CALL — THE HEALTH CARE FRAUD HDHPTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-344-8858 or write to us at 2600 Sixth Street SW, Canton, Oh 44710. You may also request replacement cards through our Web site: www.aultcare.com.

Where you get covered care

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

HDHP Plan: You will only pay deductibles and coinsurance and you will not have to file claims.

Network providers and facilities

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. The list is also on our Web site.

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.

Out-of-network providers and facilities

Better Plan benefits are available when you use AultCare Providers. In order to receive maximum Plan benefits, you must use the services of Aultman Hospital and the Physicians within the AultCare network. If, on the other hand, you use a Non-AultCare Provider, lesser benefit amounts may be payable. Should you be referred by an AultCare Provider to a Non-AultCare Provider, and the referral is approved by AultCare, benefits are payable as if provided by an AultCare Provider up to the Usual, Customary and Reasonable (UCR) fee. If the referral is not approved by AultCare, you will be subject to a reduction in benefits.

What you must do to get covered care

HMO Plan: 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.

HDHP Plan: You can get care from any "covered provider" or "covered facility." How much we pay – and you pay – depends on the type of covered provider or facility you use. If you use our preferred providers, you will pay less.

Primary care

HMO Plan: only: Your primary care physician can be a family practitioner, internist, and 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

HMO Plan: Your primary care physician will refer you to a specialist for needed 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 see obstetrician/gynecologist without a referral.

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

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

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

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

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

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

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

- Reduce our service are 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

HMO Plan: 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 1-800-344-8858. 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.

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

1-800-344-8858.

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

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

We call this review and approval process precertification. Precertification is required for all non-AultCare admissions and all Home Health Care programs. You must notify the AultCare Utilization Department prior to any planned non-AultCare admissions or to any Home Health Care program.

Other services requiring precertification include:

Partial hospitalization programs provided out-of-network;

Intensive out patient programs provided out-of-network;

Rehabilitation facility admissions;

Skilled nursing facility admissions;

Hospice Care;

Therapies, including physical, occupational, speech, cognitive and growth hormone;

Mental Health and Substance Abuse; and

Certain Drugs

HDHP Plan: Pre-Certification: The process known as pre-certification is an evaluation of your medical case by your provider and AultCare medical professionals to determine the appropriateness of your Hospital admission and expected length of stay. In some cases, an alternative to Hospital admission, such as outpatient treatment, may be recommended.

If your medical professional is an AultCare Provider, the pre-certification process will be handled for you by your provider when required. You are only responsible for alerting your provider that you are an AultCare participant. However, if your medical professional is not an AultCare Provider, you are responsible for seeing that utilization review procedures are followed. Contact the Utilization Review Department or the Service Center at 1-800-344-8858. The Utilization Review Department will handle pre-certification and tell you if a second opinion is necessary for the procedure being done and/or if outpatient surgery is required.

Depending on the circumstances and time constraints of your situation, you may be asked to have a form completed. When possible, utilization requirements will be met with a simple phone call by the Utilization Review Department to your Doctor.

Failure to meet pre-certification requirements for Non-Panel Hospital admissions will result in a reduction of benefits.

Referral Procedure: Upon occasion, it may be necessary for your AultCare Provider to refer you to a Physician outside the AultCare Network. In order for you to receive the greatest benefit possible from your AultCare Plan, the following procedure must be followed:

Your AultCare Provider must contact the pre-admission coordinator at the AultCare Utilization Management Department to explain the circumstances of the referral. This can be done by telephone or by completing a referral form available to the Physician.

The completed referral request will be reviewed by the AultCare Medical Director. You and your Physician will be contacted directly as to whether the referral has been approved. If you do not receive written confirmation of your referral, please contact the AultCare Utilization Management Department at 1-800-344-8858 prior to your appointment at the Non-AultCare Provider. When a referral is approved, benefits will be payable as outlined for other AultCare Providers, subject to UCR limitation.

When a referral is not approved, or the above procedure is not followed, benefits are payable as outlined for other Non-AultCare Providers.

Case Management: The goal of AultCare's Medical Case Management is managing the high cost of catastrophic illnesses while maintaining quality of care. Case management is used to describe a number of different approaches to planning, coordinating, providing and financing medical care. Case Management requires the simultaneous cooperation of AultCare, the Physician, the patient, and the patient's family. Telephonic follow up is provided to create and evaluate a goal oriented treatment plan. The focus of case management can include, but is not limited to, chronic disease states such as diabetes, COPD, or CHF, complex or catastrophic cases. Medical Case Management programs develop an individual plan designed to coordinate and mobilize health care resources to address specific medical problems and patient needs. The result should be a claim savings through effective medical management.

Copayments

HMO Plan: 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 physician you pay a copayment of $10 per visit.

HDHP Plan: There are no copayments in the HDHP.

Deductible

HMO Plan: There is no deductible under the HMO.

HDHP 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 them.

If you use PPO providers, the calendar year deductible is $2,000 per person. Under a family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $4,000. If you use non-PPO providers, your calendar year deductible increases to a maximum of $4,000 per person ($8,000 per family). Whether or not you use PPO providers, your calendar year deductible will not exceed $6,000 per person ($12,000 per family).

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.

And, if you change from Self and Family to Self Only, or from Self Only to Self and Family during the year, we will credit the amount of covered expenses already applied toward the deductible of your old enrollment to the deductible of your new enrollment.

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.

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance

HMO Plan: There is no coinsurance under the HMO.

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

Example: You pay 20% of our allowance for a Preferred Provider

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

For example, if your physician ordinarily charges $100 for a service but routinely waives your 20% coinsurance, the actual charge is $80. We will pay $64 (80% of the actual charge of $80).

Your catastrophic protection out-of-pocket maximum

HMO Plan: There is no catastrophic protection out of pocket maximum.

HDHP Plan: There is a limit to the amount you must pay out-of-pocket for coinsurance for the year for certain charges. When you have reached this limit, you pay no coinsurance for covered services for the remainder of the calendar year.

PPO benefit: Your out-of-pocket maximum is $4,000 for a Self Only and $8,000 for Self and Family enrollment if you are using PPO providers. Only eligible expenses for PPO providers count toward this limit.

Non-PPO benefit: Your out-of-pocket maximum is $8,000 for a Self Only and $16,000 for a Self and Family enrollment if you are using Non-PPO providers. Eligible expenses for network providers also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers.

Out-of-pocket expenses for the purposes of this benefit are:

The 20% you pay for PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services

The 40% you pay for non-PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services; and

The following cannot be included in the accumulation of out-of-pocket expenses:

Expenses in excess of our allowance or maximum benefit limitations

Expenses for out-of-network mental health or substance abuse

Any amounts you pay because benefits have been reduced for non-compliance with this Plan's cost containment requirements (see pages 13, 14, 15 and 16)

Expenses in excess of Plan maximums

Carryover

If you enrolled in our Plan during Open Season and your effective date is after January 1, your previous plan will be responsible for any medical care you received before your coverage in our Plan began. The old plan will pay your covered costs under this year's benefits since benefit changes start on January 1. If you did not meet your out-of-pocket maximum under your old plan last year, your covered out-of-pocket expenses will be applied to that maximum. If you did meet that maximum, your old plan's catastrophic protection benefit will continue to apply until your effective date in our Plan.

Differences between our allowance and the bill

In-network providersagree to limit what they will bill you. Because of that, when you use a network provider, your share of covered charges consists your copayments (HMO Plan only) or your deductible and coinsurance (HDHP Plan only).

HDHP Plan: Here is an example about coinsurance: You see a network physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just – 20% of our $100 allowance ($20). Because of the agreement, your network physician will not bill you for the $50 difference between our allowance and his bill.

Out-of-network providers, on the other hand, have no agreement to limit what they will bill you. When you use an out-of-network provider, you will pay your deductible and coinsurance – plus any difference between our allowance and charges on the bill. Here is an example: You see an out-of-network physician who charges $150 and our allowance is again $100. Because you've met your deductible, you are responsible for your coinsurance, so you pay 40% of our $100 allowance ($40). Plus, because there is no agreement between the out-of-network physician and us, he can bill you for the $50 difference between our allowance and his bill.

The following table illustrates the examples of how much you have to pay out-of-pocket for services from an in-network physician vs. an out-of-network physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The table shows the amount you pay if you have met your calendar year deductible.

Physician's charge

$150

$150

Our allowance

We set it at: 100

We set it at: 100

We pay

80% of our allowance: 80

60% of our allowance: 60

You owe: Coinsurance

20% of our allowance: 20

40% of our allowance: 40

+Difference up to charge?

No: 0

Yes: 50

TOTAL YOU PAY

$20

$90

When Government facilities bill us

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

If we overpay you

We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments.

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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.

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

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Professional services of physicians

In physician's office

In an urgent care center

Office medical consultations

Second surgical opinion

$10 per office visit

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise, $10 per office visit

Routine screenings, such as:

Physicals

Total Blood Cholesterol

Colorectal Cancer Screening, including

- Fecal occult blood test

- Sigmoidoscopy, screening – every five years starting at age 50

$10 per office visit

Routine Prostate Specific Antigen (PSA) test

$10 per office visit

Routine pap test

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

$10 per office visit

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

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

From age 40 through 64, one every calendar year

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

Nothing

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

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

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)

$10 per office visit

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery.

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

We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5.1c) and Surgery benefits (Section 5.1b).

Nothing

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 5.1b)

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

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

$10 per office visit

Not covered:

Reversal of voluntary surgical sterilization

Genetic counseling.

Elective abortion

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 injectible fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

$10 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

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 30

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. Call 1-800-344-8858 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

$10 per office visit

60 visits per conditionfor the services of each of the following:

qualified physical therapists and

occupational therapists

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

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided.

$10 per outpatient visit

Nothing per visit during covered inpatient admission.

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

Speech therapy

60 visits per condition for the services of speech therapists.

$10 per office visit

First hearing aid and testing only when necessitated by accidental injury

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

$10 per office visit

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye, annual eye refractions (to provide a written lens prescription) may be obtained from Plan providers.

$10 per office visit

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

$10 per office visit

Eye exam to determine the need for vision correction for children and adults

Coverage includes:

one complete refractory eye examination by a Plan provider every 24 months; and

one set of prescribed frames with a $55 maximum Plan payment; or

one set of single vision lenses with a $35 maximum Plan payment; or

one set of bi-focal lenses with a $55 maximum Plan payment; or

one set of tri-focal lenses with a $150 maximum Plan payment; or

one set of prescribed contact lenses with a $150 maximum Plan payment

$10 per office visit

All charges over the maximum Plan payments

Not covered:

Eye exams from an optometrist

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.

$10 per office visit

Not covered:

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

Treatment of weak, strained or flat feet 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: Internal prosthetic devices are paid as hospital benefits; see Section 5.1(c) for payment information. Insertion of the device is paid as surgery; see Section 5.1(b) for coverage of the surgery to insert the device.

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

Nothing

Not covered:

Orthopedic and corrective shoes

Arch supports

Heel pads and heel cups

Lumbosacral supports

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

All charges.

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

Hospital beds;

Wheel Chairs;

Crutches;

Walkers;

Blood glucose monitors; and

Insulin pumps.

Note: Call us at 1-800-344-8858 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Nothing

Not covered: Motorized wheelchairs.

All charges.

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

Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered:

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

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

All charges.

Manipulation of the spine and extremities

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

$10 per office visit

Not covered:

Maintenance care

All charges.

No Benefit

All charges.

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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.

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 5.1(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF 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)

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 Section 5.1(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.

$10 per office visit; nothing for hospital visits

Not covered:

Reversal of voluntary sterilization

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 Orthopedic 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.

$10 per office visit; nothing for hospital visits

Not covered:

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

Surgeries related to sex transformation

All charges.

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

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

Removal of stones from salivary ducts;

Excision of leukoplakia or malignancies;

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

TMJ treatment and services(non-dental); and

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

$10 per office visit; nothing for hospital visits

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; epit