses

PPO: 10% of the Plan allowance

Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Sun or heat lamps, whirlpool baths, heating pads, air purifiers, humidifiers, air conditioners, and exercise devices

All charges

For services provided on a part-time basis (less than an 8-hour shift):

If precertified, 90 visits per calendar year up to a maximum Plan payment of $80 per visit when:

• A registered nurse (R.N.) or licensed practical nurse (L.P.N.) provides the services;
• The attending physician orders the care;
• The physician identifies the specific professional skills required by the patient and the medical necessity for skilled services; and
• The physician indicates the length of time the services are needed.

If not precertified, 40 visits per calendar year up to a maximum plan payment of $40, subject to the above provisions

NOTE: Precertified and Nonprecertified visits are combined. Visit limit not to exceed 90 visits per calendar year.

NOTE: All therapy services will count toward the 90-day therapy visit limitation per calendar year, as listed under Physical, occupation and speech therapy in Section 5(a).

PPO: Charges in excess of $80 per visit (No Deductible) (90 visit maximum). All charges over the visit limit.

Non-PPO: Charges in excess of $80 per visit and any difference between the Plan allowance and the billed amount (No Deductible) (90 visit maximum). All charges over the visit limit.

Out-of-network: Charges in excess of $80 per visit and any difference between the Plan allowance and the billed amount (No Deductible) (90 visit maximum). All charges over the visit limit.

If not precertified, 40 visits per calendar year up to a maximum plan payment of $40, subject to the above provisions.

NOTE: Precertified and Nonprecertified visits are combined. Visit limit not to exceed 90 visits per calendar year.

For private duty nursing provided on a full-time basis (more than an 8-hour shift) by a Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.) when:

• the care is ordered by the attending physician, and
• your physician identifies the specific professional nursing skills that you require, as well as the length of time needed.

PPO: 10% of the Plan allowance

Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient's family;
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, rehabilitative:
• Custodial care as defined in Section 10.

All charges

No Benefits

All Charges

Acupuncture when used as an anesthetic agent for covered surgery

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Not covered:

• Chiropractic services
• Chelation therapy except for acute arsenic, gold, mercury, lead, or use of Deferoxamine in iron poisoning
• Naturopathic services
• Homeopathic services and medicines

(Note: Benefits of certain alternative treatment providers may be covered in medically underserved areas)

All charges

Coverage is limited to:

• Smoking Cessation Up to $100 maximum per person per calendar year
• Individual/Group counseling and over-the-counter (OTC) drugs

PPO: 10% of the Plan allowance and all charges in excess of the $100 maximum

Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the $100 maximum

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount and all charges in excess of the $100 maximum

Office visits for Smoking Cessation

Note: Prescription drugs are covered under Section 5(f).

PPO: $10 copayment (No Deductible)

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

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

IMPORTANT

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 does not apply for these benefits; however, we added —"(No Deductible)" - to show that the calendar year deductible does not apply.
• PPO benefits apply only when you reside in the PPO network area and use a PPO provider. When no PPO provider is available, non-PPO benefits apply. Out-of-network benefits apply when you reside outside the PPO network area.
• Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
• The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e., hospital, surgical center, etc.).
• YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification.

IMPORTANT

Note: The calendar year deductible applies to almost all benefits in this Section.

We say "(No deductible)" when it does not apply.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Surgical procedures - continued on next page

• Surgical treatment of morbid obesity - a condition in which an individual (1) is the greater of 100 pounds or 100% over his/her normal weight (in accordance with our underwriting standards) with complicating conditions; (2) has been so for at least five years with documented unsuccessful attempts to reduce under a doctor-monitored diet and program and (3) is age 18 or older.
• Insertion of internal prosthetic devices. See Section 5(a) for device coverage information.
• Voluntary sterilization (e.g., tubal ligation, vasectomy)
• Surgically implanted contraceptives, and intrauterine devices (IUDs)
• Treatment of burns
• Surgical treatment of bunions or spurs
• Assistant surgeons - we cover up to 20% of our allowance for the surgeon's charge

Note: For related services, see applicable benefits section (i.e., for inpatient hospital benefits, see Section 5(c)).

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to patient care, our benefits are:

• For the primary procedure:
  • PPO: 90% of the Plan allowance or (No Deductible)
  • Non-PPO: 70% of the Plan allowance or (No Deductible)
  • Out-of-network: 85% of the Plan allowance (No Deductible)
• For the secondary procedure(s):
  • PPO: 90% of one-half of the Plan allowance or (No Deductible)
  • Non-PPO: 70% of one-half of the Plan allowance (No Deductible)
  • Out-of-network: 85% of one-half of the Plan allowance (No Deductible)

Note: Multiple or bilateral surgical procedures performed through the same incision are "incidental" to the primary surgery. That is, the procedure would not add time or complexity to patient care. We do not pay extra for incidental procedures.

PPO: 10% of the Plan allowance for the primary procedure and 10% of one-half of the Plan allowance for the secondary procedure(s) (No Deductible)

Non-PPO: 30% of the Plan allowance for the primary procedure and 30% of one-half of the Plan allowance for the secondary procedure(s); and any difference between our payment and the billed amount (No Deductible)

Out-of-network: 15% of the Plan allowance for the primary procedure and 15% of one-half of the Plan allowance for the secondary procedure(s); and any difference between our payment and the billed amount (No Deductible)

Note: For certain surgical procedures, we may apply a value of less than 50% of subsequent procedures.

Not covered:

• Services of a standby surgeon, except during angioplasty or other high risk procedures when we determine standbys are medically necessary

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member's appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of the billed amount (No Deductible) congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birthmarks; and webbed fingers and toes.

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed (No Deductible)

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses; and surgical bras and replacements (see Prosthetic devices for coverage)Note: Internal breast prostheses are covered under Section 5(a).

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed (No Deductible)

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Not covered:

• Cosmetic surgery - any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury
• Surgeries related