Dean Health Plan, Inc.

http://www.deancare.com

A Health Maintenance Organization

For changes in benefits see page 10

.

Serving: South Central Wisconsin

Enrollment in this Plan is limited. You must live or work in our

Geographic service area to enroll. See page 8 for requirements.

This Plan has Excellent Accreditation from NCQA.. See the 2005 Guide for more information on accreditation.

(HMO)

Enrollment codes for this Plan:

WD1 Self Only

WD2 Self and Family

RI 73-189

Dear Federal Employees Health Benefits Program Participant:

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

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

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

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

Sincerely,

Kay Coles James

Director

Notice of the Office of Personnel Management's

Privacy Practices

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

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

OPM will use and give out your personal medical information:

To you or someone who has the legal right to act for you (your personal representative),
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/or prosecuting alleged or civil or criminal actions, and
Where required by law.

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

To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.

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

For Government healthcare oversight activities (such as fraud and abuse investigations),
For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.

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

By law, you have the right to:

See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P.O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice, look at www.opm.gov/insure on the web. You may also call

202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:

Privacy Complaints

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

The privacy practices listed in the notice are effective April 14, 2003.

Table of Contents

Introduction................................................................................................................................... 5

Plain Language....................................................................................................................................................... 5

Stop Health Care Fraud!........................................................................................................................................ 5

Preventing medical mistakes.................................................................................................................................... 6

Section 1. Facts about this HMO plan................................................................................................................... 8

How we pay providers............................................................................................................................ 8

Your Rights............................................................................................................................................. 8

Service Area........................................................................................................................................... 8

Section 2. How we change for 2005................................................................................................................... 10

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

Changes to this Plan............................................................................................................................... 10

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

Identification cards................................................................................................................................. 11

Where you get covered care.................................................................................................................. 11

� Plan providers................................................................................................................................. 11

� Plan facilities.................................................................................................................................... 11

What you must do to get covered care................................................................................................... 11

� Primary care.................................................................................................................................... 11

� Specialty care.................................................................................................................................. 11

� Hospital care................................................................................................................................... 13

Circumstances beyond our control......................................................................................................... 13

Services requiring our prior approval...................................................................................................... 13

Section 4. Your costs for covered services.......................................................................................................... 14

� Copayment...................................................................................................................................... 14

� Deductible....................................................................................................................................... 14

� Coinsurance.................................................................................................................................... 14

Section 5. Benefits - OVERVIEW (See page 10 for how our benefits changed this year and page 66 for a benefits summary.) 15..........................................................................................................................................................

Section 5(a) Medical services and supplies provided by physicians and other health care professionals............. 16

Section 5(b) Surgical and anesthesia services provided by physicians and other health care professionals.......... 27

Section 5(c) Services provided by a hospital or other facility, and ambulance services...................................... 27

Section 5(d) Emergency services/accidents...................................................................................................... 35

Section 5(e) Mental health and substance abuse benefits.................................................................................. 37

Section 5(f) Prescription drug benefits............................................................................................................. 39

Section 5(g) Special features .......................................................................................................................... 43

�Flexible benefits option

Section 5(h) Dental benefit............................................................................................................................. 43

Section 6. General exclusions -- things we don't cover......................................................................................... 44

Section 7. Filing a claim for covered services....................................................................................................... 45

Section 8. The disputed claims process................................................................................................................ 46

Section 9. Coordinating benefits with other coverage ........................................................................................... 48

When you have other health coverage.................................................................................................... 48

What is Medicare?................................................................................................................................ 48

� Should I enroll in Medicare? ........................................................................................................... 48

� The Original Medicare Plan (Part A or Part B)................................................................................. 48

� Medicare Advantage....................................................................................................................... 51

TRICARE and CHAMPVA.................................................................................................................. 52

� Workers' Compensation.................................................................................................................. 52

� Medicaid ........................................................................................................................................ 52

� When other Government agencies are responsible for your care........................................................ 52

� When others are responsible for injuries........................................................................................... 52

Section 10. Definitions of terms we use in this brochure......................................................................................... 53

Section 11. FEHB facts ...................................................................................................................................... 54

Coverage information........................................................................................................................... 54

�No pre-existing condition limitation................................................................................................. 54

�Where you can get information about enrolling in the FEHB Program.............................................. 54

�Types of coverage available for you and your family....................................................................... 54

� Children's Equity Act.................................................................................................................... 55

�When benefits and premiums start.................................................................................................. 55

� When you retire......................................................................................................................... 56

When you lose benefits......................................................................................................................... 56

�When FEHB coverage ends........................................................................................................... 56

�Spouse equity coverage................................................................................................................. 56

�Temporary Continuation of Coverage (TCC)................................................................................. 56

�Converting to individual coverage................................................................................................... 57

�Getting a Certificate of Group Health Plan Coverage...................................................................... 57

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

The Federal Flexible Spending Account Program - FSAFEDS............................................................... 58

The Federal Long Term Care Insurance Program................................................................................... 62

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

2005 Summary of benefits for Dean Health Plan.................................................................................................... 64

R ate information for Dean Health Plan..................................................................................................... Back cover

Introduction

This brochure describes the benefits of Dean Health Plan, Inc. under our contract (CS 1966) with the United States Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Dean Health Plan, Inc. administrative offices is:

Dean Health Plan, Inc.

1277 Deming Way

Madison WI 53717

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

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

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

Plain Language

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

� Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means Dean Health Plan, Inc.

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

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

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

Stop Health Care Fraud!

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

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

Protect Yourself From Fraud - Here are some things you can do to prevent fraud:

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

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

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

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

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

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

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

If the provider does not resolve the matter, call us at 800-279-1301 and explain the situation.

If we do not resolve the issue:

CALL -- THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

The United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street, NW, Room 6400

Washington, DC20415-1100

� Do not maintain as a family member on your policy:

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

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

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

� You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

Preventing medical mistakes

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

1. Ask questions if you have doubts or concerns.

� Ask questions and make sure you understand the answers.

� Choose a doctor with whom you feel comfortable talking.

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

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

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

� Tell them about any drug allergies you have.

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

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

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

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

3. Get the results of any test or procedure.

� Ask when and how you will get the results of test or procedures.

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

� Call your doctor and ask for your results.

� Ask what the results mean for your care.

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

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

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

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

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

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

� Ask your surgeon:

Exactly what will you be doing?

About how long will it take?

What will happen after surgery?

How can I expect to feel during recovery?

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

Want more information on patient safety?

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

� www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and your family.

� www.talkaboutrx.org/consumer.html. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medicines.

� www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.

� www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety.

� www.quic.gov/report. Find out what federal agencies are doing to identify threats to patient safety and help prevent mistakes in the nation's healthcare delivery system.

Section 1. Facts about this HMO plan

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

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

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

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

How we pay providers

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

Your Rights

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

� Dean Health Plan Inc. is for-profit HMO, and has been is business since 1983. If you want more information about us, call 800-2719-1301, or write to Dean Health Plan, Attention Customer Service, 1277 Deming Way Madison WI 53717. You may also contact us by fax at 608-827-4152 or visit our website at www.deancare.com.

Service Area

To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is: Adams, Columbia, Crawford, Dane, Dodge, Fond du Lac, Grant, Green, Green Lake, Iowa, Jefferson, Juneau, Lafayette, Marquette, Racine, Richland, Rock, Sauk, Vernon, Waukesha, and Walworth counties in Wisconsin.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior plan approval.

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

Section 2. How we change for 2005

Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Program-wide changes

� In Section 9, we revised the Medicare Primary Payer Chart and updated the language regarding Medicare Advantage plans (formerly called Medicare + Choice plans).

� In Section 12, we revised the language regarding the Flexible Spending Account Program - FSAFEDS and the Federal Long Term Care Insurance Program.

Changes to this Plan

� Your share of the non-Postal premium will increase by 16.0% for Self Only or 28.9% for Self and Family.

� Growth Hormones are covered with $10 generic and 30% brand name copayment with required prior authorization.

� MRI (outpatient services only) are covered with a $50 copayment (3 copayment maximum $150 per member per year).

� Emergency Room copayment of $75 will be waived if admitted as inpatient through the Emergency room.

� Immunizations due to volunteer and education as it pertains to preventive treatment while traveling are now covered.

� Cochlear Implants are now covered in full with prior authorization.

� Tobacco cessation is now covered as a benefit and not a program. Coverage is for 3 (three) 4-week (28 day) courses of zyban and/or nicotine replacement therapy ("the patch") with doctor's prescription for, $10 copay per fill.

� Treatment of bunion and spurs are now covered subject to the $10 office copay.

Section 3. How you get care

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 800-279-1301 or write to us at 1277 Deming Way Madison WI 53717.

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

Care pay copayments, deductibles, and/or coinsurance, and you will not have to file claims.

� Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to NCQA and Dean Health Plan standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website. Provider updates are also included in the quarterly mailing to all members in the Notables newsletter, or visit our website at www.deancare.com.

�Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website at www.deancare.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. When you enroll, you (and your family members) must choose a primary care physician. Each member of your family may select a different primary care physician. Your primary care physician must be a doctor who practices a general scope of medicine. A physician who specializes in only one area of medicine would not be able to treat all of your basic health care needs.

� Primary care The following types of physician can be a primary care physician for you: Family Practice doctors treat people of all ages. They focus on family health problems. General Practice doctors treat people of all ages. Pediatric doctors treat children and adolescents, and generally manage their health. Internal Medicine doctors treat adult men and women. Obstetrics and Gynecology doctors manage a woman's care during pregnancy and childbirth. They also treat conditions unique to females. 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 arrange your referral to a specialist for needed care. You may also seek services from other Plan providers, including specialists, located at the same clinic as your primary care physician, without a referral. Written referrals are not required for the following types of services when provide by a Dean Health Plan Provider: MRI (Magnetic Resonance Imaging), Diagnostic tests & respiratory therapy, Home Health, Oral Surgery for covered procedures, Routine vision care, and Chiropractic care.

Here are other things you should know about specialty care:

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

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

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

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

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

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

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

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

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

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

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800-279-1301. 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 Under certain extraordinary circumstances, such as natural disaster, we may have

our control 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 prior authorization. Your physician must obtain prior authorization before sending you to a hospital, referring you to a non-plan provider or facility, or recommending follow up care.

We will provide benefits for covered services only when the services are medically necessary to prevent, diagnose, or treat your illness or condition.

Section 4. Your costs for covered services

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

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

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay nothing per admission.

�Deductible We do not have a deductible.

�Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our Plan, you pay 50% of actual charges for diagnosis and treatment of infertility services, and 25% of charges for orthopedic services, prosthetic devices, lenses following cataract removal, and durable medical equipment.

Your catastrophic protection We do not have a catastrophic protection out-of-pocket maximum.

out-of-pocket

Section 5. Benefits -- OVERVIEW

(See page 10 for how our benefits changed this year and page 66 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 800-279-1301 or at our website at www.deancare.com

Section 5(a) Medical services and supplies provided by physicians and other health care professionals 17-27

�Diagnostic and treatment services

�Lab, X-ray, and other diagnostic tests

�Preventive care, adult

�Preventive care, children

�Maternity care

�Family planning

�Infertility services

�Allergy care

�Treatment therapies

�Physical and occupational therapies

�Speech therapy

�Hearing services (testing, treatment, and supplies)

�Vision services (testing, treatment, and supplies)

�Foot care

�Orthopedic and prosthetic devices

�Durable medical equipment (DME)

�Home health services

�Chiropractic

�Alternative treatments

�Educational classes and programs

Section 5(b) Surgical and anesthesia services provided by physicians and other health care professionals 28-23

�Surgical procedures

�Reconstructive surgery

�Oral and maxillofacial surgery

�Organ/tissue transplants

�Anesthesia

Section 5(c) Services provided by a hospital or other facility, and ambulance services 33-35

�Inpatient hospital

�Outpatient hospital or ambulatory surgical center

�Extended care benefits/skilled nursing care facility benefits

�Hospice care

�Ambulance

Section 5(d) Emergency services/accidents.......................................................................... 36-37

�Medical emergency �Ambulance

Section 5(e) Mental health and substance abuse benefits...........................................................38-39

Mental health and substance abuse benefits.................................................................................. 38-39

Section 5(f) Prescription drug benefits..................................................... ............................ 40-43

Covered medications and supplies................................................................................................ 40-43

Section 5(g) Special features........................................................................................... 44

� Dean On Call

� Flexible benefits option

Section 5(h) Dental benefits..................................................................................... 45

Accidental injury benefit............................................................................ 65

Section 5(i)"No" Dental benefits.......................................................................................45

Summary of benefits for Dean Health Plan 2005.................................................................... 66

2005 Rate Information for Dean Health Plan......................................................................... 67

Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
		I M P O R T A N T	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. � Plan physicians must provide or arrange your care. � Be sure to read Section 4, Your costs for covered services, or valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.			I M P O R T A N T
Benefit Description				You pay
	Diagnostic and treatment services			You Pay
Professional services of physicians � In physician's office				$10 per office visit
Professional services of physicians � In an urgent care center � Office medical consultations � Second surgical opinion				$10 per office visit
Lab, X-ray and other diagnostic tests
Tests, such as: � Blood tests � Urinalysis � Non-routine pap tests � Pathology � X-rays � Non-routine Mammograms � Ultrasound � Electrocardiogram and EEG				Nothing
� CAT Scan (outpatient services only)				$50 copay (3 copayment maximum $150 per member per year)
� MRI (outpatient services only)				$50 copay (3 copayment maximum $150 per member per year)
Preventive care, adult				You pay
Routine screenings, such as annual physical: � Total Blood Cholesterol � Colorectal Cancer Screening, including - Fecal occult blood test - Sigmoidoscopy, screening - every five years starting at age 50				$10 per office visit
Routine Prostate Specific Antigen (PSA) test - one annually for men age 40 and older				$10 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.			$10 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				$10 per office visit
Routine immunizations, limited to: � Tetanus-diphtheria (Td) booster - once every 10 years, ages 19 and over (except as provided for under Childhood immunizations) � Influenza vaccine, annually � Pneumococcal vaccine, age 65 and over				$10 per office visit
Not covered: Physical exams required for obtaining or continuing employment or insurance.				All charges.
Preventive care, children
� Childhood immunizations recommended by the American Academy of Pediatrics				Nothing
� Well-child care charges for routine examinations, immunizations and care (through age 17) � 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 (through age 17)				Nothing $10 per office visit
*Maternity care*				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; see page 10 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 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. Surgical benefits, not maternity benefits apply to circumcision. � We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).				Nothing
Not covered: Routine sonograms to determine fetal age, size or sex				All charges.
*Family planning*
A range of voluntary family planning services, limited to: Voluntary sterilization (See Surgical procedures Section 5 (b)) � Surgically implanted contraceptives (such as Norplant) � Injectable contraceptive drugs (such as Depo provera) � Diaphragms � Vasectomy (in an office setting) NOTE: We cover oral contraceptives under the prescription drug benefit.				$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic counseling,				All charges.
*Infertility services*				You pay
Diagnosis and treatment of infertility, such as: � Artificial insemination: - intravaginal insemination (IVI) - intracervical insemination (ICI) - intrauterine insemination (IUI) � Fertility drugs (injectables) Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit. Coverage for infertility services is limited to one diagnostic treatment per member per lifetime.				50% of actual charges
Not covered: � Assisted reproductive technology (ART) procedures, such as: - in vitro fertilization - embryo transfer, gamete GIFT and zygote ZIFT - Zygote transfer � Services and supplies related to excluded ART procedures � Cost of donor sperm � Cost of donor egg				All charges.
Allergy care
Testing and treatment Allergy injection				$10 per office visit
Allergy serum				Nothing
Not covered: provocative food testing and sublingual allergy desensitization				All charges.
*Treatment therapies*				You pay
� Chemotherapy and radiation therapy Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 26. � 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. Note: We will only cover GHT when your primary care provider prior authorizes the treatment.				$10 per office visit
Physical and occupational therapies
Outpatient basis for a combined 50 visits if significant improvement can be expected with in two months for the services of 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. Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other activities of daily living.				20% coinsurance
� Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction. Phase II treatment must begin within 90 days of surgery. Note: Speech, Physical and Occupation therapies are a combined benefit of 50 visits per year.				Nothing
Not covered: � long-term rehabilitative therapy � exercise programs				All charges
Speech therapy
Outpatient basis for a combined 50 visits when medically necessary. Please note: Speech, Physical and Occupation therapies are a combined benefit of 50 visits per year.				20% coinsurance
Hearing services (testing, treatment, and supplies)
� Hearing exam � First hearing aid and testing only when necessitated by accidental injury � Hearing testing for children through age 17 (see Preventive care, children) � Hearing Aid - limited to one in any 36 month period. This includes ear molds, hearing aid repairs and hearing aid dispensing fees NOTE: Infants and children under the age of 18 with bilateral hearing loss are eligible for bilateral hearing aids.				$10 for associated office visit All costs over $500
Not covered: � all other hearing testing � hearing aids, testing and examinations for them				All charges.
Vision services (testing, treatment, and supplies)				You pay
In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye, annual eye refractions (which include the written lens prescription for eyeglasses)				$10 per office visit
� Eye exam to determine the need for vision correction				$10 per office visit
Not covered: � Eyeglasses or fitting of contact lenses and, examinations for them � Eye exercises and orthoptics � Radial keratotomy and other refractive surgery				All charges.
*Foot care*
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes. Treatment of bunions and spurs See orthopedic and prosthetic devices for information on podiatric shoe inserts.				$10 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; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)				All Charges.
Orthopedic and prosthetic devices				You pay
� Artificial limbs and eyes; stump hose � Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy � Lenses following cataract removal � Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome. NOTE: Purchases exceeding $200 per month must be authorized by the plan's Medical Director. Your plan doctor will obtain the prior authorization.				25% of the charges per purchase or rental $30, 000 combined lifetime maximum on orthotics/prosthetics
� Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy. Note: See 5(b) for coverage of the surgery to insert the device.				Nothing
Not covered: � orthopedic and corrective shoes � arch supports � foot orthotics (that are not custom made) � heel pads and heel cups � lumbosacral supports � corsets, trusses, elastic stockings, support hose, and other supportive devices prosthetic replacements provided less than 3 years after the last one we covered				All charges.
*Durable medical equipment (DME)*				You Pay
NOTE: Medical supplies and equipment are covered when prescribed by your plan physician for treatment of a diagnosed illness or injury. The supplies or equipment must be purchased from a plan durable medical equipment provider. NOTE: Purchases exceeding $200 per month or rentals exceeding $200 per month must be authorized by the plan's Medical Director. Your plan doctor will obtain the prior authorization. � Hospital beds; � Wheelchairs; (requires prior authorization by our health services department) � Crutches, splints, trusses, orthopedic braces, and appliances � Walkers; � Blood glucose monitors; and � Insulin pumps. � TENS unit; � Intrauterine devices (IUDs) � Oxygen therapy and other inhalation therapy and related items for home use must be prior authorized by the Health Services Department � Rental of a ventilator or other mechanical equipment or purchase of such equipment at the option of Dean Health Plan Note: Call us at 800-279-1301 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.				25% of the charges per purchases or rental
Not covered: � Repairs and replacement of durable medical equipment/supplies unless they are prior authorized by the Health Services Department � Elastic support stockings (e.g., TEDS, JOBST, etc.) � Shoes or orthotics that are not custom made and can be purchased over the counter. � Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative. � Medical supplies and durable medical equipment for comfort, personal hygiene, and convenience such as, but not limited to: air conditioners, air cleaners, humidifiers, physical fitness equipment, physician's equipment, disposable supplies, alternative communication devices, and self-help devices not medical in nature. � Home testing and monitoring supplies and related equipment except those used in connection with the treatment of diabetes, � Equipment, models or devices that have features over the above that which is medically necessary. Coverage will be limited to the standard model as determined by Dean Health Plan. � Any durable medical equipment or supplies used for work, athletic or job enhancement.				All charges.
*Home health services*					You pay
� 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. � Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship, or giving oral medication.					All charges.
*Chiropractic*					You Pay
� Manipulation of the spine and extremities � Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application					$10 per office visit
*Alternative treatments*
No Benefits					All charges.
Tobacco Cessation
Coverage is limited to: Tobacco Cessation Coverage is for 3 (three) 4 week (28 day ) Courses of zyban and/or nicotine replacement therapy ("the patch") with doctor's prescription. NOTE: Please call us at 800-279-1301 for details					$10 copay per fill

Benefit Description			You pay
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
	I M P O R T A N T	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. � Plan physicians must provide or arrange your care. � 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.).		I M P O R T A N T
Surgical procedures
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. � Cochlear implants (requires prior authorization)			Nothing
� Voluntary sterilization ( e.g., Tubal ligation) � 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.			Nothing
Not covered: � Reversal of voluntary sterilization � Routine treatment of conditions of the foot; see Foot care.			All charges.
Reconstructive surgery			You Pay
� 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.			Nothing
� All stages of breast reconstruction surgery following a mastectomy, such as: - surgery to produce a symmetrical appearance on the other breast; - treatment of any physical complications, such as lymphedemas; - breast prostheses and surgical bras and replacements (see Prosthetic devices) Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.			See above.
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 and maxillofacial surgery			You Pay
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; � Surgical removal of impacted teeth, tumors, and cysts; � 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. � Diagnostic procedures and medically necessary surgical or non-surgical treatment for the correction of temporomandibular disorders (TMD) if all of the following apply: � The condition is caused by congenital, developmental or acquired deformity, disease or injury. � Under the accepted standards of the profession of the health care provider rendering the service, the procedure or device is reasonable and appropriate for the diagnosis or treatment of this condition.