CALL — THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800/522-2066 or write to us at Medical Mutual of Ohio, 2060 E. 9th Street, Cleveland, OH 44115-1355. You may also request replacement cards through our website at http://www.MedMutual.com

Where you get covered care

You get care from "Plan providers" and "Plan facilities." You will only pay copayments and you will not have to file claims.

Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards. Both primary care and specialist doctors are part of the network. Different members of the same family may select different centers or doctors.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website. (www.MedMutual.com)

Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website. (www.MedMutual.com)

What you must do to get covered care

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only when there has been a referral by a member's primary care doctor.

Primary care

Your primary care physician can be a physician, or group of physicians, trained in family or general practice, internal medicine, pediatrics or osteopathic medicine who has a contractual obligation with HMO Health Ohio to provide the primary care services listed in this brochure. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

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

Specialty care

Your primary care physician will refer you to a specialist for needed care. However, you may see a Plan Obstetrician/Gynecologist without a referral. For mental conditions and substance abuse call HMO Health Ohio Behavioral Health Care Management Department at 800/258-3186.

Here are some other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

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

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

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

Terminate our contract with your specialist for other than cause; or

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

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

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

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

Hospital care

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

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800/522-2066. If you are new to the FEHB Program, we will arrange for you to receive care.

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

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

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

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

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

Circumstances beyond our control

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

Services requiring our prior approval

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process precertification. Your physician must obtain approval before sending you to a hospital, referring you to a specialist, or recommending follow-up care.

Copayments

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

Example: You pay a copayment of $15 per office visit or outpatient therapy session.

Deductible

We have no deductible.

Coinsurance

We have no coinsurance.

Your catastrophic protection out-of-pocket maximum

Your out-of-pocket expenses for benefits under this Plan are limited to the stated copayments required for a few benefits.

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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.

Plan physicians must provide or arrange your care.

We have no calendar year deductible.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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Professional services of physicians

In physician's office

In an urgent care center

Office medical consultations

Second surgical opinion

$15 per office visit

Professional services of physicians

During a hospital stay

In a skilled nursing facility

Nothing

At home

Nothing

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise, $15 per office visit

Routine screenings, such as:

Total Blood Cholesterol

Colorectal Cancer Screening, including

Fecal occult blood test

Sigmoidoscopy, screening - every five years starting at age 50

Nothing if you receive these services during your office visit; otherwise, $15 per office visit

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

$15 per office visit

Routine pap test

Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.

$15 per office visit

Routine mammogram - 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

$15 per office visit

Preventive care, adult - continued on next page

Routine immunizations, limited to:

Tetanus-diphtheria (Td) booster - once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually

Pneumococcal vaccine, age 65 and older

$15 per office visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.

All charges

Childhood immunizations recommended by the American Academy of Pediatrics

$15 per office visit

Well-child care charges for routine examinations, immunizations and care (up to age 22)

Examinations, such as:

Eye exams through age 17 to determine the need for vision correction

Ear exams through age 17 to determine the need for hearing correction

Examinations done on the day of immunizations (up to age 22)

$15 per office visit

You pay

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.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.

We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

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

Circumcision is a surgical benefit, not a maternity benefit.

$15 per office visit; initial visit only

Not covered: Routine sonograms to determine fetal age, size or sex.

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.

$15 per office visit

Not covered:

Reversal of voluntary surgical sterilization

Genetic counseling.

All charges

Diagnosis and treatment of infertility such as:

Artificial insemination:

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

$15 per office visit

Not covered:

Assisted reproductive technology (ART) procedures, such as:

in vitro fertilization

embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)

Services and supplies related to ART procedures

Cost of donor sperm

Cost of donor egg

All charges

Testing and treatment

Allergy injections

$15 per office visit

Allergy serum

Nothing

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 under Organ/Tissue Transplants on page 25.

Respiratory and inhalation therapy

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.

$15 per office visit

For the greater of 20 visits or up to two months per condition, on an inpatient or outpatient basis, if significant improvement can be expected within two months, for each of the following:

qualified physical therapists and

occupational therapists

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

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, provided at a Plan facility as prescribed by your primary care doctor.

$15 copayment

Nothing per visit during covered inpatient admission

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges

For the greater of 20 visits or up to two months per condition

$15 copayment per office visit

Nothing per visit during covered inpatient admission

Hearing evaluations

$15 per office visit

Not covered:

Hearing aids, testing and examinations for hearing aids

All charges

We provide the following vision care benefits when received from Cole Network Managed Vision Providers:

One eye refraction, including lens prescription, every year.

Members must use a Cole Network Managed Vision provider.

Member is responsible for any difference in cost between an examination for glasses and an examination for contact lenses.

NOTE: For medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye, members must continue to be referred to a HMO Health Ohio optometrist or ophthalmologist for care

$10 per office visit

Not covered:

Corrective lenses or frames

Eye exercises and orthoptics

Sunglasses

All charges

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

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$15 per office visit

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

Orthopedic devices, such as braces; foot orthotics

Artificial 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 implant following mastectomy. Note: Internal prosthetic devices are paid as hospital benefits; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b) for coverage of the surgery to insert the device.

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Nothing

Not covered:

Arch supports

Heel pads and heel cups

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

All charges

Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover:

Hospital beds;

Wheelchairs;

Crutches;

Walkers;

Blood glucose monitors; and

Insulin pumps.

Note: Call us at 800/522-2066 as soon as your Plan physician prescribes this equipment. We will 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.

Nothing

Not covered:

Specially designed wheel chairs for use in sporting events

All charges

Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.

Services include oxygen therapy, intravenous therapy and medications.

Nothing

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, or rehabilitative.

All charges

Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$15 copayment

No benefit

All charges

Coverage is limited to:

Smoking Cessation

Diabetes self management

$15 per office visit

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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.

Plan physicians must provide or arrange your care.

We have no calendar year deductible.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other 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.).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES.

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A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see reconstructive surgery)

Surgical treatment of morbid obesity -- a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over

Insertion of internal prosthetic devices. See 5(a) - Orthopedic and prosthetic devices for device coverage information.

$15 per office visit; nothing for hospital visits

Voluntary sterilization (e.g., Tubal ligation, Vasectomy)

Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$15 per office visit; nothing for hospital visits

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care

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 congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

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)

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.

$15 per office visit; nothing for hospital visits

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 to sex transformation

All charges

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;

Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures; and

Other surgical procedures that do not involve the teeth or their supporting structures.

TMJ treatment and services (non-dental)

$15 per office visit

Not covered:

Oral implants and transplants

Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

Dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

All charges

Limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

Lung: Single - Double

Pancreas

Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas

National Transplant Program (NTP) - Ohio Department of Health and Ohio Organ Transplant Consortium

Limited Benefits - Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in a National Cancer Institute - or National Institutes of Health-approved clinical trial at a Plan-designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient.

Nothing

Not covered:

Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs

Transplants not listed as covered

All charges

Professional services provided in -

Hospital (inpatient)

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Office

Nothing

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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.

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

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Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets.

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$250 per admission up to a maximum of $500 per individual and a $1250 maximum per family per calendar year

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed private nursing care

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Administration of blood and blood products

Blood or blood plasma, if not donated or replaced

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies.)

Nothing

Not covered:

Custodial care

Non-covered facilities, such as nursing homes, schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care

All charges

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals

Blood and blood plasma, if not donated or replaced

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

Nothing

Not covered: Blood and blood derivatives not replaced by the member

All charges

Extended care benefit:

The Plan provides a comprehensive range of benefits for up to 100 days

per calendar year when full-time skilled nursing care is necessary and

confinement in a skilled nursing facility is medically appropriate as

determined by a Plan doctor and approved by the Plan. All necessary

services are covered, including:

Bed, board and general nursing care

Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor.

$250 per admission up to a maximum of $500 per individual and a $1250 maximum per family per calendar year

Not covered:

Custodial care, rest cures, domiciliary or convalescent care

Personal comfort items, such as telephone and television

All charges

Supportive and palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient care, family counseling, and durable medical equipment; these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

Nothing

Not covered: Independent nursing, homemaker services

All charges

Local professional ambulance service when medically appropriate

Nothing

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

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

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies - what they all have in common is the need for quick action.

What to do in case of emergency:

If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 telephone system) or go to the nearest hospital emergency room.

Emergencies within our service area:

Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours, unless it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with and ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

The Plan pays reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.

Emergencies outside our service area:

Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

The Plan pays reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers.

Emergency care at a doctor's office

$15 per office visit

Emergency care at an urgent care center

Nothing

Emergency care as an outpatient or inpatient at a hospital, including doctors' services

Note: If the emergency results in admission to a hospital, the emergency care copayment is waived.

$75 copayment per visit

Not covered: Elective care or non-emergency care

All charges

Emergency care at a doctor's office

$15 per office visit

Emergency care at an urgent care center

Nothing

Emergency care as an outpatient or inpatient at a hospital, including doctors' services

$75 copayment per visit

Not covered:

Elective care or non-emergency care

Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

Professional ambulance service when medically appropriate.

Air ambulance when ordered or authorized by a Plan doctor

See 5(c) for non-emergency service.

Nothing

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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions.

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

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

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

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All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure.

Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve.

Your cost sharing responsibilities are no greater than for other illnesses or conditions

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers

Medication management

$15 per visit

Diagnostic tests

Nothing

Services provided by a hospital or other facility

Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, facility based intensive outpatient treatment

$250 per admission up to a maximum of $500 per individual and a $1250 maximum per family per calendar year

Not covered: Services we have not approved.

Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following network authorization processes:

Call the HMO Health Ohio Behavioral Health Care Management Department at 800/258-3186. It is not necessary to obtain a referral from your primary care doctor.

Limitation We may limit your benefits if you do not obtain a treatment plan.

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

We cover prescribed drugs and medications, as described in the chart beginning on the next page.

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

We have no calendar year deductible

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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There are important features you should be aware of. These include:

Who can write your prescription. A plan or referral physician must write the prescription.

Where you can obtain them. You must fill the prescription at a plan pharmacy, except for out-of-area emergencies, or by mail for a maintenance medication.

We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. A formulary is a list of selected FDA approved, prescription medications reviewed by an independent Pharmacy and Therapeutics Committee brought together by Medco Health Solutions, Inc. These drugs are made by many different pharmaceutical manufacturers. To order a prescription drug brochure, call 800/417-1961.

Mail Order Program. To receive mail order prescription drug benefits, you mail your prescription order and the prescription drug deductible amount which is specified below to a contracting mail order pharmacy. No benefits are payable if your prescription order is sent to a pharmacy other than a contracting mail order pharmacy. The contracting mail order pharmacy will fill your prescription order and send you up to a 90-day supply of the mail order prescription drug which your physician has prescribed. The contracting mail order pharmacy will dispense the medication and mail it to you within 72 hours. If the contracting mail order pharmacy fails to send you the mail order prescription drug within ten days after you mailed in your prescription order, you may call the contracting mail order pharmacy directly to determine the status of the prescription order.

These are the dispensing limitations. Prescription drugs obtained at a Plan pharmacy will be dispensed for up to a 30-day supply. Prescription drugs obtained by using the mail order prescription drug program will be dispensed for up to a 90-day supply. When a generic substitution is permissible (i.e. generic drug is available), but you request the name brand drug, you pay the price difference between the generic and name brand drug, as well as the generic copayment per prescription unit or refill. Members called to active military duty in a time of national or other emergency who need to obtain a greater-than-normal supply of prescribed medications should call us at 1-800-522-2066.

Why use generic drugs? To reduce your out-of-pocket expenses! A generic drug is the chemical equivalent of a corresponding brand name drug. Generic drugs are less expensive than brand name drugs; therefore, you may reduce your out-of-pocket costs by choosing to use a generic drug.

When you have to file a claim. You should contact Medco Health at 800/417-1961 for prescription drug claim forms. You should submit all claims to Paid Prescriptions, L.L.C., P.O. Box 2277, Lee Summit, MO 64063. Normally, when you use plan pharmacies, you will not have to file claims.

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

Drugs for which a prescription is required by Federal Law

Insulin

Disposable needles and syringes for the administration of covered medications (must be dispensed the same day as insulin)

Contraceptive drugs and devices

Smoking cessation drugs and medication, including nicotine patches

Growth hormone

Limited benefits:

Sexual dysfunction drugs have dispensing limitations. Contact the Plan for details.

Retail Pharmacy (up to a 30-day supply)

$10 copayment per prescription or refill for generic drugs

$20 copayment per prescription or refill for formulary name brand drugs

$30 copayment per prescription or refill for non-formulary name brand drugs

Mail Order (up to a 90-day supply)

$20 copayment per prescription or refill for generic drugs

$40 copayment per prescription or refill for formulary name brand drugs

$60 copayment per prescription or refill for non-formulary name brand drugs

Things to keep in mind:

A generic equivalent will be dispensed if it is available. If you purchase a Brand Name Prescription Drug when a Federally-approved Generic Drug is available, you will be required to pay any applicable Generic Drug Copayment plus the difference between the cost of the Generic Prescription Drug and the Brand Name Drug. You are still responsible for paying the difference between the cost of the Generic Prescription Drug and the Brand Name Drug, even if your Physician prescribes a brand name prescription drug and indicates that this drug is to be dispensed as written.

Not covered:

Drugs available without a prescription or for which there is a nonprescription equivalent available.

Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies.

Vitamins and nutritional substances that can be purchased without a prescription.

Medical supplies such as dressings and antiseptics

Fertility drugs

Drugs for cosmetic purposes

Drugs to enhance athletic performance

Diabetic supplies, except as specified, including glucose test tablets and test tape, Benedict's solution, or equivalent, and acetone test tablets

Diet pills and appetite suppressants

All charges

Feature

Description

Flexible Benefits Option

Under the flexible benefits option, we determine the most effective way to provide services.

We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

Alternative benefits are subject to our ongoing review.

By approving an alternative benefit, we cannot guarantee you will get it in the future.

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.

Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

Congestive Heart Failure (Heart SenseTM)

For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-877-726-2715 and talk with a cardiac nurse disease manager who will set up a program of telephone and home visit(s) that will help you learn more about your condition and how to manage your symptoms.

Maternity Care
(BabyLink®)

For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800-338-4114 and talk with a maternity care nurse who can answer your questions and provide necessary information and additional resources that you may need concerning maternity care, during and after pregnancy.

Asthma (Breathe Easy®)

For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-888-244-6906 and talk with a specially trained respiratory nurse who will set up a program of telephone calls that will help you learn more about your breathing conditions and how to manage your symptoms.

Chronic Obstructive Pulmonary Disease (Breathe Easy®)

For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-888-244-6906 and talk with a specially trained respiratory nurse who will set up a program of telephone calls that will help you learn more about your breathing condition (also known as COPD or emphysema) and how to manage your symptoms.

Diabetes (Diabetes AdvantageTM)

For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800-861-4826 and talk with a Diabetes Care Coordinator who will set up a program of telephone calls that will help you learn more about your condition and how to manage your symptoms. You can also speak with a certified dietician and receive diabetes testing supplies at no out-of-pocket cost once you are enrolled in the program.