Enrollment codes for this Plan:

F81 High Option Self Only

F82 High Option Self and Family

F84 Standard Option Self Only

F85 Standard Option Self and Family

This Plan has excellent accreditation from the NCQA.

See the 2005 Guide for more information on accreditation.

Special notice: This Plan is offering a Standard Option for the first time under the Federal Employees Health Benefits Program during the 2005 Open Season.

2005

RI 73-321

Kaiser Foundation

Health Plan of Georgia, Inc.

my.kaiserpermanente.org/federalemployees

For changes in benefits see page 9.

Serving: Atlanta, Georgia metropolitan area

Enrollment in this plan is limited. You must live or work in our Geographic service area to enroll. See page 8 for requirements.

A Health Maintenance Organization

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 United States Office of Personnel Management’s

Privacy Practices

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

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

OPM will use and give out your personal medical information:

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

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

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

Where required by law.

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

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

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

For OPM and the General Accounting Office when conducting audits.

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

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

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

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

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

By law, you have the right to:

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

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

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

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

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

Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice, look at www.opm.gov/insure on the Web. You may also call 202-606-0745 and ask for OPM’s FEHB Program privacy official for this purpose.

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

Privacy Complaints

Unites States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

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

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

Table of Contents

Introduction................................................................................................................................................................................................... 2

Plain Language.............................................................................................................................................................................................. 2

Stop Health Care Fraud!............................................................................................................................................................................... 2

Preventing medical mistakes........................................................................................................................................................................ 2

Section 1. Facts about this HMO plan....................................................................................................................................................... 2

How we pay providers........................................................................................................................................................... 2

Your Rights.............................................................................................................................................................................. 2

Language Interpretation Services........................................................................................................................................ 2

Service Area............................................................................................................................................................................. 2

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

Program-wide changes........................................................................................................................................................... 2

Changes to this Plan............................................................................................................................................................... 2

Section 3. How you get care........................................................................................................................................................................ 2

Identification cards................................................................................................................................................................. 2

Where you get covered care................................................................................................................................................. 2

Plan providers................................................................................................................................................................... 2

Plan facilities...................................................................................................................................................................... 2

What you must do to get covered care............................................................................................................................... 2

Primary care....................................................................................................................................................................... 2

Specialty care.................................................................................................................................................................... 2

Hospital care...................................................................................................................................................................... 2

Rescheduling of services................................................................................................................................................ 2

Circumstances beyond our control...................................................................................................................................... 2

Services requiring our prior approval.................................................................................................................................. 2

Section 4. Your costs for covered services............................................................................................................................................... 2

Copayments............................................................................................................................................................................. 2

Deductible................................................................................................................................................................................ 2

Pharmacy deductible.............................................................................................................................................................. 2

Coinsurance............................................................................................................................................................................. 2

Fees when you fail to make your copayment or coinsurance.......................................................................................... 2

Missed appointment fee........................................................................................................................................................ 2

Your catastrophic protection out-of-pocket maximum...................................................................................................... 2

Section 5. Benefits – OVERVIEW (See page 9 for how our benefits changed this year and pages 76 and 77 for a benefits summary.) 2

Section 5(a) Medical services and supplies provided by physicians and other health care professionals............. 2

Section 5(b) Surgical and anesthesia services provided by physicians and other health care professionals......... 2

Section 5(c) Services provided by a hospital or other facility, and ambulance services............................................. 2

Section 5(d) Emergency services/accidents....................................................................................................................... 2

Section 5(e) Mental health and substance abuse benefits............................................................................................... 2

Section 5(f) Prescription drug benefits................................................................................................................................ 2

Section 5(g) Special features................................................................................................................................................. 2

Flexible benefits option............................................................................................................................. 2

24 hour nurse line....................................................................................................................................... 2

Services for deaf and hearing impaired................................................................................................... 2

High risk pregnancies................................................................................................................................ 2

Centers of Excellence................................................................................................................................. 2

Travel benefit.............................................................................................................................................. 2

Smoking cessation..................................................................................................................................... 2

Services from other Kaiser Permanente plans....................................................................................... 2

Section 5(h) Dental benefits.................................................................................................................................................. 2

Section 5(i) Non-FEHB benefits available to Plan members............................................................................................. 2

Section 6. General exclusions – things we don’t cover........................................................................................................................... 2

Section 7. Filing a claim for covered services........................................................................................................................................... 2

Section 8. The disputed claims process..................................................................................................................................................... 2

Section 9. Coordinating benefits with other coverage............................................................................................................................ 2

When you have other health coverage............................................................................................................................... 2

What is Medicare?.................................................................................................................................................................. 2

Should I enroll in Medicare?........................................................................................................................................... 2

If you enroll in Medicare Part B...................................................................................................................................... 2

The Original Medicare Plan (Part A or Part B)............................................................................................................. 2

Medicare Advantage....................................................................................................................................................... 2

TRICARE and CHAMPVA.................................................................................................................................................... 2

Workers’ Compensation........................................................................................................................................................ 2

Medicaid................................................................................................................................................................................... 2

When other Government agencies are responsible for your care................................................................................... 2

When others are responsible for injuries............................................................................................................................ 2

Section 10. Definitions of terms we use in this brochure........................................................................................................................ 2

Section 11. FEHB Facts................................................................................................................................................................................ 2

Coverage information............................................................................................................................................................. 2

No pre-existing condition limitation............................................................................................................................... 2

Where you can get information about enrolling in the FEHB Program.................................................................... 2

Types of coverage available for you and your family................................................................................................ 2

Children’s Equity Act...................................................................................................................................................... 2

When benefits and premiums start................................................................................................................................ 2

When you retire................................................................................................................................................................ 2

When you lose benefits......................................................................................................................................................... 2

When FEHB coverage ends............................................................................................................................................ 2

Spouse equity coverage.................................................................................................................................................. 2

Temporary Continuation of Coverage (TCC)............................................................................................................... 2

Converting to individual coverage................................................................................................................................ 2

Getting a Certificate of Group Health Plan Coverage.................................................................................................. 2

Section 12.Two Federal Programs complement FEHB benefits.............................................................................................................. 2

The Federal Flexible Spending Account Program – FSAFEDS....................................................................................... 2

The Federal Long Term Care Insurance Program............................................................................................................... 2

Index................................................................................................................................................................................................................ 2

Summary of benefits for Kaiser Foundation Health Plan of Georgia, Inc............................................................................................. 2

2005 Rate Information for Kaiser Foundation Health Plan of Georgia, Inc........................................................................................... 2

Introduction

This brochure describes the benefits of Kaiser Foundation Health Plan of Georgia, Inc. under our contract (CS 2163) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. The address for Kaiser Foundation Health Plan of Georgia, Inc.’s administrative offices is:

Kaiser Foundation Health Plan of Georgia, Inc.

Nine Piedmont Center

3495 Piedmont Road, NE

Atlanta, Georgia 30305-1736

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

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

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2005, and changes are summarized on page 9. Rates are shown on the back cover 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” or “Plan” means Kaiser Foundation Health Plan of Georgia, 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 U.S. Office of Personnel Management, Insurance Services Programs, Program Planning & Evaluation Group, 1900 E Street, NW, Washington, DC 20415-3650.

Stop Health Care Fraud!

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

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

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

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

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

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

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

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

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

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

If the provider does not resolve the matter, call us at 404/261-2590 and explain the situation.

If we do not resolve the issue:

CALL ¾ 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

Do not maintain as a family member on your policy:

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

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

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

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

Preventing medical mistakes

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

1. Ask questions if you have doubts or concerns.

Ask questions and make sure you understand the answers.

Choose a doctor with whom you feel comfortable talking.

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

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

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

Tell them about any drug allergies you have.

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

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

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

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

3. Get the results of any test or procedure.

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

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

Call your doctor and ask for your results.

Ask what the results mean for your care.

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

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

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

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

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

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

Ask your surgeon:

Exactly what will you be doing?

About how long will it take?

What will happen after surgery?

How can I expect to feel during recovery?

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

Want more information on patient safety?

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

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

Ø 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.

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

Ø www.ahqa.org. The American Health Quality Association represents organizations and health care professionals working to improve patient safety.

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

Section 3. How you get care

Identification card s	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 404/261-2590 (locally), 888/865-5813 (long distance), or 800/255-0056 (TTY number), or write to us at Kaiser Permanente, Member Services Department, Nine Piedmont Center, 3495 Piedmont Road, NE, Atlanta, GA 30305-1736. You may also request replacement cards through our Web site at my.kaiserpermanente.org/federalemployees.
Where you get covered care	You get care from “Plan providers” and “Plan facilities.” You will only 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 contract with The Southeast Permanente Medical Group, Inc. (Plan physicians), an independent multi-specialty group of physicians, to provide or arrange all necessary physician care. Plan physicians, nurse practitioners, physician assistants, and other skilled medical personnel working as medical teams provide your health care services. Specialists consult with these medical teams in determining your treatment. Plan physicians refer patients to community specialists when necessary. We list Plan providers in the physician directory, which we update periodically. The list is also on our Web site my.kaiserpermanente.org/federalemployees.
Plan facilities	Plan facilities include our medical offices, as well as hospitals and other facilities in our service area that we contract with to provide covered services to our members. Other services, such as physical therapy, laboratory, and X-ray, are available at Plan facilities and other designated locations. Hospital care is provided at local community hospitals. We list these in the physician directory, which we update periodically. The list is also on our Web site. You must receive your health services at Plan facilities, except if you have an emergency. If you are visiting another Kaiser Permanente service area, you may receive health care services at those Kaiser Permanente facilities. Under the circumstances specified in this brochure, you may receive follow-up or continuing care while you travel anywhere.
What you must do to get covered care	It depends on the type of care you need. First, you and each family member should choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. To learn how to choose or change your primary care physician, call our Member Services Department at 404/261-2590 (locally), 800/ 611-1811 (long distance), or 800/255-0056 (TTY number).
Primary care	We require you to choose a primary care physician when you enroll. Every member of your family should have his or her own primary care physician. If you do not select a primary care physician upon enrollment, we will assist you by identifying a physician in a medical center near your home and including you in that physician’s panel of patients. That physician will be listed in our records as your primary care physician until you make a selection and inform us of your decision. When choosing your primary care physician, keep in mind that your choice may determine where you will receive specialty care. Your primary care physician has an established relationship with a specific group of specialty care physicians with whom he or she works on a regular basis. By referring only to a select group of specialists, your primary care physician is better able to ensure that you receive quality care. You may select your primary care physician from the Medical Group Physicians or from a contracted Affiliated Community Physicians practicing in their own offices all over town. The Medical Group physicians provide care at Kaiser Permanente medical centers in our service area. An Affiliated Community Physician provides care in his or her own medical office. Your primary care physician can be a family practitioner, internist, or pediatrician. Adults should select an internal medicine or family practice physician. Parents can choose a pediatrician or family practice physician for their children. Note: Some family medicine physicians only treat adults. If you select a family medicine physician for your child, please make sure that physician treats children. If you wish to be treated by a physician at a Kaiser Permanente medical center or by another Affiliated Community Physician, you should select that individual as your new primary care physician before scheduling treatment. 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. Your primary care physician will provide most of your health care, or give you a referral to see a specialist. To learn how to choose or change your primary care physician, call our Member Services Department at 404/261-2590 (locally), 800/ 611-1811 (long distance), or 800/255-0056 (TTY number).
Specialty care	Your primary care physician will refer you to a specialist for needed care. Under the Standard Option plan, you pay a different copayment for your specialty care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may seea gynecologist, a dermatologist, an optometrist, an ophthalmologist or our mental health and substance abuse Plan providerswithout a referral. Here are some other things you should know about specialty care: Keep in mind that your primary care physician choice determines which specialists are available to you. Your primary care physician has an established relationship with a specific group of specialty care doctors. By referring only to a certain group of specialists, your primary care physician is better able to ensure that you receive quality 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 Member Services Department immediately at 404/261-2590. 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.
Rescheduling of services	Copayments, deductibles and coinsurance for services are due at the time of your visit. We reserve the right to reschedule non-urgent care if you do not pay at the time of your visit.
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 preauthorization. Your physician must obtain preauthorization for the following services. This list is subject to change. For the most current information, call our Member Services Department at 404/261-2590. All inpatient hospital care services (this does not apply to emergency admissions) Skilled nursing care benefits Inpatient mental health or substance abuse services Inpatient rehabilitation therapy services or programs Organ and tissue transplants Bariatric surgery Infertility procedures Outpatient procedures and services: Ambulatory Surgery Biofeedback or other pain management treatment Comprehensive outpatient rehabilitation facility services Cryosurgery of the prostate Dialysis Drugs: Botox injections, human growth hormone, Panretin, Targretin, Actimmune, Flolan, Tracleer, Fuzeon, Amevive, Raptiva, Enbrel, Remicade, Humira, Remodulin and Xolair Durable medical equipment, and orthopedic and prosthetic devices Epidural steroid injections Home Health Care Hospice care Hyperbaric oxygen (HBO) treatment Implantable cardiac defibrillators (AICD) Intrathecal and epidural infusion pumps Lithotripsy PET Scans Prostate seed implants Sclerotherapy or other varicose vein treatment Speech therapy, physical therapy, occupational therapy Spinal cord stimulation Transplant related services Uvulopalatopharyngoplasty Any request for non-Plan provider

Section 5. Benefits – OVERVIEW
(See page 9 for how our benefits changed this year and pages 76 and 77 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 404/261-2590 or at our Web site at my.kaiserpermanente.org/federalemployees.

Section 5(a) Medical services and supplies provided by physicians and other health care professionals.................................... 2

Diagnostic and treatment services....................................................................................................................................... 2

Lab, X-ray and other diagnostic tests................................................................................................................................. 2

Preventive care, adult............................................................................................................................................................. 2

Preventive care, children........................................................................................................................................................ 2

Maternity care......................................................................................................................................................................... 2

Family planning....................................................................................................................................................................... 2

Infertility services................................................................................................................................................................... 2

Allergy care.............................................................................................................................................................................. 2

Treatment therapies................................................................................................................................................................ 2

Physical and occupational therapies................................................................................................................................... 2

Speech therapy........................................................................................................................................................................ 2

Hearing services (testing, treatment, and supplies).......................................................................................................... 2

Vision services (testing, treatment, and supplies)............................................................................................................. 2

Foot care................................................................................................................................................................................... 2

Orthopedic and prosthetic devices...................................................................................................................................... 2

Durable medical equipment (DME)...................................................................................................................................... 2

Home health services............................................................................................................................................................. 2

Chiropractic.............................................................................................................................................................................. 2

Alternative treatments............................................................................................................................................................ 2

Educational classes and programs....................................................................................................................................... 2

Section 5(b) Surgical and anesthesia services provided by physicians and other health care professionals............................... 2

Surgical procedures................................................................................................................................................................ 2

Reconstructive surgery.......................................................................................................................................................... 2

Oral and maxillofacial surgery............................................................................................................................................... 2

Organ/tissue transplants....................................................................................................................................................... 2

Anesthesia............................................................................................................................................................................... 2

Section 5(c) Services provided by a hospital or other facility, and ambulance services................................................................... 2

Inpatient hospital.................................................................................................................................................................... 2

Outpatient hospital or ambulatory surgical center............................................................................................................ 2

Extended care benefits/Skilled nursing care facility benefits........................................................................................... 2

Hospice care............................................................................................................................................................................ 2

Ambulance............................................................................................................................................................................... 2

Section 5(d) Emergency services/accidents.............................................................................................................................................. 2

Emergency within our service area....................................................................................................................................... 2

Emergency outside our service area.................................................................................................................................... 2

Ambulance............................................................................................................................................................................... 2

Section 5(e) Mental health and substance abuse benefits..................................................................................................................... 2

Mental health and substance abuse benefits..................................................................................................................... 2

Section 5(f) Prescription drug benefits...................................................................................................................................................... 2

Covered medications and supplies...................................................................................................................................... 2

Section 5(g) Special features....................................................................................................................................................................... 2

Flexible benefits option.......................................................................................................................................................... 2

24 hour nurse line.................................................................................................................................................................... 2

Services for deaf and hearing impaired................................................................................................................................ 2

High risk pregnancies............................................................................................................................................................. 2

Centers of excellence.............................................................................................................................................................. 2

Travel benefit........................................................................................................................................................................... 2

Smoking cessation.................................................................................................................................................................. 2

Services from other Kaiser Permanente plans.................................................................................................................... 2

Section 5(h) Dental benefits........................................................................................................................................................................ 2

Accidental injury benefit....................................................................................................................................................... 2

Dental benefits........................................................................................................................................................................ 2

Section 5(i) Non-FEHB benefits available to Plan members................................................................................................................... 2

Summary of benefits for Kaiser Foundation Health Plan of Georgia, Inc. - 2005................................................................................. 2

2005 Rate Information for Kaiser Foundation Health Plan of Georgia, Inc........................................................................................... 2

Benefit Description			You pay
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 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. Under Standard Option – The calendar year deductible is $500 per person ($1,500 per family). The calendar year deductible and plan coinsurance apply to some benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply. Under High Option - 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. Different copayments apply for primary care visits and specialty care visits in the Standard Option. Please refer to Section 10, Definitions, to learn more about when your primary and specialty care copayments will apply. YOU MUST GET PREAUTHORIZATION FOR SOME MEDICAL PROCEDURES. Please refer to the preauthorization shown in Section 3 to be sure which services and supplies require preauthorization. Note: We waive or lower the office visit charge when you enroll in our Medicare Advantage High Option plan and assign your Medicare benefits to the Plan.			I M P O R T A N T
Note: The Standard Option plan calendar year deductible applies to some benefits in this Section. We say “(No deductible)” when it does not apply.
Diagnostic and treatment services			Standard Option	High Option
Professional services of physicians and other health care professionals In physician’s office Office medical consultations Second surgical opinion			$20 per visit to your primary care provider $30 per visit to a specialist (No deductible)	$15 per visit
In a Plan After-Hours Care Center or any other urgent care center designated by the Plan			$40 per visit (No deductible)	$30 per visit
During a hospital stay In a skilled nursing facility			20% of our allowance after you have met your calendar year deductible	Nothing
Diagnostic and treatment services – continued on next page

Diagnostic and treatment services (continued)	You pay – Standard Option	You pay – High Option
At home	Nothing (No deductible)	Nothing
Certain procedures received during an office visit, such as cardiac stress tests, nerve conduction studies, pulmonary function tests and loop electrode excision procedures (LEEP).	20% of our allowance after you have met your calendar year deductible	Nothing
Lab, X-ray and other diagnostic tests
Tests, such as: Blood tests Urinalysis Pathology	20% of our allowance after you have met your calendar year deductible	Nothing
X-rays Non-routine Mammograms CT scans, MRI, PET scans, nuclear medicine Ultrasound
Electrocardiogram and EEG	Nothing (No deductible)	Nothing
Preventive care, adult
Routine screenings, such as: Total blood cholesterol Routine Prostate Specific Antigen (PSA) test – one annually for men age 40 and older Routine Pap test	$20 per visit to your primary care provider $30 per visit to a specialist (No deductible)	$15 per visit
Colorectal Cancer Screening, including Double contrast barium enema – every five years starting at age 50 Colonoscopy screening – every ten years starting at age 50	20% of our allowance after you have met your calendar year deductible	$15 per visit
Fecal occult blood test Sigmoidoscopy, screening – every five years starting at age 50	Nothing	Nothing
Notes: You should consult with your physician to determine what screenings are appropriate for you. You pay only one copayment if you receive your routine screening on the same day as your office visit.
Preventive care, adult - continued on next page

Preventive care, adult (continued)	You pay – Standard Option	You pay – High Option
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 Note: In addition to routine screening, we cover mammograms when medically necessary to diagnose or treat your illness.	Nothing (No deductible)	Nothing
Routine immunizations, limited to: Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and over (except as provided for under Childhood immunizations) Influenza vaccine, annually Pneumococcal vaccine, age 65 and older	Nothing if you receive these services during your office visit; otherwise $20 per visit. (No deductible)	Nothing if you receive these services during your office visit; otherwise $15 per visit.
Not covered: Physical exams required for obtaining or continuing employment, insurance or licensing; participating in employee programs; attending schools or camp; travel; or court order required for parole or probation.	All charges	All charges
Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Well-child preventive care visits (up to 2 years of age)	Nothing if you receive these services during your office visit; otherwise $20 per visit. (No deductible)	Nothing if you receive these services during your office visit; otherwise $15 per visit.
Services, such as: Eye screenings to determine the need for vision correction Hearing screenings to determine the need for hearing correction Examinations done on the day of immunizations Well-child care charges for routine examinations, and care (age 2 and over)	$20 per visit (No deductible)	$15 per visit
Not covered: Physical exams required for obtaining or continuing employment, insurance or licensing; participating in employee programs; attending schools or camp; travel; or court order required for parole or probation.	All charges	All charges

Maternity care	You pay – Standard Option	You pay – High Option
Complete maternity (obstetrical) care, such as: Routine prenatal care visits (obstetrician, nurse midwife, and OB nurse practitioner First postnatal care visit	Nothing (No deductible)	Nothing
All other visits during pregnancy (such as visits to genetics counselors and perinatologists)	$30 per visit (No deductible)	$15 per visit
Delivery Notes: 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. Your plan physician 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 surgeon services (delivery) and hospitalization the same as for illness and injury. See Surgery benefits (Section 5(b)) and Hospital benefits (Section 5(c)).	20% of our allowance after you have met your calendar year deductible (See Section 5(c) for Hospital charges)	Nothing
Not covered: Routine sonograms to determine fetal age, size or sex.	All charges	All charges
Family planning
A range of voluntary family planning services, such as: Voluntary sterilization (See Surgical procedures Section 5(b)) Information on birth control Note: We cover surgically implanted contraceptives, diaphragms, injectable contraceptive drugs, intrauterine devices (IUDs) and oral contraceptives under your prescription drug benefit. See Section 5(f).	$20 per visit to your primary care provider* $30 per visit to a specialist* (*No deductible) 20% of our allowance for surgical procedures after you have met your calendar year deductible	$15 per visit
Not covered: Reversal of voluntary surgical sterilization Genetic counseling.	All charges	All charges
Infertility services	You pay – Standard Option	You pay – High Option
Visits for diagnosis of involuntary infertility Diagnostic imaging and laboratory tests, limited to: hysterosalpingogram (HSG), post-coital test, fasting blood glucose, fasting insulin, semen analysis, tests to rule out sexually transmitted diseases and hormone level tests.	50% of our allowance after you have met your calendar year deductible	50% of our allowance
Treatment of involuntary infertility Artificial insemination: intravaginal insemination (IVI) intracervical insemination (ICI) intrauterine insemination (IUI) Fertility drugs Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under your prescription drug benefits. See Section 5(f).	50% of our allowance (No deductible)	50% of our allowance
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 Semen or eggs, and services and supplies related to their procurement and storage. Notes: These exclusions apply to fertile as well as infertile individuals or couples. Infertility services are not available when either member of the family has been voluntarily surgically sterilized.	All charges	All charges

Allergy care	You pay – Standard Option	You pay – High Option
Testing	20% of our allowance after you have met your calendar year deductible	$15 per visit
Allergy injections (allergy treatment)	$10 per visit (No deductible)	$10per visit
Allergy serum	Nothing (No deductible)	Nothing
Not covered: Provocative food testing and sublingual allergy desensitization	All charges	All charges
Treatment therapies
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 in Section 5(b). Respiratory and inhalation therapy Dialysis – hemodialysis and peritoneal dialysis	$30 per visit (No deductible)	$15 per visit
Notes: We waive dialysis office visit charges if you enroll in Medicare Part B and assign your Medicare benefits to us. Growth hormone is covered under the prescription drug benefit. We only cover GHT when we preauthorize the treatment.
Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy	Nothing at home $30 per visit in physician’s office (No deductible)	Nothing at home $15 per visit in physician’s office
Not covered: Chemotherapy supported by a bone marrow transplant or with stem cell support, for any diagnosis not listed as covered.	All charges	All charges
Physical and occupational therapies	You pay – Standard Option	You pay – High Option
If, in the judgment of a Plan physician, significant improvement is achievable within a two-month period, two consecutive months of therapy per condition: Physical therapy by qualified physical therapists to restore bodily function when you have a total or partial loss of bodily function due to illness or injury Occupational therapy by occupational therapists to assist you in achieving and maintaining self-care and improved functioning in other activities of daily life Note: If you have not received 20 or more outpatient visits within the two-month period that started with your first visit to a therapist, we may continue your therapy for up to 20 outpatient visits per therapy per condition. Cardiac rehabilitation following a heart transplant, bypass surgery, or a myocardial infarction is provided for up to 12 weeks or 36 visits Comprehensive outpatient rehabilitation facility services are provided up to two months per condition. Outpatient rehabilitation, including diagnostic and restorative services, providing a program of physical, speech, occupational, respiratory therapy, social and psychological services, and other items and services that are medically necessary for rehabilitation. The two month limit applies to all inpatient and outpatient comprehensive rehabilitation services you may receive for the same condition.	20% of our allowance after you have met your calendar year deductible	$15 per outpatient visit Nothing per visit during covered inpatient admission
Not covered: Long-term physical therapy or occupational therapy Exercise programs Cognitive rehabilitation programs Vocational rehabilitation programs Therapies done primarily for education purposes	All charges	All charges

Speech therapy	You pay – Standard Option	You pay – High Option
Two consecutive months of therapy per condition: Speech therapy by speech therapists when medically necessary Note: If you have not received 20 or more outpatient visits within the two-month period that started with your first visit to a therapist, we may continue your therapy for up to 20 outpatient visits per therapy per condition.	20% of our allowance after you have met your calendar year deductible	$15 per outpatient visit Nothing per visit during covered inpatient admission
Not covered: Speech therapy that is not medically necessary such as - Therapy for educational placement or other educational purposes Training or therapy to improve articulation in the absence of injury, illness, or medical condition affecting articulation Therapy for tongue thrust in the absence of swallowing problems Voice therapy for occupation or performing arts	All charges	All charges
Hearing services (testing, treatment, and supplies)
Hearing test to determine the need for hearing correction Hearing testing for children through age 17 (see Preventive care, children)	$30 per visit (No deductible)	$15 per visit
Audiometric exams	20% of our allowance after you have met your calendar year deductible	$15 per visit
Not covered: All other hearing testing Hearing aids, tests to determine their effectiveness and examinations for them	All charges	All charges

Vision services (testing, treatment, and supplies)	You pay – Standard Option	You pay – High Option
Eye refractions for eyeglasses (to provide written lens prescription) Diagnosis and treatment of diseases of the eye	$30 per visit (No deductible)	$15 per visit
Not covered: Corrective eyeglasses and frames or contact lenses (including the examination and fitting of contact lenses) Refractions for contact lenses Eye exercises, orthoptics, and visual training Radial keratotomy and other refractive surgery Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as nearsightedness (myopia), farsightedness (hyperopia), and astigmatism Low vision aids	All charges	All charges
Foot care
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.	$20 per visit to your primary care provider $30 per visit to a specialist (No deductible)	$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	All charges
Orthopedic and prosthetic devices	You pay – Standard Option	You pay – High Option
External prosthetic and orthotic devices, such as: Ostomy and urological supplies Artificial limbs and eyes; stump hose Braces Therapeutic shoes required for conditions associated with diabetes Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy Scoliosis braces Lenses following cataract removal Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome	20% of our allowance after you have met your calendar year deductible	20% of our allowance
Internal prosthetic devices, such as artificial joints, pacemakers, intraocular lens following cataract removal, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See Section 5(b) for coverage of the surgery to insert the device.	Nothing (No deductible)	Nothing
Not covered: Orthopedic and corrective shoes Arch supports Foot orthotics Heel pads and heel cups Lumbosacral supports Corsets, trusses, elastic stockings, support hose, and other supportive devices External and internally implanted hearing aids Experimental or research equipment	All charges	All charges

Durable medical equipment (DME)	You pay – Standard Option	You pay – High Option
Covered DME items include: Hospital beds Wheelchairs, except motorized Crutches Walkers Infant apnea monitors Oxygen-dispensing equipment Oxygen Note: We decide whether to rent or purchase the equipment, and we select the vendor. We will repair the equipment without charge, unless the repair is due to loss or misuse. You must return the equipment to us or pay us the fair market price of the equipment when it is no longer prescribed.	20% of our allowance after you have met your calendar year deductible	20% of our allowance
Not covered: Motorized wheel chairs Comfort, convenience, or luxury equipment or features Exercise or hygiene equipment Non-medical items such as sauna baths or elevators Modifications to your home or car Devices for testing blood or other body substances Electronic monitors of bodily functions, except apnea monitors and blood glucose monitors Disposable supplies Replacement of lost equipment Repair, adjustments, or replacements necessitated by misuse More than one piece of durable medical equipment serving essentially the same function, except for replacements other than those necessitated by misuse or loss Spare or alternate use equipment Devices, equipment, supplies, and prosthetics for the treatment of sexual dysfunction disorders External and internally implanted hearing aids Experimental or research equipment	All charges	All charges
Home health services	You pay – Standard Option	You pay – High Option
If you are homebound and reside in the service area: You may receive home health services of nurses and health aides, physical or occupational therapists, and speech and language pathologists Services include oxygen therapy, intravenous therapy, and medications Note: Your Plan physician will periodically review the program for continuing appropriateness and need.	Nothing (No deductible)	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 Custodial care Care that the Medical Director of the Medical Group or his/her designee determines may be appropriately provided in a Plan facility, skilled nursing facility, or other facility we designate and we provide or offer to provide that care in one of these facilities Services outside our service area	All charges	All charges
Chiropractic	You pay – Standard Option	You pay – High Option
Chiropractic services up to 30 visits per calendar year, for the following services: Evaluation and management of musculoskeletal disorders Routine chiropractic X-rays provided in the chiropractor’s office (not to exceed 4 views) Chiropractic adjustments Appropriate therapies (e.g., hot and cold packs) not to exceed 2 per visit Note: You may see a chiropractor without referral from your Plan physician. Services must be provided from our list of Participating Chiropractors. Please contact us to get the list.	Not Covered	$15 per visit
Not covered: Vitamins and supplements Vax-D Structural supports Massage therapies Maintenance/preventative care Acupuncture therapy Physical, speech, and occupational therapy provided by a chiropractor Neurological testing, unless authorized by your primary care physician Laboratory and pathology services, unless authorized by your primary care physician	All charges	All charges
Alternative treatments
No benefit	All charges	All charges

Educational classes and programs	You pay – Standard Option	You pay – High Option
Training in self-care and preventive care	$20 per visit	$15 per visit
Health education publications and education about how to use our services and supplies	Nothing	Nothing
General health education not addressed to a specific condition, as well as Lamaze classes and weight control classes	Charges vary ($0 to $75 for most classes)	Charges vary ($0 to $75 for most classes)
Quit Smart Smoking Cessation Program This program includes six sessions with one follow up session, lectures, a quit smoking kit, discussions and relaxation techniques, a patented realistic cigarette substitute, and vouchers for nicotine patches Georgia tobacco Quit Line The Quit Line is a toll-free telephone resource for people who want to quit using tobacco. Callers will receive screening, counseling, and referral to resources and written materials. Friends and family members can call to get information about how to help their loved ones quit.	Nothing	Nothing
Any member who is enrolled and attends the Quit Smart smoking cessation program or enrolls in the Quit Line telephone counseling program is eligible to receive a two-week supply of nicotine patches (with voucher) at a Plan pharmacy	$5	$5
Any member who is enrolled and attends the Quit Smart smoking cessation program or enrolls in the Quit Line telephone counseling program is eligible to receive a one-month supply of Buproprion SR (with voucher) at a Plan pharmacy. A prescription from a Plan physician is required.	$40	$40
Note: This information is a summary of services available. Please call us at 404/261-2590 for availability and location of these classes.

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 $15 per office visit and when you go in the hospital, you pay $250 per admission.
Deductible	Standard Option plan: A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. The calendar year deductible for the Standard Option plan is $500 per person. Under a family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $1,500. Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan. Any payment you make toward the deductible for services you receive during the last three months of a calendar year will also apply toward the deductible for the next calendar year.
	High Option plan: We do not have a deductible in the High Option plan.
Pharmacy deductible	Standard Option plan: The fixed amount of covered expenses you must incur for certain prescribed drugs (except IV fluids and medications for home use, drugs for covered infertility treatment, and drugs for covered sexual dysfunction treatment) before we start paying benefits for covered prescription drugs. The annual pharmacy deductible for the Standard Option is $100 per person. Once the annual pharmacy deductible is met, you pay your applicable prescription drug copayment. Each of your covered family members must meet their individual annual pharmacy deductible before we pay any prescription drug benefit. This pharmacy deductible is calculated on a calendar year basis and does not carry-over from year to year. Once your pharmacy deductible has been met, you will pay your prescription drug copayment. If you are filling multiple prescriptions or refills, the deductible will be calculated in the order processed. Please note: Payments made for prescription drugs will be applied only to the pharmacy deductible and accumulate separately from the calendar year deductible for covered medical services.
	High Option plan: We do not have a pharmacy deductible in the High Option plan.
Coinsurance	Coinsurance is the percentage of our allowance that you must pay for certain services that you receive. Example: In our Plan, you pay 50% of our allowance for infertility services and 20% of our allowance for durable medical equipment.
Fees when you fail to make your copayment or coinsurance	If you do not pay your copayment or coinsurance at the time you receive services, we will bill you. You will be required to pay a $20 charge for each bill sent for unpaid services. Affiliated Community Physicians may bill you an additional charge along with any unpaid copayments or coinsurance.
Missed appointment fee	If you do not cancel your appointment with your Plan provider at least 24 hours in advance of the appointment, you may be required to pay an administrative fee of $25 and the cost of any drugs and supplies that were prepared for your appointment and that cannot be reused. Note: Affiliated physician offices and other providers and facilities may bill you an additional charge along with any unpaid copayments, coinsurance or for missed appointments that you fail to cancel.
Your catastrophic protection out-of-pocket maximum	Standard Option Plan: After your copayments and coinsurance total $2,000 per person or $6,000 per family enrollment in any calendar year, you do not have to pay any more for certain covered services. However, the following do not count toward your catastrophic protection out-of-pocket maximum, and you must pay them even after your expenses exceed the limits described above. Any services for which you pay a copayment (except inpatient hospital facility) Expenses in excess of our allowable amount or maximum benefit limitations Expenses for infertility treatment services Expenses for dental services Fees or administrative charges Any non-FEHB benefits Note: the calendar year deductible and the annual pharmacy deductible do not count toward your catastrophic protection out-of-pocket maximum. Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the maximum.
	High Option plan: We do not have a catastrophic protection out-of-pocket maximum in the High Option plan.

Surgical procedures(continued)	You pay – Standard Option	You pay – High Option
Insertion of internal prosthetic devices. See Section 5(a) – Orthopedic and prosthetic devices for device coverage information Voluntary sterilization (e.g., Tubal ligation, Vasectomy) Surgically implanted time-release contraceptive drugs and intrauterine devices (IUDs). Other implanted time-release drugs Treatment of burns Note: Drugs and devices are covered under Section 5(f)	$30 per visit with specialist* (*No deductible) 20% of our allowance for outpatient and inpatient surgery and procedures after you have met your calendar year deductible See Section 5(c) for facility charges.	$15 per office visit Nothing for hospital or ambulatory surgical center physician and professional services See Section 5(c) for facility charges.
Not covered: Reversal of voluntary sterilization Routine treatment of conditions of the foot (Section 5(a)); see Foot care	All charges	All charges
Reconstructive surgery
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. Treatment of port wine stains on the face of members 18 years or younger All stages of breast reconstruction surgery following a mastectomy, such as: - surgery to produce a symmetrical appearance of breasts;