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A Managed Fee- for- Service Plan with a Preferred Provider Organization and a Point- of- Service Product Administered by the Blue Cross and Blue Shield Association

Who may enroll in this Plan: All Federal employees and annuitants who are eligible to enroll in the FEHBP.

Enrollment code for this Plan: 101 High Option Self Only 102 High Option Self and Family 104 Standard Option Self Only 105 Standard Option Self and Family

Visit the OPM website at http:// www. opm. gov/ insure and

this Plans website at http:// www. fepblue. org

Authorized for distribution by the:

1999 Blue Cross and Blue Shield

Service Benefit Plan

United States Office of Personnel Management

RI 71- 5

For chan ges

i n b

enefits see page 57

Blue Cross and Blue Shield Service Benefit Plan

The Blue Cross and Blue Shield Association (Carrier), on behalf of Blue Cross and Blue Shield Plans, has entered into Contract No. CS 1039 with the Office of Personnel Management (OPM) to provide a health benefits plan (Plan) authorized by the Federal Employees Health Benefits (FEHB) law. The Plan is underwritten by Participating Blue Cross and Blue Shield Plans which administer this Plan on behalf of the Carrier and are referred to as Local Plans in this brochure. The FEHB contract specifies the manner in which it may be modified or terminated.

This brochure is the official statement of benefits on which you can rely. It describes the benefits, exclusions, limitations, and maximums of the Blue Cross and Blue Shield Service Benefit Plan for 1999 until amended by future benefit negotiations between OPM and the Carrier. It also describes procedures for obtaining benefits. You should use this brochure to determine your entitlement to benefits. Oral statements cannot modify the benefits described in this brochure.

An enrollee does not have a vested right to receive the benefits in this brochure in 2000 or later years, and does not have a right to benefits available prior to 1999 unless those benefits are contained in this brochure.

Inspector General Advisory: Stop Health Care Fraud!

Fraud increases the cost of health care for everyone. Anyone who intentionally makes a false statement or a false claim in order to obtain FEHB benefits or increase the amount of FEHB benefits is subject to prosecution for FRAUD which may result in CRIMINAL PENALTIES.

Please review all medical bills, medical records, and claims statements carefully. If you find that a provider, such as a doctor, hospital, pharmacy, etc., charged your Plan for services you did not receive, billed for the same service twice, or misrepresented any other information, take the following actions:

Call the provider (doctor, hospital, etc.) and ask for an explanation sometimes the problem is a simple error.

If the provider does not resolve the matter, or if you remain concerned, call your Carrier at 1- 800/ FEP- 8440 and explain the situation.

If the matter is not resolved after speaking to your Carrier (and you still suspect fraud has been committed), call or write:

THE HEALTH CARE FRAUD HOTLINE 202/ 418- 3300

The Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E Street, N. W., Room 6400 Washington, DC 20415

The inappropriate use of membership identification cards, e. g., to obtain benefits for a person who is not an eligible family member or after you are no longer enrolled in the Plan, is also subject to review by the Inspector General and may result in an adverse administrative action by your agency.

When you need help with Plan benefits, or getting your ID card, call your Local Plan; check your phone book for the number. The Fraud Hotline cannot help you with these.

Using This Brochure

The Table of Contents will help you find the information you need to make the best use of your benefits. To get the best value for your money, you should read Facilities and Other Providers. It will help you understand how your choice of doctors and hospitals will affect how much you pay for services under this Plan.

This brochure explains all of your benefits. Its important that you read about your benefits so you will know what to expect when a claim is filed. Most of the benefit headings are self- explanatory. Other Medical Benefits and Additional Benefits, on the other hand, both include a variety of unrelated benefits. What is different about these benefits is how they are paid: Other Medical Benefits are generally paid after you satisfy the calendar year deductible and Additional Benefits are generally not subject to the calendar year deductible.

You will find that some benefits are listed in more than one section of the brochure. This is because how they are paid depends on which provider bills for the service. For example, physical therapy is paid differently depending on whether it is billed by an inpatient facility, a doctor, a physical therapist, or an outpatient facility.

The last part of the brochure contains information useful to you under certain circumstances. For example, if you have to go to the hospital you need to read Precertification; generally, hospital stays must be precertified for all payable benefits to apply. If you are enrolled in Medicare, take a look at This Plan and Medicare. And, the Enrollment Information section tells you about several FEHB enrollment requirements that could affect your future coverage.

Registered marks of The Blue Cross and Blue Shield Association

Table of Contents

How This Plan Works

Help Contain Costs................................................................................................................................................ 5

Ways you and the Carrier can work together to keep costs down

Facilities and Other Providers.............................................................................................................................. 5

Medical personnel and facilities covered by this Plan and how your choice of provider will affect what you pay for benefits

Cost Sharing........................................................................................................................................................... 9

What you need to know about deductibles, coinsurance and copayments, your share of covered health care expenses, and the maximum amounts this Plan will pay for certain types of care

General Limitations............................................................................................................................................. 11

How the Plan works if you have other health care coverage or receive health care services through another

Government program; limit on your costs if you are 65 or older and dont have Medicare

General Exclusions .............................................................................................................................................. 13

What is not covered by this Plan

Benefits

Inpatient Hospital Benefits ................................................................................................................................. 15

Your benefits for inpatient hospital and physician care (see below for mental conditions/ substance abuse care)

Surgical Benefits .................................................................................................................................................. 18

Your benefits for doctors services for inpatient and outpatient surgery and related procedures, including organ/ tissue transplants

Maternity Benefits ............................................................................................................................................... 21

Your benefits for prenatal care, childbirth, contraceptives, and infertility treatment

Mental Conditions/ Substance Abuse Benefits .................................................................................................. 23

Your benefits for outpatient, inpatient and other facility care for mental conditions, alcoholism and drug abuse

Other Medical Benefits (deductible applies) ..................................................................................................... 25

Your benefits for outpatient facility care, outpatient surgery (deductible does not apply), doctors home and office visits, routine preventive services, ambulance transport services, dental care for accidental injury, durable medical equipment (e. g., crutches and hospital beds), home nursing services, allergy tests and injections, chemotherapy, radiation therapy, physical, occupational, and speech therapy, and smoking cessation

Additional Benefits (no deductible).................................................................................................................... 29

Your benefits for preventive services provided by Preferred providers, well child care, outpatient care for accidental injury, home health care (High Option only), home hospice care, and skilled nursing facility (SNF) care

Prescription Drug Benefits.................................................................................................................................. 32

Your benefits for prescription drugs and supplies you get from pharmacies or by mail order

Standard Option Dental Benefits ....................................................................................................................... 34

Your Standard Option benefits for dental care

How to Claim Benefits......................................................................................................................................... 36

Getting your claims paid when your provider does not file them for you; how to ask OPM to review a claims dispute between you and the Carrier

Protection Against Catastrophic Costs .............................................................................................................. 40

The maximum amount of covered expenses you can expect to pay for health care

Table of Contents continued

Other Information

Information You Have a Right to Know ........................................................................................................... 41 Precertification..................................................................................................................................................... 41

Hospital stays generally must be precertified to avoid a $500 benefit reduction

This Plan and Medicare ...................................................................................................................................... 43

Information you need if you are covered by Medicare

Enrollment Information...................................................................................................................................... 45

Your enrollment in the Federal Employees Health Benefits Program and how to maintain FEHB coverage when enrollment ends

Definitions............................................................................................................................................................. 48

Explanations of some of the terms used in this brochure

Index...................................................................................................................................................................... 53

List of covered benefits and services, by page number

Non- FEHB Benefits ............................................................................................................................................. 54

Other services available to members of this Plan

How This Plan Changes

How the Blue Cross and Blue Shield Service Benefit Plan Changes January 1999 ...................................... 57

Summary of Benefits

High Option.......................................................................................................................................................... 58 Standard Option .................................................................................................................................................. 59

1999 Rate Information

Rates...................................................................................................................................................................... 60 Get the most value for your benefit dollar.

Use a Preferred provider when selecting your health care practitioner. Your outof- pocket expenses will be reduced and the provider will submit claims for you. Your next best choice is a Participating provider, one who accepts the Participating Provider Allowance as payment in full. If you use a Nonparticipating provider, your out- of- pocket costs will increase.

When you call to obtain precertification, be sure also to verify whether the hospital is a Preferred, Member, or Non- member hospital. Use of Non- member hospitals will increase your out- of- pocket costs.

How This Plan Works

Help Contain Costs

FEHB plans are expected to manage their costs prudently. All FEHB plans have cost containment measures in place. All fee- for- service plans include two specific provisions in their benefits packages: precertification of inpatient admissions and the flexible benefits option. Some include

managed care options, such as PPOs, to help contain costs. As a result of your cooperative efforts, the FEHB Program has been able to control premium costs. Please keep up the good work and continue to help keep costs down.

Precertification evaluates the medical necessity of proposed admissions and the number of days required to treat your condition. You are responsible for ensuring that the precertification requirement is met (except for routine maternity admissions). You or your doctor must check with your Local Plan before being admitted to the hospital. If that doesnt happen, your Plan will reduce benefits by $500. Be a responsible consumer. Be aware of your Plans cost containment provisions. You can avoid penalties and help keep premiums under control by following the procedures specified on page 41 of this brochure.

Under the flexible benefits option, the Local Plan has the authority to determine the most effective way to provide services. The Local Plan may identify medically appropriate alternatives to traditional care and coordinate the provision of Plan benefits as a less costly alternative benefit. Alternative benefits are subject to ongoing review. The Local Plan may decide to resume regular contract benefits at its sole discretion. Approval of an alternative benefit is not a guarantee of any future alternative benefits. The decision to offer an alternative benefit is solely the Local Plans and may be withdrawn at any time. It is not subject to OPM review under the disputed claims process.

This Plan has established Preferred provider organization (PPO) arrangements. You can receive covered services from PPO providers at a reduced cost. Be sure to look to see if there are PPO cost savings when you review the benefits described in this brochure. The Local Plan (or for pharmacies, PCS Health Systems, Inc.) is solely responsible for the selection of PPO providers and any questions regarding PPO providers should be directed to the Local Plan (or for pharmacies, PCS Health Systems, Inc.) (see page 52 for more information). Call your Local Plan to obtain the names of PPO providers and to verify continued participation as a PPO provider.

PPO benefits apply only when you use a PPO provider. Provider networks may be more extensive in some areas than others. The availability of every specialty in all areas cannot be guaranteed. If no PPO provider is available, or you do not use a PPO provider, the standard non- PPO benefits apply.

This Plan offers a Point- of- Service (POS) program under Standard Option in the following Local Plan areas: Connecticut, Georgia, Kansas, Louisiana (New Orleans area), Massachusetts, Minnesota, New Jersey, New York (areas served by the Empire Plan), North Dakota (Fargo area), Ohio (Cincinnati area), and Oklahoma. The POS program provides a higher level of benefits when services are provided or referred by a primary care physician selected by the member, while providing Standard Option non- Preferred benefits for services received without a referral. An addendum and a POS selection form are available from the Local Plans in the areas noted above that outline service areas, benefit levels, and special requirements of the POS program.

Facilities and Other Providers

Covered facility providers include:

Preferred Freestanding Ambulatory Facility A facility with which a local Blue Cross Plan has, at the time a member is admitted or receives services, an agreement to render outpatient surgical or renal dialysis care. Other facilities determined to be Preferred facilities by a local Blue Cross Plan are Preferred freestanding ambulatory facilities for purposes of this Plan. Contact your local Blue Cross Plan to find out if the facility you plan to be admitted to, or receive services from, is a Preferred facility.

You can help Precertification Flexible benefits option

PPO POS Covered facilities

Freestanding ambulatory facilities

Facilities and Other Providers continued

Member Freestanding Ambulatory Facility A facility with which a local Blue Cross Plan has, at the time a member is admitted or receives services, an agreement to render outpatient surgical or renal dialysis care. Other facilities determined to be Member facilities by a local Blue Cross Plan are Member freestanding ambulatory facilities for purposes of this Plan.

Non- Member Freestanding Ambulatory Facility A facility that 1) is not a Preferred or Member freestanding ambulatory facility; 2) has permanent facilities and equipment for the primary purpose of performing surgical and/ or renal dialysis procedures on an outpatient basis; 3) provides treatment by or under the supervision of physicians and nursing services whenever the patient is in the facility; 4) does not provide inpatient accommodations; and 5) is not, other than incidentally, a facility used as an office or clinic for the private practice of a physician or other professional.

Preferred Hospital A hospital with which a local Blue Cross Plan has, at the time a member is admitted or receives services, an agreement to render hospital services. Other hospitals determined to be Preferred hospitals by a local Blue Cross Plan are Preferred hospitals for purposes of this Plan, including those hospitals in Hawaii determined to be Preferred hospitals by the local Blue Shield Plan. Contact your local Blue Cross Plan to find out if the hospital you plan to be admitted to, or receive services from, is a Preferred hospital.

Member Hospital A hospital with which a local Blue Cross Plan has, at the time a member is admitted or receives services, an agreement to render hospital services to members. Other hospitals determined to be Member hospitals by a local Blue Cross Plan are Member hospitals for purposes of this Plan, including those hospitals in Hawaii determined to be Member hospitals by the local Blue Shield Plan. Contact your local Blue Cross Plan to find out if the hospital you plan to be admitted to, or receive services from, is a Member hospital.

Non- Member Hospital A hospital, or distinct part of an institution, that 1) is not a Preferred or Member hospital; 2) for compensation from its patients and on an inpatient basis is engaged primarily in providing diagnostic and therapeutic facilities for surgical and medical diagnoses, treatment, and care of injured and sick persons by or under the supervision of a staff of licensed doctors of medicine (M. D.) or licensed doctors of osteopathy (D. O.); 3) continuously provides 24- hour- a- day professional registered nursing (R. N.) services; and 4) is not, other than incidentally, an extended care facility; a nursing home; a place for rest; an institution for exceptional children, the aged, drug addicts, or alcoholics; or a custodial or domiciliary institution which has as its primary purpose the furnishing of food, shelter, training, or nonmedical personal services.

College infirmaries are considered Non- member hospitals. In addition, the Carrier may, at its discretion, recognize any institution located outside the 50 states and the District of Columbia as a Non- member hospital.

Qualified Skilled Nursing Facility A facility that: 1) specializes in skilled care and meets Medicares special qualifying criteria, and

2) has the staff and equipment to provide skilled nursing care performed by, or under the supervision of, licensed nursing personnel, or skilled rehabilitation services such as physical therapy performed by, or under the supervision of, a professional therapist, and other related health services.

The term qualified skilled nursing facility does not include any institution that primarily cares for and treats mental diseases.

Cancer Research Facility A facility that is: 1) a National Cooperative Cancer Study Group institution that is funded by the National Cancer Institute (NCI) and has been approved by a Cooperative Group as a bone marrow transplant center; 2) an NCI- designated Cancer Center; or 3) an institution that has an NCI- funded, peer- reviewed grant to study allogeneic or autologous bone marrow transplants and blood stem cell transplant support.

Others as set forth within the benefits description.

Freestanding ambulatory facilities continued

Hospitals Skilled nursing facilities

Cancer research facilities

Others

Facilities and Other Providers continued

See Definitions for an explanation of Preferred rate, Member rate, Non- member rate, Average charge, and Billed charge under Covered charges.

Covered professional providers include:

Physician Doctors of medicine (M. D.), osteopathy (D. O.), dental surgery (D. D. S.), medical dentistry (D. M. D.), podiatric medicine (D. P. M.), and optometry (O. D.), when acting within the scope of their licenses, are considered physicians.

Attending Physician The physician who has responsibility for the care and treatment of the member on an inpatient basis. A consulting physician who is an employee of the hospital in which the member is an inpatient is not the attending physician.

The following are considered covered providers when they perform covered services within the scope of their license or certification:

Independent Laboratory A laboratory that is licensed under State law or, where no licensing requirement exists, is approved by the Local Plan.

Qualified Clinical Psychologist A psychologist who 1) is licensed or certified in the state where the services are performed, 2) has a doctoral degree in psychology or an allied degree if, in the individual state, the academic licensing/ certification requirement for clinical psychologist is met by an allied degree, or meets the requirements of the Carrier, and 3) has met the clinical psychological experience requirements of the individual State Licensing Board.

Nurse Midwife A person who is certified by the American College of Nurse Midwives or is licensed or certified as a nurse midwife in states requiring licensure or certification.

Nurse Practitioner/ Clinical Specialist A person who 1) has an active R. N. license in the United States, 2) has a baccalaureate or higher degree in nursing, and 3) is licensed or certified as a nurse practitioner or clinical nurse specialist in states requiring licensure or certification.

Clinical Social Worker A social worker who 1) has a masters or doctoral degree in social work, 2) has at least two years of clinical social work practice, and 3) in states requiring licensure, certification, or registration, is licensed, certified, or registered as a social worker where the services are rendered.

Nursing School Administered Clinic A clinic that is 1) licensed or certified in the state where the services are performed, and 2) provides ambulatory care in an outpatient setting primarily in rural or inner- city areas where there is a shortage of physicians. Services billed for by these clinics are considered outpatient office services rather than facility charges.

Others as set forth within the benefits description. Within States designated as medically underserved areas, any licensed medical practitioner will be treated as a covered provider for any covered services performed within the scope of that license. For 1999, the States designated as medically underserved are: Alabama, Idaho, Louisiana, Mississippi, New Mexico, North Dakota, South Carolina, South Dakota, and Wyoming.

There are four types of Allowable charges: the Preferred Provider Allowance (PPA), which applies to charges from Preferred professional providers and pharmacies; the Participating Provider Allowance (PAR), which applies to charges from Participating professional providers; the Nonparticipating Provider Allowance (NPA), which applies to charges from Non- participating professional providers; and the Average Wholesale Price (AWP), which applies to charges from Non- preferred pharmacies. (See Definitions for an explanation of Allowable charges under Covered charges, and Preferred, Participating, and Non- participating physicians.) Most Preferred physicians accept 100% of the PPA as payment in full (see page 8 for exceptions). In most cases, when you use a Preferred physician, you are responsible for your coinsurance (after any applicable deductible has been met), and are not responsible for any covered expense in excess of the PPA.

Note: Providers who participate with more than one Plan may be Preferred in one area and Participating in a different area. In those instances, the Allowable charge is determined by the providers status in the Plan area where services are rendered. Preferred provider status is indicated in the Preferred provider network directory of the Plan where services are rendered. To verify the status of a provider, contact the Local Plan serving the area where services are rendered.

How facilities are paid

Covered providers Coverage in medically underserved areas

How providers are paid

Facilities and Other Providers continued

Participating physicians usually accept 100% of the Local Plans PAR as payment in full. That means when you use a Participating physician, you are usually only responsible for your coinsurance for covered services (after any applicable deductible has been met), and are not responsible for any covered expense in excess of the PAR. In some Plan areas, physicians who were formerly Participating physicians are now Preferred physicians for the purposes of this Plan.

In the following areas, there are Preferred physicians but no Participating physicians for the purposes of either option of this Plan:

Alabama Mississippi Puerto Rico Alaska New Jersey South Carolina Connecticut New York areas served Tennessee Hawaii by the Empire Plan Utah Illinois

Non- participating physicians, on the other hand, may, but are not required to, accept the Local Plans NPA as payment in full. These physicians may bill you up to their charge, even after the Local Plan has paid its portion of your bill. Members may be held responsible for any amounts over the NPA, in addition to applicable coinsurance amounts, copayment amounts, amounts applied to the calendar year deductible, and noncovered services. It is important that you are aware that your out- ofpocket costs may be higher when you use Non- participating physicians.

In all Local Plan areas other than those described below, Preferred physicians will accept 100% PPA as payment in full and Participating physicians will accept 100% PAR as payment in full for covered services. As a result, members are only responsible for applicable coinsurance amounts, copayment amounts, amounts applied to the calendar year deductible, and noncovered services. Any balance above the applicable Allowable charge (PPA or PAR) billed by a Preferred or Participating physician under either High Option or Standard Option should be brought to the attention of the Local Plan.

In Arizona, if there is secondary coverage not administered by this Plan, or other source of payment, Preferred and Participating physicians are not obligated to accept the PPA or PAR as payment in full.

In Puerto Rico, Preferred physicians can collect the difference between the Plans payment and the physicians charge.

In Montana, Preferred and Participating physicians can collect the difference between the Plans payment and the physicians charge.

In Pennsylvania and Utah, the agreement described above applies only when the Local Plan makes a payment as the secondary payer to other coverage (see pages 11- 13).

In the following areas, Preferred and Participating physicians can collect the difference between the Plans payment and the physicians charge except when this Plan pays secondary to other Blue Cross and Blue Shield coverage:

New York areas served South Carolina by the Rochester* Plan Vermont Rhode Island West Virginia*

*The above agreement applies only when the primary coverage is administered by the same Local Plan.

The Washington, DC Plan processes overseas claims (see page 37 for instructions on submitting overseas claims) at Preferred levels based on an Overseas Fee Schedule. Members are responsible for the difference between the Plans payment and the providers charge.

How providers are paid continued

When this Plan pays primary or secondary benefits

Exception when this Plan pays primary

Exceptions when this Plan pays secondary

Areas outside the United States and Puerto Rico

Cost Sharing

A deductible is the amount of expense an individual must incur for covered services and supplies before the Plan starts paying benefits for the expense involved. A deductible is not reimbursable by the Plan and benefits paid by the Plan do not count toward a deductible. When a benefit is subject to a deductible, only expenses allowable under that benefit count toward the deductible.

The calendar year deductible is the amount of expenses an individual must incur for covered services and supplies each calendar year before the Plan pays certain benefits. The calendar year deductible is $150 per person under High Option and $200 per person under Standard Option. The calendar year deductible applies to all covered services and supplies except for certain Inpatient Hospital

Benefits, Facility Benefits Outpatient Surgery, Additional Benefits, Prescription Drug Benefits,

Standard Option Dental Benefits, or, under High Option, Surgical Benefits and Maternity Benefits.

If the Billed charge for services you receive is less than the remaining portion of your deductible, you pay the Billed charge. If the Billed charge is more than the remaining portion of your deductible, you pay the remaining portion, and you and the Plan pay the stated percentage of the amount of the Covered charge remaining, if any (see the discussion of coinsurance on page 10).

If you change options in this Plan during the calendar year, the amount of covered expenses already applied toward the deductible of your old option will be credited to the deductible of your new option.

The per admission deductible is the amount of covered hospital room and board expenses an individual must incur during each Non- preferred hospital admission before the Plan pays benefits. The per admission deductible is $100 under High Option and $250 under Standard Option.

The prescription drug deductible is the amount of covered retail pharmacy- obtained drug expenses an individual must incur each calendar year before the Plan pays retail pharmacy drug benefits. The prescription drug deductible is $50 per person under High and Standard Options. Prescription drugs not obtained from a retail pharmacy, such as those provided to you by your physician, are eligible for Other Medical Benefits and are subject to the calendar year deductible.

Drugs obtained through the Mail Service Prescription Drug Program are not subject to any deductible and are eligible for benefits only as described on page 33.

If you changed to this Plan during open season from a plan with a deductible and the effective date of the change was after January 1, any expenses that would have applied to that plans deductible in the prior year will be covered by your old plan if they are for care you got in January before the effective date of your coverage in this Plan. If you have already met the deductible in full, your old plan will reimburse these covered expenses. If you have not met it in full, your old plan will first apply your covered expenses to satisfy the rest of the deductible and then reimburse you for any additional covered expenses. The old plan will pay these covered expenses according to this years benefits; benefit changes are effective on January 1.

There is a separate calendar year deductible of $150 per person under High Option and $200 per person under Standard Option, as well as a prescription drug deductible of $50 per person under

High and Standard Options. 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 $300 under High Option and $400 under

Standard Option.

Similarly, under a family enrollment, when the combined covered retail pharmacy- obtained drug expenses applied to the prescription drug deductible for family members reach $100 under High Option or Standard Option during a calendar year, the family prescription drug deductible is satisfied and retail pharmacy- obtained drug expenses are payable for all family members. Family members may contribute to the deductible in increments lower than $50.

Deductibles Calendar year

Hospital admission Prescription drugs

Carryover Family limit

Cost Sharing continued

Coinsurance is the stated percentage of Covered charges you must pay after you have met any applicable deductibles. The Plan will base this percentage on either the Billed charge or the Allowable charge, whichever is less. For instance, when the Plan pays 80% of the Allowable charge (see Definitions) for a covered service, you are responsible for the coinsurance, which is 20% of the

Allowable charge. In addition, you will be responsible for any excess charge over the Plans Allowable charge when you use a Non- participating physician or pharmacy. For example, if a Nonparticipating physician ordinarily charges $100 for a service, but the Plans Allowable charge is $95, the Plan will pay 80% of the Allowable charge ($ 76). You must pay the 20% coinsurance of the Allowable charge ($ 19), plus the difference between the Billed charge and the Allowable charge ($ 5), for a total member responsibility of $24. Remember, if you use Preferred or Participating physicians and pharmacies, your share of Covered charges (after meeting any deductible) is limited to the stated coinsurance amounts based on the Allowable charge in most Local Plan areas (see page 8 for exceptions). If you use Non- participating physicians or pharmacies, your out- of- pocket costs will be higher, as shown in the example above.

Your local Blue Cross and Blue Shield Plan negotiates payment arrangements with Preferred and Member hospitals and other facilities, and with Preferred and Participating physicians and other professional providers, that result in overall cost containment. The amounts these providers agree to accept as payment in full are generally, but not always, lower than the Billed charge (see Definitions for an explanation of Preferred and Member rates, Preferred and Participating Provider Allowances, and Billed charge under Covered charges). For services of these providers, your coinsurance will be based on the lesser of the Billed charge or the negotiated amount that these providers have agreed to accept, including any savings the Local Plan realizes through discounts that are known and that can be accurately calculated at the time your claim is processed. If you are age 65 or older and not enrolled in Medicare, this may not apply (see page 12). If you use Non- member facilities for inpatient care, the Plan will pay its percentage based on the Billed charge or Average charge (see Definitions under Covered charges). You will be responsible for the coinsurance calculated on the Billed charge or Average charge and any excess charge over the Average charge.

A copayment is the stated amount the Plan may require you to pay for a covered service, such as $12 per prescription by mail or $12 per office visit charge at a Preferred physician. For instance, when you visit a Preferred physician for a covered service, after you pay the $12 copayment, the Plan pays the remainder of the Preferred Provider Allowance (PPA).

For outpatient facility care and inpatient and outpatient mental conditions/ substance abuse care in Preferred and Member hospitals, you are responsible for the least of the sum of the applicable per day copayments, the Billed charge, or the Preferred or Member rate, after you have met any applicable deductibles. For example, if you receive four days of inpatient mental condition care at a Member hospital for which your copayments are $1,000 (4 x $250), the Billed charge is $900, and the Member rate is $800, you will be responsible for the Member rate ($ 800). For Non- member facilities, you will be responsible for the lesser of the sum of your copayments or the Billed charge.

If a provider routinely waives (does not require you to pay) your share of the charge for services rendered, the Plan is not obligated to pay the full percentage of the amount of the providers original charge it would otherwise have paid. A provider or supplier who routinely waives coinsurance, copayments, or deductibles is misstating the actual charge. This practice may be in violation of the law. The Plan will base its percentage on the fee actually charged. For example, if the provider ordinarily charges $100 for a service but routinely waives the 20% coinsurance, the actual charge is $80. The Plan will pay $64 (80% of the actual charge of $80).

Under High and Standard Options, benefits are limited to $100 per person per lifetime for one smoking cessation treatment program (see page 28).

Under High and Standard Options, inpatient care for treatment of alcoholism and drug abuse is limited to one treatment program (28- day maximum) per person per lifetime (see page 24).

When an enrollee changes options within the Blue Cross and Blue Shield Service Benefit Plan, each enrollee and covered family member is entitled to new benefits subject to the deductibles, limitations, exclusions, and definitions of the new option. Benefit amounts accrued under High Option or Standard Option are accumulated in a permanent record regardless of the number of enrollment changes.

Coinsurance Copayments

If provider waives your share

Lifetime maximums

General Limitations

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable when determined by the Carrier to be medically necessary. Coverage is provided only for services and supplies that are listed in this brochure. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this brochure, convey or void any coverage, increase or reduce any benefits under the Plan or be used in the prosecution or defense of a claim under the Plan. This brochure is the official statement of benefits on which you can rely.

This section applies when you or your family members are entitled to benefits from a source other than this Plan. You must disclose information about other sources of benefits to the Carrier and complete all necessary documents and authorizations requested by the Carrier.

If you or a covered family member is enrolled in this Plan and Part A, Part B, or Parts A and B of Medicare, the provisions on coordination of benefits with Medicare described on pages 43- 45 apply.

Coordination of benefits (double coverage) applies when a person covered by this Plan also has, or is entitled to benefits from, any other group health coverage, or is entitled to the payment of medical and hospital costs under no- fault or other automobile insurance that pays benefits without regard to fault. Information about the other coverage must be disclosed to this Carrier.

When there is double coverage, one plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced benefit as the secondary payer. When this Plan is the secondary payer, it will pay the lesser of 1) its benefits in full, or 2) a reduced amount that, when added to the benefits payable by the other coverage, will not exceed 100% of the Covered charges for the service. When

this Plan pays secondary, it will generally only make up the difference between the primary plans benefit payment and this Plans coverage subject to this Plans applicable deductibles, coinsurance and copayments (see pages 43- 44 for exceptions when Medicare is the primary payer). Thus, the combined payments from both plans may not equal the entire amount billed by the provider. In certain circumstances, where there is no adverse effect on the member, this Plan may also take advantage of any provider discount arrangements the primary plan may have and make up only the difference between the primary plans payment and the amount the provider has agreed to accept as payment in full from the primary plan. When this Plan pays secondary to primary coverage you may have from a prepaid plan, this Plans benefits will be determined based on your out- of- pocket liability under the prepaid plan (generally the prepaid plans copayment), and subject to this Plans deductibles, coinsurance and copayments (see page 44 for exceptions when a Medicare prepaid plan is the primary payer).

The determination of which health coverage is primary (pays its benefits first) is made according to guidelines provided by the National Association of Insurance Commissioners (NAIC). When benefits are payable under automobile insurance, including no- fault, the automobile insurer is primary (pays its benefits first) if it is legally obligated to provide benefits for health care expenses without regard to other health benefits coverage the enrollee may have.

This provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given this Carrier to obtain information about benefits or services available from the other coverage, or to recover overpayments from other coverages.

If you are covered by both this Plan and the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), this Plan will pay benefits first.

If you are covered by both this Plan and Medicaid, this Plan will pay benefits first. The Plan will not pay for benefits or services required as the result of occupational disease or injury for which any medical benefits are determined by the Office of Workers Compensation Programs (OWCP) to be payable under workers compensation (under section 8103 of title 5, U. S. C.) or by a similar agency under another Federal or State law. This provision also applies when a third party injury settlement or other similar proceeding provides medical benefits in regard to a claim under workers compensation or similar laws. If medical benefits provided under such laws are exhausted, medical benefits may be provided for services or supplies covered by this Plan. The Plan is entitled to be reimbursed by OWCP (or the similar agency) for benefits paid by the Plan that were later found to be payable by OWCP (or the agency).

Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from the Plan for certain services and supplies provided to you or a family member to the extent that reimbursement is required under the Federal statutes governing such facilities.

Other sources of benefits

Medicare Group health insurance and automobile insurance

CHAMPUS Medicaid

Workers compensation DVA facilities, DoD facilities and Indian Health Service

General Limitations continued

The Plan will not provide benefits for services and supplies paid for directly or indirectly by any other local, State, or Federal Government agency.

This subrogation and right of recovery provision applies when you or your dependent are sick or injured as a result of the act or omission of another person or party. The Plan has the right to

recover payments the Plan has made to you or your dependent from a third party or third partys insurer because of illness or injury caused by a third party. In addition to its right of recovery, the Plan is subrogated to you and your dependents present and future claims against a third party. Third party means another person or organization.

If you or your covered dependent suffer an injury or illness through the act or omission of another, you and your dependent agree: 1) to reimburse the Plan for benefits paid by the Plan in an amount not to exceed the amount of the recovery; and 2) that the Plan be subrogated to your (or your dependents) rights to the extent of the benefits paid, including the right to bring suit. All recoveries from a third party (whether by lawsuit, settlement, or otherwise) must be used to reimburse the Plan for benefits paid. The Plans share of the recovery will not be reduced because you or your dependent do not receive the full amount of damages claimed, unless the Plan agrees in writing to a reduction.

When you or your dependent make a claim against a third party or the third partys insurer as a result of an injury or illness for which that third party is legally responsible, the Plan shall have a lien on the proceeds of that claim in order to reimburse itself to the full amount of benefits it is called upon to pay. The Plans lien will apply to any and all recoveries for such claim whether by court order or out- of- court settlement.

If you or your dependent are injured because of a third partys action or omission: 1) the Plan will pay benefits for that injury subject to the conditions that you and your dependent a) do not take any action that would prejudice the Plans ability to recover benefits, and b) will cooperate in doing what is reasonably necessary to assist the Plan in any recovery; 2) the Plans right of reimbursement extends only to the amount of Plan benefits paid or to be paid because of the injury; and 3) the Plan may insist upon an assignment of the proceeds of the claim or right of action against the third party and may withhold payment of benefits otherwise due until the assignment is provided.

You are required to notify the Plan promptly of any third party claim that you may have for damages for which the Plan has paid or may pay benefits. In addition, you are required to notify the Plan of any recovery, whether in or out of court, that you or your dependent obtain and to reimburse the Plan to the extent of benefits paid by the Plan. Any reduction of the Plans claim for payment of attorneys fees or costs associated with the claim is subject to prior approval by the Plan.

The Carrier will make reasonably diligent efforts to recover benefit payments made erroneously but in good faith and may apply subsequent benefits otherwise payable to offset any overpayments.

The information in the following paragraphs applies to you when 1) you are not covered by either Medicare Part A (hospital insurance) or Part B (medical insurance), or both, 2) you are enrolled in this Plan as an annuitant or as a former spouse or family member covered by the family enrollment of an annuitant or former spouse, and 3) you are not employed in a position which confers FEHB coverage.

If you are not covered by Medicare Part A, are age 65 or older or become age 65 while receiving inpatient hospital services, and you receive care in a Medicare participating hospital, the law (5 U. S. C. 8904( b)) requires the Plan to base its payment on an amount equivalent to the amount Medicare would have allowed if you had Medicare Part A. This amount is called the equivalent Medicare amount. After the Plan pays, the law prohibits the hospital from charging you for covered services after you have paid any deductibles, coinsurance, or copayments you owe under the Plan. Any coinsurance you owe will be based on the equivalent Medicare amount, not the actual charge. You and the Plan, together, are not legally obligated to pay the hospital more than the equivalent Medicare amount.

The Carriers explanation of benefits (EOB) will tell you how much the hospital can charge you in addition to what the Plan paid. If you are billed more than the hospital is allowed to charge, ask the hospital to reduce the bill. If you have already paid more than you have to pay, ask for a refund. If you cannot get a reduction or refund, or are not sure how much you owe, call your Local Plan at the telephone number on the back of your identification card for assistance.

Other Government agencies

Liability insurance and third party actions

Overpayments Vested rights Limit on your costs

if youre age 65 or older and dont have Medicare

Inpatient hospital care

General Limitations continued

Claims for physician services provided for retired FEHB members age 65 and older who do not have Medicare Part B are also processed in accordance with 5 U. S. C. 8904( b). This law mandates the use of Medicare Part B limits for covered physician services for those members who are not covered by Medicare Part B.

The Plan is required to base its payment on the Medicare- approved amount (which is the Medicare fee schedule for the service), or the actual charge, whichever is lower. If your physician is a member

of the Plans Preferred Provider Organization (PPO) and participates with Medicare, the Plan will base its payment on the lower of these two amounts and you are responsible only for any deductible and the PPO copayment or coinsurance.

If you go to a PPO physician who does not participate with Medicare, you are responsible for any deductible and the copayment or coinsurance. In addition, you must pay the difference between the Medicare- approved amount and the limiting charge (115% of the Medicare- approved amount).

If your physician is not a Plan PPO physician but participates with Medicare, the Plan will base its regular benefit payment on the Medicare- approved amount. For instance, under this Plans

Standard Option surgical benefit, the Plan will pay 75% of the Medicare- approved amount. You will only be responsible for any deductible and coinsurance equal to 25% of the Medicare- approved amount.

If your physician does not participate with Medicare, the Plan will still base its payment on the Medicare- approved amount. However, in most cases you will be responsible for any deductible, the coinsurance or copayment amount, and any balance up to the limiting charge amount (115% of the Medicare- approved amount).

Since a physician who participates with Medicare is only permitted to bill you up to the Medicare fee schedule amount even if you do not have Medicare Part B, it is generally to your financial advantage to use a physician who participates with Medicare.

The Carriers explanation of benefits (EOB) will tell you how much the physician can charge you in addition to what the Plan paid. If you are billed more than the physician is allowed to charge, ask the physician to reduce the bill. If you have already paid more than you have to pay, ask for a refund. If you cannot get a reduction or refund, or are not sure how much you owe, call your Local Plan at the telephone number on the back of your identification card for assistance.

General Exclusions

These exclusions apply to more than one or to all benefits categories. Exclusions that are primarily identified with a single benefit category are listed along with that benefit category, but may apply to other categories. Therefore, please refer to the specific benefit sections as well to assure that you are aware of all benefit exclusions.

Benefits are provided only for services and supplies that are medically necessary (see Definitions). The Carrier reserves the right to determine medical necessity. The fact that a covered provider has prescribed, recommended, or approved a service or supply does not, in itself, make it medically necessary.

No charge would be made if the covered individual had no health insurance coverage

Furnished without charge (except as described on page 11); while in active military service; or required for illness or injury sustained on or after the effective date of enrollment 1) as a result of an act of war within the United States, its territories, or possessions or 2) during combat

Furnished by immediate relatives or household members, such as spouse, parent, child, brother, or sister, by blood, marriage, or adoption

Furnished or billed by a provider or facility that has been barred from the FEHB Program

Furnished or billed by a noncovered facility, except that medically necessary prescription drugs are covered

For or related to sex transformation, sexual dysfunction, or sexual inadequacy

Not specifically listed as covered

Experimental or investigational (see Definitions), except for devices classified by the U. S. Food and Drug Administration as Category B Non- experimental/ Investigational Devices and the clinical trials benefit on page 19

Not provided in accordance with accepted professional medical standards in the United States

Physician services Benefits will not be paid for services and supplies when:

General Exclusions continued

Any portion of a providers fee or charge ordinarily due from the enrollee but that has been waived. If a provider routinely waives (does not require the enrollee to pay) a deductible, copay, or coinsurance, the Carrier will calculate the actual provider fee or charge by reducing the fee or charge by the amount waived.

Charges the enrollee or Plan has no legal obligation to pay, such as: excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/ or B (see pages 12- 13), doctor charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare (limiting charge) (see page 44), or State premium taxes however applied.

In the case of inpatient care, medical services which are not medically necessary, i. e., those which did not require the acute hospital inpatient (overnight) setting, but could have been provided in a physicians office, the outpatient department of a hospital, or some other setting, without adversely affecting the patients condition or the quality of medical care rendered. Some examples are:

admissions for or consisting primarily of observation and/ or evaluation that could have been provided safely and adequately in some other setting, e. g., physicians office

admissions primarily for diagnostic studies (X- ray, e. g., Magnetic Resonance Imagings MRIs, laboratory, and pathological services and machine diagnostic tests) which could have been provided safely and adequately in some other setting, e. g., outpatient department of a hospital or physicians office

Standby physicians

Biofeedback and other forms of self- care or self- help training

Outpatient cardiac rehabilitation

Any dental and oral surgical procedures or drugs involving orthodontic care, the teeth, dental implants, periodontal disease, or preparing the mouth for the fitting or the continued use of dentures. These are covered only as described under Standard Option Dental Benefits, Dental care for accidental injury, Hospitalization for dental work, or Surgical Benefits for Oral and maxillofacial surgery

Orthodontic care for temporomandibular joint (TMJ) syndrome

Custodial care (see Definitions)

Services and supplies furnished or billed by an extended care facility, nursing home, or other noncovered facility, except as specifically described on page 31. Medically necessary prescription drugs are covered

Eyeglasses, contact lenses, routine eye examinations, or vision testing for the prescribing or fitting of eyeglasses or contact lenses, except as provided for on page 28

Eye exercises, visual training, or orthoptics, except for nonsurgical treatment of amblyopia and strabismus as described on page 28

Hearing aids or examinations for the prescribing or fitting of hearing aids

Treatment (including drugs) of obesity, weight reduction, or dietary control, except for gastric bypass surgery or gastric stapling procedures

Personal comfort items such as beauty and barber services, radio, television, or telephone

Services or supplies used for cosmetic purposes

Routine services (see Definitions), except for those Preventive services specifically described in this brochure on pages 25, 26, 27, and 29. For purposes of this Plan, routine services include, but are not limited to, periodic physical examinations, screening examinations or tests, immunization shots, and X- rays, Magnetic Resonance Imagings MRIs, laboratory and pathological services, and machine diagnostic tests that are not related to a specific diagnosis, illness, injury, set of symptoms, or maternity care

Routine foot care, including corn or callus removal, or nail trimming

Recreational or educational therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay or through an approved Home health care program

Assisted Reproductive Technology (ART) procedures and related services and supplies (see page 22)

Services rendered by noncovered providers such as chiropractors, except in medically underserved areas

Procedures, services, drugs, and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

Benefits will not be paid for:

Benefits

Inpatient Hospital Benefits

The Plan pays for inpatient hospital services as shown below. The medical necessity of your hospital admission must be precertified for you to receive full Plan benefits. Emergency admissions not precertified must be reported within two business days following the day of admission even if you have been discharged. Otherwise, the benefits payable will be reduced by $500. See page 41 for details.

This precertification requirement does not apply to persons whose primary coverage is Medicare Part A or another health insurance policy or when the hospital admission is outside the United States. For information on when Medicare is primary, see pages 43- 45.

The Plan provides coverage at the benefit levels indicated below for services provided by the following facilities when furnished and billed as regular inpatient hospital services:

High Option Standard Option

PPO/ Preferred hospitals With no per admission

deductible, Plan pays in full for unlimited days

With no per admission deductible, Plan pays in full for unlimited days

Member hospitals After you pay a $100 per

admission deductible, Plan pays

in full for unlimited days After you pay a $250 per

admission deductible, Plan pays

in full for unlimited days Non- member hospitals After you pay a $100 per admission deductible under High Option or a

$250 per admission deductible under Standard Option, hospital charges in the United States and Puerto Rico are paid at 70% of the

Non- member rate (see Definitions), or the per diem charge in full after the per admission deductible in U. S. Public Health Service and Armed Forces Hospitals. The Plan pays in full for facilities outside of the United States and Puerto Rico with no per admission deductible.

Note: You should be aware that some Preferred hospitals may have Non- preferred providers on staff. Following is a list of some of the frequently referred providers about whose Preferred status you should inquire to help ensure that you receive your maximum benefits: Radiologist, Pathologist, Anesthesiologist, and Assistant Surgeon.

Covered services are noted below:

Semiprivate accommodations

Intensive care units

A private room is covered only when the patients isolation is required by law; when the Carrier determines that isolation is medically necessary to prevent contagion; or, in Preferred and Member hospitals, when the hospital only offers private rooms.

In noncovered private accommodations and in other noncovered accommodations, the Plan pays the hospitals average daily rate for semiprivate accommodations, which is determined by the Local Plan. Other hospital services are paid as shown above.

What is covered Precertification

Waiver Room and board and Other charges

Room and board Private room

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Inpatient Hospital Benefits continued

Operating, recovery, and other treatment rooms

Drugs and medical supplies

X- ray (e. g., Magnetic Resonance Imagings MRIs), laboratory, and pathological services, and machine diagnostic tests

Dressings, splints, plaster casts

Anesthetics and anesthesia service

Administration of blood and blood plasma; see page 28 for coverage of blood and blood products

Pre- admission testing recognized as part of the hospital admissions procedures The Plan pays for room and board and other hospital services for hospitalization in connection with dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient.

Chemotherapy and/ or radiation therapy when supported by allogeneic or autologous bone marrow transplants or blood stem cell transplant support is only covered for specific diagnoses (see Organ/ tissue transplants and donor expenses under Surgical Benefits on page 19).

See page 25 for outpatient hospital care benefits and outpatient surgery/ facility care benefits. See page 18 for surgical benefits when provided, or ordered, and billed by a physician. See Other Medical Benefits for coverage of blood, drugs, and ambulance transport services. The Plan provides coverage at the benefit levels indicated below for the following nonsurgical services provided, or ordered, and billed by a physician:

High Option Standard Option

PPO/ Preferred physicians Plan pays 95% PPA After you pay the $200 calendar

year deductible, Plan pays 95% PPA

Participating physicians Plan pays 80% PAR After you pay the $200 calendar

year deductible, Plan pays 75% PAR

Nonparticipating physicians

Plan pays 80% NPA. The member is responsible for the difference between the Plans payment and the physicians actual charge

After you pay the $200 calendar year deductible, Plan pays 75% NPA. The member is responsible for the difference between the Plans payment and the physicians actual charge

See Definitions for an explanation of: Preferred, Participating, and Non- participating physicians, and PPA, PAR, and NPA under Covered charges.

Medical care by the attending physician on days covered by Inpatient Hospital Benefits

Intensive physician care by the attending physician for treatment of a condition other than that for which surgical or maternity care is required

Consultations when requested by the attending physician, not including routine radiological and staff consultations required by hospital rules and regulations

Concurrent care (see Definitions)

Physical therapy when provided by a physician other than the attending physician

Other hospital charges Limited benefits

Hospitalization for dental work

Chemotherapy/ radiation therapy

Related benefits Outpatient hospital benefits

Surgical benefits Other charges Inhospital physician care

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Inpatient Hospital Benefits continued

Room and board and inhospital physician care when, in the Carriers judgment, a hospital admission or portion of an admission is one of the following types:

Custodial care (see Definitions)

Convalescent care or a rest cure

Domiciliary care provided because care in the home is not available or is unsuitable

Inpatient private duty nursing

Not medically necessary, i. e., for services which did not require the acute hospital inpatient (overnight) setting, but could have been provided in a physicians office, the outpatient department of a hospital, or some other setting, without adversely affecting the patients condition or the quality of medical care rendered. Some examples are:

admissions for or consisting primarily of observation and/ or evaluation that could have been provided safely and adequately in some other setting, e. g., physicians office

admissions primarily for diagnostic studies (X- ray, e. g., Magnetic Resonance Imagings MRIs, laboratory, and pathological services, and machine diagnostic tests) which could have been provided safely and adequately in some other setting, e. g., outpatient department of a hospital or physicians office

If a hospital admission is determined to be one of the types listed above, the Plan will pay benefits for services or supplies other than room and board and inhospital physician care at the level at which they would have been covered if provided in some other setting.

What is not covered The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Surgical Benefits

The Plan provides coverage at the benefit levels indicated below, except as noted, for the following services provided, or ordered, and billed by a physician:

High Option Standard Option

PPO/ Preferred physicians Plan pays 95% PPA After you pay the $200 calendar

year deductible, Plan pays 95% PPA

Participating physicians Plan pays 80% PAR After you pay the $200 calendar

year deductible, Plan pays 75% PAR

Nonparticipating physicians

Plan pays 80% NPA. The member is responsible for the

difference between the Plans payment and the physicians actual charge

After you pay the $200 calendar year deductible, Plan pays 75% NPA. The member is responsible for the difference between the Plans payment and the physicians actual charge

See Definitions for an explanation of: Preferred, Participating, and Non- participating physicians, and PPA, PAR, and NPA under Covered charges.

Operative or cutting procedures, including treatment of fractures and dislocations, surgical sterilization, and normal pre- and post- operative care by the operating physician

Diagnostic procedures such as endoscopies and biopsies

Treatment of burns

Surgical correction of congenital anomalies (see Definitions)

Extraction or reinfusion of bone marrow, blood stem cells, or cord blood as a source of stem cells as part of an allogeneic or autologous bone marrow transplant or blood stem cell transplant support procedure, including marrow harvesting in anticipation of a covered autologous bone marrow transplant, for patients diagnosed at the time of harvesting with one of the conditions listed on page 19. The collection, processing, storage and distribution of cord blood must be performed by a cord blood bank approved by the FDA. Expenses for storage of harvested bone marrow, blood stem cells, or cord blood as a source of stem cells are not covered, unless the covered transplant has already been scheduled

When unusual circumstances require removal of casts or sutures by a physician other than the one who applied them, the Local Plan may determine that a separate allowance is payable

Surgical correction of amblyopia and strabismus When multiple or bilateral surgical procedures that add time or complexity to patient care are performed during the same operative session, the Plan pays these multiple, bilateral, or incidental surgical (combined) procedures on the basis of the Allowable charge that is determined by the Local Plan. The Plan determines which procedure is primary and which procedures are secondary, tertiary, etc., and provides a reduced allowance for the non- primary procedures.

Surgical assistance by a physician if required by the complexity of the surgical procedure. Anesthesia service (including acupuncture) when requested by the attending physician and performed by a certified registered nurse anesthetist (CRNA) or a physician, other than the operating physician or the assistant, for covered surgical services. CRNAs are reimbursed at the payment levels indicated above for Participating and Non- participating physicians.

What is covered Surgical services

Multiple surgical procedures

Assistant surgeon (inpatient/ outpatient)

Anesthesia (inpatient/ outpatient)

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Surgical Benefits continued

The following human organ/ tissue transplant procedures:

Allogeneic bone marrow transplant and allogeneic cord blood stem cell transplant (from related or unrelated donors) for 1) Advanced neuroblastoma; 2) Infantile malignant osteopetrosis; 3) Severe combined immunodeficiency; 4) Wiskott- Aldrich syndrome; 5) Mucopolysaccharidosis (e. g., Hunter, Hurlers, Sanfilippo, Maroteaux- Lamy variants); 6) Mucolipidosis (e. g., Gauchers disease, metachromatic leukodystrophy, adrenoleukodystrophy); 7) Severe or very severe aplastic anemia; 8) Thalassemia major (homozygous beta- thalassemia); and 9) Sickle cell anemia.

Allogeneic bone marrow transplant, allogeneic cord blood stem cell transplant (from related or unrelated donors) and allogeneic peripheral blood stem cell transplant for 1) Acute lymphocytic or non- lymphocytic (i. e., myelogenous) leukemia; 2) Advanced Hodgkins lymphoma; 3) Advanced non- Hodgkins lymphoma; 4) Chronic myelogenous leukemia; and 5) Advanced forms of myelodysplastic syndromes.

Autologous bone marrow transplant and autologous peripheral blood stem cell transplant (collectively referred to as autologous stem cell support) for 1) Acute lymphocytic or nonlymphocytic (i. e., myelogenous) leukemia; 2) Advanced Hodgkins lymphoma; 3) Advanced non- Hodgkins lymphoma; 4) Advanced neuroblastoma; 5) Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors; and 6) Multiple myeloma.

Allogeneic bone marrow transplant, syngeneic bone marrow transplant, and allogeneic peripheral blood stem cell transplant for Multiple myeloma; and autologous bone marrow transplant and autologous peripheral blood stem cell transplant (collectively referred to as autologous stem cell support) for 1) Breast cancer; 2) Epithelial ovarian cancer; and 3) Chronic myelogenous leukemia; only when performed as part of a clinical trial that meets the requirements noted in the Limitations below and is conducted at a Cancer Research Facility (see page 6). In the event no non- randomized clinical trials meeting the requirements set forth below are available at Cancer Research Facilities for a member eligible for such clinical trials, the Plan will make arrangements for the transplant to be provided at another Plan- designated transplant facility.

Related services or supplies provided to the recipient are covered, including chemotherapy and/ or radiation therapy when supported by allogeneic or autologous bone marrow transplants or blood stem cell transplant support, and drugs or medications administered to stimulate or mobilize stem cells for the transplant procedures described above.

Single or double lung transplants for the following end- stage pulmonary diseases: 1) Pulmonary fibrosis, 2) Primary pulmonary hypertension, and 3) Emphysema. Double lung transplant for end- stage cystic fibrosis.

Cornea Heart Heart- lung Small bowel

Kidney Liver Pancreas Related medical and hospital expenses of the donor are covered.

Prior approval by the Local Plan of the procedure and the facility is required for bone marrow, cord blood stem cell, and peripheral blood stem cell transplant support procedures, heart, heartlung, liver, lung, pancreas, and small bowel transplants (see page 42)

For the bone marrow transplant procedures and related services or supplies covered only through clinical trials:

1) Prior approval by the Carrier is required (see page 42); 2) The clinical trial must be reviewed and approved by the Institutional Review Board of the

Cancer Research Facility where the procedure is to be delivered; and 3) The patient must be properly and lawfully registered in the clinical trial, meeting all the

eligibility requirements of the trial

Services or supplies for or related to artificial or human organ/ tissue transplants for any diagnosis not specifically listed as covered. Related services or supplies for noncovered procedures, including chemotherapy and/ or radiation therapy when supported by allogeneic or autologous bone marrow transplants, cord blood stem cell transplants (from related or unrelated donors), or peripheral blood stem cell transplant support, drugs or medications administered to stimulate or mobilize stem cells for transplant, and all other services or supplies which would not be medically necessary or appropriate but for the noncovered procedure.

Organ/ tissue transplants and donor expenses

What is covered Limitations What is not covered The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Surgical Benefits continued

Limited to the following surgical procedures:

Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of mouth when pathological examination is required

Surgery needed to correct accidental injuries (see Definitions) to jaws, cheeks, lips, tongue, roof and floor of mouth

Excision of exostoses of jaws and hard palate

External incision and drainage of cellulitis

Incision and surgical treatment of accessory sinuses, salivary glands or ducts

Reduction of dislocations and excision of temporomandibular joints

Removal of impacted teeth Women who undergo mastectomies may, at their option, have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Reconstructive surgery, including breast reconstruction following mastectomy and treatment to restore the mouth to a pre- cancer state.

Outpatient surgical services billed for by a facility are covered under Other Medical Benefits. See page 25.

Cosmetic surgery (see Definitions) unless required for a congenital anomaly or to restore or correct a part of the body which has been altered as a result of accidental injury, disease, or surgery

Radial keratotomy and other refractive surgeries

Services for or related to reversal of surgical sterilization

Oral and maxillofacial surgery

Mastectomy surgery Reconstructive surgery Related benefits

Outpatient surgery/ facility care benefits

What is not covered The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider.

When no PPO provider is available, non- PPO benefits apply.

Maternity Benefits

The Plan provides coverage at the benefit levels indicated below for services provided by the following facilities when furnished and billed as regular inpatient hospital services. The mother, at her option, may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. Inpatient stays will be extended if medically necessary.

Precertification is not required for maternity admissions for routine deliveries. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, your physician or the hospital must contact the Local Plan for certification of additional days. The Plan will not pay for charges incurred on any extra days that are not medically necessary. See pages 41- 42 for details.

High Option Standard Option

PPO/ Preferred hospitals With no per admission

deductible, Plan pays in full for unlimited days

With no per admission deductible, Plan pays in full for unlimited days

Member hospitals After you pay a $100 per

admission deductible, Plan pays

in full for unlimited days After you pay a $250 per

admission deductible, Plan pays

in full for unlimited days Non- member hospitals After you pay a $100 per admission deductible under High Option or a

$250 per admission deductible under Standard Option, hospital charges in the United States and Puerto Rico are paid at 70% of the

Covered services are noted below: Room and board and other hospital services. (See Inpatient Hospital Benefits for a description of all covered services, and payment levels for Non- member hospitals.)

Hospital bassinet or nursery charges for days in which both the mother and newborn are confined in the hospital are considered as expenses of the mother and not expenses of the child. When a newborn requires definitive treatment (including incubation charges by reason of prematurity), or evaluation for medical or surgical reasons, during or after the mothers confinement, the newborn is considered a patient in his or her own right and a separate per admission deductible, if applicable, applies. Expenses of the newborn (including circumcision) are eligible for benefits only if the child is covered by a Self and Family enrollment. See pages 41- 42 for information on requesting additional days for a covered newborn confined beyond the mothers discharge date.

Operating, recovery, and other treatment rooms

Drugs and medical supplies

Other covered ancillary services Outpatient hospital care for delivery including care in freestanding ambulatory facilities, including birthing centers, is covered as described under Other Medical Benefits, Outpatient surgery Facility care benefits (see pages 25- 26).

Note: When you use Preferred facilities, benefits for obstetrical care, including prenatal testing, are provided in full, not subject to the calendar year deductible or copayment.

What is covered Inpatient hospital

Precertification Room and board

Private room Bassinet and nursery Other charges Outpatient care

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Maternity Benefits continued

The Plan provides coverage at the benefit levels indicated below for services provided, or ordered, and billed by a physician or nurse midwife:

High Option Standard Option

PPO/ Preferred physicians Plan pays in full Plan pays in full

Participating physicians/ Nurse midwives

Plan pays 80% PAR After you pay the $200 calendar year deductible, Plan pays 75% PAR

Non- participating physicians/ Nurse midwives

Plan pays 80% NPA. The member is responsible for the

difference between the Plans payment and the physicians actual charge

After you pay the $200 calendar year deductible, Plan pays 75% NPA. The member is responsible for the difference between the Plans payment and the physicians actual charge

See Definitions for an explanation of: Preferred, Participating, and Non- participating physicians, and PAR and NPA under Covered charges.

Physician care for pregnancy (including related conditions) and resulting childbirth or miscarriage

Services of a licensed or certified nurse midwife for pre- and post- partum care and delivery

Anesthesia services, services of a nurse anesthetist, and surgical assistance as described under Surgical Benefits

Intrauterine devices (IUDs), Norplant, Depo- Provera, diaphragms, and oral contraceptives obtained from a physician are covered at the levels indicated on page 18; when obtained from a facility, they are covered at Other Medical Benefit levels (see page 25)

IUDs, Norplant, Depo- Provera, diaphragms, and oral contraceptives dispensed by a retail pharmacy are covered as prescription drugs (see page 32)

Oral contraceptives are also covered under the Mail Service Prescription Drug Program (see page 33)

Diagnosis and treatment of infertility are covered at the benefit levels indicated on page 18; related prescription drugs are covered under Prescription Drug Benefits (see pages 32- 33); see exclusion below for Assisted Reproductive Technology (ART) procedures.

Prenatal testing is covered at the benefit levels shown above and on page 25. Sterilization procedures (see page 18 for benefits for surgical sterilization). Well child care is covered under Additional Benefits (see page 29). Benefits are payable under Self Only enrollments and for family members under Self and Family enrollments.

Assisted Reproductive Technology (ART) procedures, such as artificial insemination, in vitro fertilization, embryo transfer, and GIFT, as well as services and supplies related to ART procedures, including sperm banking

Reversal of voluntary sterilization

Contraceptive devices, except as specifically described above

Professional care Obstetrical care Related benefits

Contraceptive devices and drugs

Diagnosis and treatment of infertility

Prenatal testing Voluntary sterilization Well child care For whom

What is not covered The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider.

When no PPO provider is available, non- PPO benefits apply.

Mental Conditions/ Substance Abuse Benefits

The Plan provides coverage at the benefit levels indicated below for services provided by the following facilities and professionals when furnished and billed as regular inpatient hospital services:

Note: Please check with your Local Plan and/ or PPO directory for listings of Preferred facilities and contracted professional providers.

The medical necessity of your admission to a hospital or other covered facility must be precertified for you to receive full Plan benefits. Emergency admissions must be reported within two business days following the day of admission even if you have been discharged. Otherwise, the benefits payable will be reduced by $500. See page 41 for details.

High Option Standard Option

PPO/ Preferred hospitals After you pay a $75 per day

copayment, Plan pays the remainder of the Preferred rate

up to 120 days After you pay a $150 per day

copayment, Plan pays the remainder of the Preferred rate

up to 100 days Member hospitals After you pay a $150 per day

copayment, Plan pays the remainder of the Member rate

up to 120 days After you pay a $250 per day

copayment, Plan pays the remainder of the Member rate

up to 100 days Non- member hospitals After you pay a $300 per day

copayment, Plan pays the remainder of the Non- member rate up to 120 days

After you pay a $400 per day copayment, Plan pays the remainder of the Non- member rate up to 100 days

After you pay the per day copayments, the Plan pays the remainder of the Preferred rate, Member rate, or Non- member rate in excess of the sum of your copayments. In Preferred and Member hospitals, in some instances, when the Preferred or Member rate or the Billed charge is less than the sum of your copayments, you will be responsible only for the lowest amount. In Non- member hospitals, in some instances, the Average charge may be less than the sum of your copayments.

See the definition of Covered charges for an explanation of Preferred rate, Member rate, Nonmember rate, Billed charge, and Average charge. See also the discussion of copayments in Cost Sharing on page 10.

Covered services include room and board and other hospital services (see Inpatient Hospital Benefits for a description of all covered services).

The Plan provides coverage at the benefit levels indicated below for inpatient mental conditions and substance abuse professional care rendered by Participating and Non- participating providers:

High Option Standard Option

After you pay the $150 calendar year deductible, Plan pays 80% of the

Allowable charge (see Definitions) After you pay the $200 calendar year

deductible, Plan pays 60% of the

Allowable charge (see Definitions)

What is covered Mental conditions

Inpatient care Precertification

Hospital care Inpatient visits The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Mental Conditions/ Substance Abuse Benefits continued

The Plan pays all covered outpatient care (including related services and supplies, such as psychological testing) for the treatment of a mental condition, including substance abuse, as follows:

High Option Standard Option

After satisfaction of the $150 calendar year deductible, Plan pays in full, subject to the following copayments:

After satisfaction of the $200 calendar year deductible, Plan pays in full, subject to the following copayments:

PPO/ Preferred facilities You pay $10 You pay $25

Member facilities You pay $50 You pay $100

Non- member facilities You pay $100 You pay $150

These copayments will be applied per facility per day, not per service. After meeting the deductibles, you will be responsible for the lesser of the stated copayment or the Billed charge( s). If Preferred or Member facilities are available, and utilized, you will be responsible for the lesser of the stated copayments, the Billed charge( s), or the Preferred or Member rate at the time your claim is processed.

The Plan provides coverage at the benefit levels described below for outpatient mental conditions and substance abuse professional care rendered by Participating and Non- participating providers:

High Option Standard Option

After you pay the $150 calendar year deductible, Plan pays 70% of the

Allowable charge (see Definitions) After you pay the $200 calendar year

deductible, Plan pays 60% of the

Allowable charge (see Definitions) Outpatient visits are available up to 50 visits under High Option and 25 visits under Standard Option per person per calendar year for:

Individual or group therapy, or combination of individual and group therapy, up to two hours

per day, including collateral visits with members of the patients immediate family, provided by a physician, qualified clinical psychologist, psychiatric nurse, or clinical social worker

Day- night hospital services (sometimes called partial hospitalization) The number of visits for which you receive reimbursement will be reduced if these services are used to meet part or all of your calendar year deductible.

The Plan provides benefits for the inpatient treatment of alcoholism and drug abuse at the levels indicated on the previous page for hospital care and inpatient visits for mental conditions care. Treatment is also payable in a freestanding alcoholism facility approved by the Local Plan.

Inpatient care for the treatment of alcoholism and drug abuse is limited to one treatment program (28- day maximum) per lifetime under High and Standard Options.

The Plan provides benefits for outpatient facility and professional care for the treatment of substance abuse at the benefit levels indicated above. Outpatient visits accrue toward the visit limits described above.

Marital, family, educational, or other counseling or training services

Services rendered or billed by a school or halfway house or a member of its staff

Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present

Services and supplies that are not medically necessary (see Definitions and General Exclusions)

Outpatient care Facility care

Professional care Therapy Substance abuse

Inpatient care Lifetime maximum Outpatient care

What is not covered The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider.

When no PPO provider is available, non- PPO benefits apply.

Other Medical Benefits

Except as noted, after any applicable deductibles and copayments have been met, the Plan pays the following:

High Option Standard Option

After satisfaction of the $150 calendar year deductible, Plan pays in full, subject to the following copayments:

After satisfaction of the $200 calendar year deductible, Plan pays in full, subject to the following copayments:

PPO/ Preferred facilities You pay $10 You pay $25 Member facilities You pay $50 You pay $100 Non- member facilities You pay $100 You pay $150

These copayments will be applied per facility per day, not per service. After meeting the deductible, you will be responsible for the lesser of the stated copayments or the Billed charge( s). If Preferred or Member facilities are available, and utilized, you will be responsible for the lesser of the stated copayments, the Billed charge( s), or the Preferred or Member rate at the time your claim is processed.

Covered services, 1) when furnished by the hospital outpatient department, ordered by a physician, and billed by a hospital, or 2) for renal dialysis, when furnished and billed by a freestanding ambulatory facility (see Facilities and Other Providers), are as follows:

X- ray (e. g., Magnetic Resonance Imagings MRIs), laboratory, and pathological services, and machine diagnostic tests. Certain diagnostic cancer tests are covered differently when provided by a Preferred facility (see page 29).

In Member and Non- member facilities, each cervical cancer screening, mammogram for breast cancer screening, fecal occult blood test for colorectal cancer screening, PSA (Prostate Specific Antigen) test for prostate cancer screening, tetanus- diphtheria (Td) booster, and immunization for influenza and pneumonia is paid as described above. See pages 26 and 27 for the screening schedules related to these tests and immunizations for Member and Non- member facilities and for Participating and Non- participating providers. These services are covered differently when you use Preferred providers (see page 29).

Radiation therapy, chemotherapy, and renal dialysis (chemotherapy and/ or radiation therapy when supported by allogeneic or autologous bone marrow transplants or blood stem cell transplant support is covered only for those covered conditions as described under Organ/ tissue transplants and donor expenses under Surgical Benefits on page 19)

Physical, occupational, and speech therapy (for visit limitations, see page 28)

Allergy tests, surveys, and injections, blood (as described under Miscellaneous services on page 28), and prescription drugs, billed for by the facility

Hospital services in connection with dental procedures only when a nondental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient.

Pharmacotherapy (see pages 32 and 33 for coverage for prescription drugs) The Plan provides coverage at the benefit levels indicated below, not subject to the calendar year deductible, for the outpatient surgical services listed on the next page when billed for by a facility:

High Option Standard Option

Plan pays in full, subject to the following copayments: Plan pays in full, subject to the

following copayments: PPO/ Preferred facilities You pay $10 You pay $25

Member facilities You pay $50 You pay $100

Non- member facilities You pay $100 You pay $150

What is covered Outpatient facility care

Diagnostic services

Preventive services

Other outpatient services

Outpatient surgery

Facility care benefits

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Other Medical Benefits continued

These copayments will be applied per facility per day, not per service. You will be responsible for the lesser of the stated copayments or the Billed charge( s). If Preferred or Member facilities are available, and utilized, you will be responsible for the lesser of the stated copayments, the Billed charge( s), or the Preferred or Member rate at the time your claim is processed.

Overseas care The Plan pays in full for outpatient surgical services at hospitals located outside the United States or Puerto Rico.

Covered facility- billed services are noted below:

Surgical services and related other hospital services

Related X- ray (e. g., Magnetic Resonance Imagings MRIs), laboratory, and pathological services, and machine diagnostic tests within one business day of the covered surgical services

Facility supplies for hemophilia home care Except as noted, the Plan provides coverage at the benefit levels indicated below for services provided, or ordered, and billed by a physician:

High Option Standard Option

PPO/ Preferred physicians After you pay the $150 calendar

year deductible, Plan pays 95% PPA

After you pay the $200 calendar year deductible, Plan pays 95% PPA

Participating physicians After you pay the $150 calendar

year deductible, Plan pays 80% PAR

After you pay the $200 calendar year deductible, Plan pays 75% PAR

Non- participating physicians After you pay the $150 calendar

year deductible, Plan pays 80% NPA. The member is responsible for the difference between the Plans payment and the physicians actual charge

After you pay the $200 calendar year deductible, Plan pays 75% NPA. The member is responsible for the difference between the Plans payment and the physicians actual charge

See Definitions for an explanation of: Preferred, Participating, and Non- participating physicians, and PPA, PAR, and NPA under Covered charges.

When you use Preferred physicians, home and office visits, physicians outpatient consultations, and second surgical opinions are paid in full under High and Standard Options after a $12 copayment for each outpatient office visit charge. These services are paid as described above when rendered by Participating and Non- participating physicians.

X- ray (e. g., Magnetic Resonance Imagings MRIs), laboratory, and pathological services, and machine diagnostic tests, including mammograms and Pap smears. Certain diagnostic cancer tests are covered differently when provided by a Preferred provider (see page 29).

Laboratory and pathological services billed by an independent laboratory The following routine (screening) procedures are paid as described above when performed by

Participating and Non- participating providers. These services are covered differently when you use Preferred providers, and the visit charge associated with these services is covered only with Preferred providers; see Additional Benefits, page 29.

The following schedules are applicable for Member and Non- member facilities and Participating and Non- participating providers.

Mammograms are covered for females age 35 and older as follows:

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

From age 40 through 64, one mammogram screening every calendar year

At age 65 or over, one mammogram screening every two consecutive calendar years One Pap smear for females of any age every calendar year.

Facility care benefits continued

Physician care Home and office visits

Diagnostic services

Preventive services

Breast cancer screening

Cervical cancer screening

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Other Medical Benefits continued

One fecal occult blood test for members age 40 and older every calendar year. One PSA (Prostate Specific Antigen) test for males age 40 and older every calendar year.

For influenza and pneumonia, once every calendar year

Tetanus- diphtheria (Td) booster, once every ten calendar years

Physical, occupational, and speech therapy (for visit limitations, see page 28)

Allergy tests, surveys, and injections, blood as described on page 28, and prescription drugs

Under High Option, physician home visits when receiving covered home health care (see page 30)

Covered services provided by a nurse midwife acting within the scope of licensure

Pharmacotherapy (see pages 32 and 33 for coverage for prescription drugs) Except as noted, benefits for the following services are paid as follows:

High Option Standard Option

After you pay the $150 calendar year deductible, Plan pays 80% of the

Allowable charge (see Definitions) After you pay the $200 calendar year

deductible, Plan pays 75% of the

Allowable charge (see Definitions)

Note: Preferred and Participating providers may not be available for the following services in your area. When they are available, and utilized, the Plan pays benefits as shown under Physician care

on page 26. Professional ambulance transport services associated with covered hospital inpatient care, when related to and within 72 hours after an accidental injury or medical emergency, or during covered home health care.

Services, supplies, or appliances for dental care to sound natural teeth (see Definitions) required as a result of, and directly related to, an accidental injury (see Definitions).

Rental by the member or, at the Carriers option, purchase, if it will be less expensive, of durable medical equipment (such as respirators and home dialysis equipment) including replacement, repair, and adjustment of purchased equipment

Wheelchairs, hospital beds, crutches, and other items determined by the Carrier to be durable medical equipment

Orthopedic braces and prosthetic appliances (such as artificial legs and pacemakers) including replacement, repair, and adjustment

One bra, per person per calendar year, designed for use with an external breast prosthesis Care by a registered nurse (R. N.) or licensed practical nurse (L. P. N.), when the care is ordered by a physician. Home nursing care is available for two (2) hours per day up to 50 visits per calendar year under High Option and 25 visits per calendar year under Standard Option. The number of visits for which you receive reimbursement will be reduced if these services are used to meet part or all of your calendar year deductible.

Preventive services

continued

Colorectal cancer screening

Prostate cancer screening

Immunizations Other outpatient services

Other services Ambulance Dental care for accidental injury

Durable medical equipment

Home nursing care The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Other Medical Benefits continued

Allergy tests, surveys, and injections

Blood and blood plasma except when donated or replaced, and blood plasma expanders

Neurological testing when rendered and billed by a qualified clinical psychologist

One set of eyeglasses or contact lenses, or one replacement to an existing prescription, required as a result of, and directly related to, a single instance of intra- ocular surgery or a single ocular injury. This benefit also applies when, in situations as described above, the condition can be corrected by surgery, but surgery is precluded (i. e., cannot be performed because of age or medical complications), and lenses are prescribed in lieu of surgery

Ostomy and catheter supplies

Oxygen, regardless of the provider

Medical foods for children with inborn errors of amino acid metabolism

Prescription drugs not billed by a retail pharmacy (excludes those drugs obtained through the Mail Service Prescription Drug Program)

Home infusion therapy (prescription drugs; medical supplies; durable medical equipment (DME); and home nursing visits, subject to the calendar year visit limitations described above under Home nursing care)

Nonsurgical treatment for amblyopia and strabismus, for children from birth through age 12

Functional foot orthotics when medically necessary and prescribed by a physician

Rigid devices attached to the foot or a brace or placed in a shoe

Acupuncture as a modality of physical therapy and for pain management when rendered and billed by a physician or licensed physical therapist

Physical, occupational, and speech therapy when rendered and billed by a physical, occupational, or speech therapist who is licensed or meets the requirements of the Carrier, by a physician rendered on an outpatient basis, or by an outpatient facility. The following limits apply to outpatient care:

Physical therapy: 75 visits under High Option and 50 visits under Standard Option per person per calendar year

Occupational therapy, speech therapy, or a combination of both: 25 visits under High and

Standard Options per person per calendar year The number of visits for which you receive reimbursement will be reduced if these services are used to meet part or all of your calendar year deductible.

See page 16 for physical, occupational, and speech therapy provided by a physician on an inpatient basis. See pages 25 and 26 for payment levels for outpatient physical, occupational, and speech therapy provided by a physician or outpatient facility.

After satisfaction of the calendar year deductible, under High and Standard Options, the Plan will pay 100% of Billed charges up to a maximum payment of $100 for enrollment in one smoking cessation program per member per lifetime. Services may be rendered by any covered provider or by a smoking cessation clinic.

See pages 32 and 33, Prescription Drug Benefits, for coverage of smoking cessation drugs.

Exercise and bathroom equipment

Lifts, such as seat, chair, or van lifts

Air conditioners, humidifiers, dehumidifiers, and purifiers

Shoes and over- the- counter orthotics

Wigs

Implanted bone conduction hearing aids

Computer story boards or light talkers for communication- impaired individuals

Maintenance or palliative physical, occupational, or speech therapy for a chronic disease or condition which does not require the technical proficiency or the skill and training of a physician or qualified physical, occupational, or speech therapist, except during acute exacerbations of the disease or condition

Home nursing care when: 1) Requested by, or for the convenience of, the patient or the patients family 2) It consists primarily of bathing, feeding, exercising, homemaking, moving the patient,

giving medication, or acting as a companion or sitter

Miscellaneous services

Physical, occupational, and speech therapy

Limited benefits Smoking cessation benefit

What is not covered The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider.

When no PPO provider is available, non- PPO benefits apply.

Additional Benefits

The Plan provides coverage for each home and office visit for a routine physical examination at the benefit levels indicated below when provided by a Preferred physician or Preferred facility:

After you pay a $12 copayment, After you pay a $12 copayment,

High Option pays in full Standard Option pays in full

Home and office visits for routine (screening) examination, consisting of a history and risk assessment, chest X- ray, electrocardiogram (EKG), urinalysis, basic metabolic or comprehensive metabolic panel test, and complete blood count (CBC), are covered for members as follows:

Through age 64, once every three consecutive calendar years

At age 65 or over, once every calendar year This benefit does not apply to children eligible for Well Child Care benefits. Additionally, the preventive (screening) tests and immunizations noted below are paid in full when provided by a Preferred physician or a Preferred facility on an outpatient basis, subject to the schedules indicated. If these services are rendered by a Preferred physician separately from the routine physical examination, you will be responsible for the $12 copayment for each associated office visit.

Cholesterol tests are covered for members as follows:

Through age 64, once every three consecutive calendar years

At age 65 or over, once every calendar year This benefit does not apply to children eligible for Well Child Care benefits. Preventive (screening) cholesterol tests are only covered and paid in full when provided by Preferred providers or any independent laboratory.

For influenza and pneumonia, once every calendar year

Tetanus- diphtheria (Td) booster, once every ten calendar years See pages 25, 26, and 27, Other Medical Benefits, for benefits for these immunizations provided by Member and Non- member facilities and Participating and Non- participating providers. The visit charge associated with these services is covered only with Preferred facilities or Preferred providers.

The following diagnostic and screening cancer tests are paid in full after the associated office visit copay when provided by a Preferred facility or Preferred provider on an outpatient basis:

Mammogram

Pap smear

Fecal occult blood test

PSA (Prostate Specific Antigen) test See pages 25, 26, and 27, Other Medical Benefits, for payment levels and applicable schedules for these diagnostic and preventive services provided by Member and Non- member facilities and Participating and Non- participating physicians. The visit charge associated with these services is covered only with Preferred facilities or Preferred providers.

For children up to age 22 under High and Standard Options, the Plan pays 100% of the Allowable charge for the following covered routine services for well child care:

All healthy newborn inpatient physician visits, including routine screening (inpatient or outpatient)

Routine physical examinations, laboratory tests, immunizations, and related office visits, including those for children living, traveling, or adopted from outside the United States, as recommended by the American Academy of Pediatrics

Preventive services provided by Preferred providers

Routine physical examination

Coronary artery disease screening

Immunizations Cancer tests (diagnostic/ screening) provided by Preferred providers

Well child care The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Additional Benefits continued

High and Standard Options pay 100% of Covered charges for the following covered services and supplies in connection with, and within 72 hours after, accidental injury (see Definitions):

Other hospital services in Preferred, Member, and Non- member hospitals, including related X- ray (e. g., Magnetic Resonance Imagings MRIs), laboratory, and pathological services, and machine diagnostic tests

Physician services in the office or hospital outpatient department, including X- ray (e. g., Magnetic Resonance Imagings MRIs), laboratory, and pathological services and machine diagnostic tests

See Definitions for an explanation of Preferred, Participating, and Non- participating physicians, and Covered charges.

The following related services are covered under Other Medical Benefits (see pages 25- 28):

Services related to accidental injury rendered more than 72 hours after the injury

Care for accidental dental injury

Ambulance transport services

High Option pays in full for 90 days per calendar year for the covered home health care services listed below if:

1) the services rendered are billed by a home health care agency (such as the hospital or a visiting nurse association) which has a written agreement with the Local Plan to provide home health care services, and

2) prior approval is obtained from the Local Plan. If prior approval is not obtained, Other Medical Benefits will be provided as applicable.

Note: The member has the responsibility to make sure that the home health care provider has received prior approval from the Local Plan (see page 42 for instructions). Please check with your Local Plan and/ or your PPO directory for listings.

Nursing care such as dressing changes, injections, and monitoring of vital signs

Physical therapy

Respiratory or inhalation therapy

Prescription drugs

Medical supplies which serve a specific therapeutic or diagnostic purpose

Infusion therapy

Other medically necessary services or supplies that would have been provided by a hospital if the member was hospitalized

See page 27 for High Option coverage for physician home visits while receiving covered home health care services

Home health care services related to the treatment of mental conditions/ substance abuse, for routine maternity care, for routine monitoring of a condition, for intermittent care of a stable condition, or for initial evaluation of the patient to determine whether or not home health care is appropriate

Homemaking services, including housekeeping, preparing meals, or acting as a companion or sitter

See page 27 for Standard Option coverage of home nursing care.

Accidental injury (outpatient care)

Related benefits Home health care

High Option What is covered What is not covered Standard Option

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Additional Benefits continued

High and Standard Options pay in full if prior approval is obtained from the Local Plan for covered home hospice services rendered to members with a life expectancy of six months or less when billed by a home hospice care agency which is approved by the Local Plan.

Note: The member has the responsibility to make sure that the home hospice care provider has received prior approval from the Local Plan (see page 42 for instructions). Please check with your Local Plan and/ or your PPO directory for listings.

Physician visits Services of home health aides

Nursing care Durable medical equipment rental

Medical social services Prescription drugs

Physical therapy Medical supplies Inpatient hospice benefits are available only to a member receiving Home hospice care benefits. Benefits are provided for up to five (5) consecutive days in a hospital or a freestanding hospice inpatient facility. These covered inpatient hospice benefits are available only when inpatient services are necessary to control pain and manage the symptoms of the patient or to provide an interval of relief to the family (respite).

Each inpatient stay must be separated by at least 21 days and is paid in full under High and

Standard Options with no per admission deductible when you are admitted to a Preferred hospital. Each inpatient stay in a Member or Non- member hospital is subject to a $100 per admission deductible under High Option and a $250 per admission deductible under Standard Option. (See page 15 for Inpatient Hospital Benefits.)

Homemaker or bereavement services When Medicare Part A is primary payer (it pays first) and has made payment, High and Standard Options provide secondary benefits for the applicable Medicare Part A copayments incurred in full

during the first through the 30th day of confinement per each benefit period, as defined by Medicare, in a qualified skilled nursing facility (see Facilities and Other Providers). If Medicare pays the first 20 days in full, Plan benefits will begin on the 21st day, when Medicare Part A copayments begin, and will end on the 30th day.

Help with health concerns is available 24 hours a day, 365 days a year, by calling a toll- free telephone number or accessing an Internet web site if you belong to Blue Cross and Blue Shield Plans in certain pilot areas. In 1999, this service is available to members who live in Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, the District of Columbia, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Massachusetts, Nevada, New Jersey, New Mexico, New York areas served by the Empire Plan, Ohio, South Dakota, Texas, Virginia, Washington and West Virginia. The service, called Blue Health Connection, features health advice or health information and counseling by registered nurses. Also available is the AudioHealth Library with hundreds of tapes, ranging from first aid to infectious diseases to general health issues. You can get information about health care resources to help you find local doctors, hospitals or other health care services affiliated with the Blue Cross and Blue Shield Service Benefit Plan.

Enrollees who live in the states where this service is available will receive a membership kit and other information about Blue Health Connection in the mail.

The Service Benefit Plan is developing and may offer patient support programs for certain diagnoses in select locations on a pilot basis.

Home hospice care What is covered Related inpatient services

What is not covered Limited benefits

Skilled nursing facilities

24- Hour nurse telephone service

Patient support programs

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Prescription Drug Benefits

You may purchase up to a 90- day supply of the following medications and supplies prescribed by a doctor from either a pharmacy or by mail; however, quantities may be limited for certain drugs such as narcotics:

Drugs, vitamins and minerals, and nutritional supplements that by Federal law of the United

States require a doctors prescription for their purchase

Insulin

Needles and disposable syringes for the administration of covered medications

Intrauterine devices (IUDs), Norplant, Depo- Provera, diaphragms, and oral contraceptives dispensed by a retail pharmacy; and oral contraceptives obtained through the Mail Service Program

Drugs to aid smoking cessation that require a prescription by Federal law (limited to one regimen per calendar year)

In most cases, refills cannot be obtained until 75% of the drug has been used. Call the Retail Pharmacy Program (1- 800/ 624- 5060 / TDD: 1- 800/ 624- 5077) or the Mail Service Prescription Drug Program (1- 800/ 262- 7890 / TDD: 1- 800/ 446- 7292) for exceptions to this policy. Not all drugs are available through the Mail Service Program.

You can save money by using generic drugs. By submitting your prescription (or those of family members covered by the Plan) to your retail pharmacy or the Mail Service Prescription Drug Program, you authorize them to substitute a Federally approved generic equivalent, if available, unless you or your physician specifically requests a name brand.

Medical supplies such as dressings and antiseptics

Drugs and supplies for cosmetic purposes

Medication that does not require a prescription under Federal law even if your doctor prescribes it or a prescription is required under your State law

Drugs prescribed for weight loss

Drugs for orthodontic care, dental implants, and periodontal disease

Drugs for which prior approval has been denied You may purchase up to a 90- day supply of covered drugs and supplies through the Retail Pharmacy Program. Call 1- 800/ 624- 5060 (TDD: 1- 800/ 624- 5077) to locate a Preferred pharmacy in your area.

High Option Standard Option

PPO/ Preferred retail pharmacies After you pay the $50

prescription drug deductible, Plan pays 85% PPA

After you pay the $50 prescription drug deductible, Plan pays 80% PPA

Non- preferred retail pharmacies After you pay the $50

prescription drug deductible, Plan pays 65% AWP. The member is responsible for the difference between the Plans payment and the pharmacys actual charge

After you pay the $50 prescription drug deductible, Plan pays 60% AWP. The member is responsible for the difference between the Plans payment and the pharmacys actual charge

You must present your Plan ID card at the time of purchase at a Preferred pharmacy and pay 100% of the PPA up to the $50 prescription drug deductible ($ 100 per family; see page 9). After satisfaction of the $50 deductible, you are only responsible for the appropriate coinsurance at the time of purchase. All Preferred retail pharmacies will file claims for you. Preferred pharmacies will receive the payment and agree to accept 100% of the PPA as payment in full. At Non- preferred retail pharmacies, you must pay the full cost at the time of purchase and submit a claim. You are responsible for the $50 drug deductible, the applicable coinsurance based upon the Average Wholesale Price (AWP), and any amounts in excess of the allowance. Certain prescription drugs and supplies may require prior approval (see page 33). Any savings received by the Carrier on the cost of drugs purchased under this Plan from drug manufacturers are credited to the reserves held for this Plan.

When Medicare Part B is the primary payer, the $50 prescription drug deductible under High

and Standard Options and the 15% PPA when you use a Preferred retail pharmacy under High Option will be waived after you supply proof of your enrollment in Part B directly to the Plan (see page 44). If you use a Preferred retail pharmacy, you are required to pay 20% PPA under Standard Option (coinsurance is waived after you supply proof of your confinement in a nursing home).

What is covered What is not covered From a pharmacy

Waiver The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider.

When no PPO provider is available, non- PPO benefits apply.

Prescription Drug Benefits continued

If you use a Non- preferred retail pharmacy, you are required to file a paper claim and pay 15% AWP under High Option and 40% AWP under Standard Option (reduced to 20% AWP when confined

in a nursing home). The member is responsible for the difference between the Plans payment and the pharmacys actual charge.

Use a retail prescription drug claim form for prescription drugs and supplies purchased at Nonpreferred retail pharmacies. You may obtain these forms by calling 1- 800/ 624- 5060 (TDD: 1- 800/ 624- 5077). Follow the instructions on the form and mail it to the Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P. O. Box 52057, Phoenix, AZ 85072- 2057.

If your doctor orders more than a 21- day supply of covered drugs or supplies, up to a 90- day supply, you may order your prescription or refill by mail from the Mail Service Prescription Drug Program. Merck- Medco Rx Services will fill your prescription.

You pay an $8 copayment under High Option and a $12 copayment under Standard Option for each prescription drug, supply, or refill you purchase through the Mail Service Program.

When Medicare Part B is the primary payer, and you use the Mail Service Prescription Drug Program, your copayment is waived after you supply proof of your enrollment in Part B directly to Merck- Medco Rx Services (see page 44).

The Plan will send you information on the Mail Service Prescription Drug Program. To use the Program:

1) Complete the initial mail order form. 2) Enclose your prescription and copayment. 3) Mail your order to Merck- Medco Rx Services, P. O. Box 30492, Tampa, FL 33633- 0144. 4) Allow approximately two weeks for delivery.

Alternatively, your physician may call in your initial prescription at 1- 800/ 262- 7890 (TDD: 1- 800/ 446- 7292). You will be billed later for the copayment. After that, to order your refill