CALL — THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Primary Care Office visit

$10 Copayment per visit

$15 Copayment per visit

Specialist's Office Visit

$10 copayment per visit

$20 copayment per visit

Emergency Urgent Care Center

$20 copayment per visit

$30 copayment per visit

Emergency Room

$40 copayment per visit

$50 copayment per visit

Outpatient Surgical Facility

No charge

$50 copayment per visit

Inpatient Hospital
(including emergency admissions)

No charge

$50 copayment per day up to a maximum of $250 per member per year

Prescription Drugs

$10 generic

$20 formulary brand-name

$35 non-formulary brand-name for up to 34 day supply,

$15 generic

$25 formulary brand-name

$40 non-formulary brand-name for up to 34 day supply,

Mail Order Prescription Drugs

2 times the above copays for up to a 100 day supply through mail order

2 times the above copays for up to a 100 day supply through mail

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 1-800-251-7722, or write to us at ConnectiCare, Inc., 175 Scott Swamp Road, Farmington, CT 06032-3124. You may also request replacement cards through our Web site at www.connecticare.com.

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 credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. This list is also on our Web site. Since the list changes it is best to contact us to confirm that a provider participates.

· 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 Web site.

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. You can choose a PCP from our provider directory. If you don't provide us with your PCP, we will select one for you, which you can change at any time by calling 1-800-251-7722.

· Primary care

Your primary care physician can be a family practitioner, internist, general practitioner or a pediatrician. 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

Members may see any participating doctor for covered services without a referral with the following exceptions.

For information on how to obtain specialty care services, contact us at 1-800-251-7722.

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

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

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

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

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

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

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

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

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

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

· Hospital care

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

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-251-7722. If you are new to the FEHB Program, we will arrange for you to receive care.

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

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

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

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

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

Circumstances beyond our control

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

Services requiring our prior approval

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

We call this review and approval process Plan authorization.

Your doctor will get Plan authorization for: hospital admissions (except out-of-service area emergencies), outpatient alcohol and substance abuse treatment, home health care, out-of-Plan services (nonparticipating providers), human organ transplants, and skilled nursing facilities. For a complete listing, call our Member Services Department at 1-800-251-7722.

For information on how to obtain specialty care services, contact us at 1-800-251-7722.

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 $100 per admission.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible. We do not have a deductible on our overall Plan.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. DME has coinsurance.

Your catastrophic protection out-of-pocket maximum

Copayments for services are minimal. The plan provides unlimited benefits (except as noted in the plan document) for covered services.

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

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

Plan physicians must provide or arrange your care.

We have no calendar year deductible, except for DME.

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

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Professional services of physicians

In Primary Care Physician's office

In Specialist's office

$15 per office visit

$20 per office visit

Professional services of physicians

In an urgent care center

During a hospital stay

In a skilled nursing facility

Office medical consultations

Second surgical opinion

$30 per office visit

Nothing.

Nothing for up to 90 days per calendar year.

$15 for PCP, $20 for Specialists, per office visit.

$15 for PCP, $20 for Specialists, per office visit.

At home

$15 for PCP, $20 for Specialists, per visit.

Vaccines for pediatric and adult immunizations

Nothing if you receive these services during your office visit.

Not covered

Nondental treatment of temporomandibular joint (TMJ) syndrome

Services for which a member has no responsibility to pay

Services for intentionally inflicted injuries

Services for injuries resulting from hazardous activities

Injuries received in connection with the commission of a felony

All charges

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

$15 in a Primary Care Physician's office,

$20 in a Specialist's office

Routine screenings, such as periodic check-ups and routine immunizations including those tests as ordered by your doctor.

Total Blood Cholesterol

Colorectal Cancer Screening, including

Fecal occult blood test

Sigmoidoscopy, screening - every five years starting at age 50

Double contrast barium enema - every five years starting at age 50

Colonoscopy screening - every ten years starting at age 50

$15 per office visit

$20 in a Specialist's office

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

Routine pap test

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

$15 per office visit

$15 per office visit

$20 in a Specialist's office

Routine mammogram - covered for women age 35 and older, as follows:

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

From age 40 through 64, one every calendar year

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

$15 per office visit

$20 in a Specialist's office

Routine immunizations, limited to:

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

Influenza vaccine, annually

Pneumococcal vaccine, age 65 and older

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

$20 in a Specialist's office

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

All charges.

Childhood immunizations recommended by the American Academy of Pediatrics

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

$20 in a Specialist's office

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

Examinations, such as:

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

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

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

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

$20 in a Specialist's office

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 12 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.

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

$15 for initial visit, then nothing.

$20 in a Specialist's office

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

All charges.

A range of voluntary family planning services, limited to:

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

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

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

$15 per office visit

$20 in a Specialist's office

Not covered:

Reversal of voluntary surgical sterilization

Genetic counseling.

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

Fertility drugs

Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

$20 per office visit

Not covered:

Assisted reproductive technology (ART) procedures, such as:

in vitro fertilization

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

Services and supplies related to ART procedures

Cost of donor sperm

Cost of donor egg

All charges.

Testing and treatment

Allergy injections

$20 per office visit

Allergy serum

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 29.

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 only cover GHT when we preauthorize the treatment. Your doctor would have to submit your case in writing to the Plan. Your case will be reviewed for medical necessity and, if approved, you may then seek treatment.

Nothing.

Not covered:

All charges.

60 visits per condition per calendar year for the services for each of the following:

qualified physical therapists and

occupational therapists

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

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided as part of your rehabilitation.

$20 per office visit

$20 per outpatient visit

Nothing per visit during covered inpatient admission

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

60 visits per condition per calendar year

$20 per office visit

$20 per outpatient visit

Nothing per visit during covered inpatient admission.

Not covered:

Non-authorized, non-medically necessary treatment

All charges.

First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 17 (see Preventive care,
children)

$15 copayment in PCP office;

$20 copayment in specialist's office

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

Our vision program includes frames and lenses, prescription contact lenses available only at Plan routine vision providers (offered at various discounts, not a $10 copay). For a full description of the Vision Care Coverage, please see the routine vision information located in the enrollment packet.

25% discount on frames and lenses at or below $250; 30% discount over $250 at plan vision providers

One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

Eye exam to determine the need for vision correction for children through age 17 (see Preventive care, children)

Annual eye refractions once per calendar year, when obtained by Plan providers

25% discount on frames and lenses at or below $250; 30% discount over $250 at plan vision providers.

$15 per office visit

$15 per office visit

Not covered:

Eyeglasses or contact lenses and after age 17, examinations for them

Eye exercises and orthoptics

Radial keratotomy and other refractive surgery

All charges.

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

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

$15 copayment in PCP office;

$20 copayment in a specialist's office

Not covered:

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

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

All charges.

Artificial limbs and eyes; stump hose

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

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

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: Internal prosthetic devices are paid as hospital benefits; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b) for coverage of the surgery to insert the device.

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

$15 copayment in PCP office

$20 copayment in a specialist's office

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

Prosthetic replacements provided less than 3 years after the last one we covered

All charges.

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

Hospital beds;

Wheelchairs; (Motorized chairs covered only with plan approval of doctor's written request detailing medical necessity);

Crutches;

Walkers;

Blood glucose monitors; and

Insulin pumps.

Note: Call us at 1-800-251-7722 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

$100 deductible per calendar year and 20% of charges up to a maximum Plan payment of
$1,500 per calendar year.

Note: Prior Plan authorization is required and coverage is limited to the initial acquisition.

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

Services include oxygen therapy, intravenous therapy and medications.

Nothing.

Not covered:

Nursing care requested by, or for the convenience of, the patient or the patient's family;

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges.

Manipulation of the spine and extremities; 20 visits per calendar year

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

$20 per office visit

Alternative treatments - continued on next page

Acupuncture - by a doctor of medicine or osteopathy for: anesthesia, pain relief

All charges.

Not covered:

Naturopathic services

Hypnotherapy

Biofeedback

All charges.

Diabetes, Heart, Asthma and Smoking Cessation programs are available. Information can be obtained by calling Member Services at 1-800-251-7722.

Nothing.

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

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

Plan physicians must provide or arrange your care.

We have no calendar year deductible except for DME.

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

The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).

YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

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A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

$15 copayment in PCP office

$20 per office visit

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

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

Treatment of burns

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

Nothing (when approved in advance by Plan.)

Nothing.

$15 copayment in PCP office

$20 per office visit

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care

All charges.

Surgery to correct a functional defect

Surgery to correct a condition caused by injury or illness if:

the condition produced a major effect on the member's appearance and

the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:

surgery to produce a symmetrical appearance of breasts;

treatment of any physical complications, such as lymphedemas;

breast prostheses and surgical bras and replacements (see Prosthetic devices)

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

$15 copayment in PCP office

$20 per office visit

Not covered:

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

Surgeries related to sex transformation

All charges.

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

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

Removal of stones from salivary ducts;

Excision of leukoplakia or malignancies;

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

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

· Oral surgery services: Medically necessary oral surgical services for
the treatment of tumors, cysts (of non-dental origin), injuries of the facial bones and for the treatment of fractures and dislocations involving the face and jaw, including temporamandibular joint (TMJ) dysfunction surgery (for demonstrable joint disease only) provided by a Participating Physician are covered. Certain oral surgery requires Pre-Authorization.

$15 copayment in PCP office

$20 per office visit

Not covered:

Oral implants and transplants

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

All charges.

Limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

Lung: Single - Double

Pancreas

Allogeneic (donor) bone marrow transplants

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

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

National Transplant Program (NTP)

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

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

$50 per day up to a maximum of $250 per member per year for inpatient hospital procedures

Note: Plan authorization is required at the time of diagnosis, prior to any evaluative services and will only be authorized at Plan facilities, contracted Centers of Excellence.

Not covered:

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

Implants of artificial organs

Transplants not listed as covered

All charges.

Professional services provided in -

Hospital (inpatient)

Nothing

Professional services provided in -

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Office

$20 per visit

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

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

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

We have no calendar year deductible, except for DME.

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

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

YOUR PHYSICIANMUSTGETPRECERTIFICATIONFORHOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

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Benefit Description

You pay

Inpatient hospital

Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets.

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

$50 per day up to a maximum of $250 per member per year