CT FEHB

Kaiser Foundation Health Plan of Connecticut, Inc.

A Health Maintenance Organization Serving: Most of Connecticut Enrollment in this Plan is limited; see page 8 for requirements.

Enrollment code: DM1 Self Only DM2 Self and Family

Visit the OPM website at http:// www. opm. gov/ insure and this Plans National Website at http:// www. kaiserpermanente. org

RI 73- 114

Authorized for distribution by the:

United States Office of Personnel Management

1999

This Plan has full accreditation from the NCQA. See the FEHB Guide for more

information on NCQA.

Kaiser Foundation Health Plan of Connecticut, Inc.

Kaiser Foundation Health Plan of Connecticut, Inc., 200 Corporate Place, Suite 300, Rocky Hill, Connecticut 06067, has entered into a contract (CS 1944) with the Office of Personnel Management (OPM) as authorized by the Federal Employees Health Benefits (FEHB) law, to provide a comprehensive medical plan herein called Health Plan, Kaiser Permanente, or the Plan.

This brochure is the official statement of benefits on which you can rely. A person enrolled in the Plan is entitled to the benefits stated in this brochure. If enrolled for Self and Family, each eligible family member is also entitled to these benefits.

Premiums are negotiated with each plan annually. Benefit changes are effective January 1, 1999, and are shown on page 24 of this brochure.

Table of Contents Inspector General Advisory on Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Confidentiality; If you are a new member; If you are hospitalized when you change plans; Your responsibility; Things to keep in mind; Coverage after enrollment ends (Former spouse coverage; Temporary continuation of coverage; Conversion to individual coverage; and Certificate of Creditable Coverage)

Facts about this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

I n fo rm ation you have a right to know; Who provides care to Plan members? Role of a pri m a ry care doctor, Choosing your doctor; Refe rrals for specialty care, Au t h o ri z ations; For new members; Hospital care; Out- of- pocket maximum; Deductible carryover; Submit claims pro m p t ly; Experi m e n t a l / I nve s t i gational determ i n ations; Other considerations; The Plans service are a s

General Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Important notice; Circumstances beyond Plan control; Other sources of benefits

General Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Medical and Surgical Benefits; Hospital/ Extended Care Benefits; Benefits Available Away From Home; Emergency Benefits, Mental Conditions/ Substance Abuse Benefits; Prescription Drug Benefits

Other Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Dental care; Vision care

Non- FEHB Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 How to Obtain Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 How Kaiser Foundation Health Plan of Connecticut, Inc. Changes January 1999. . . . . . . . . . . . . . . . . . . . . . . . . 24 Summary of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Rate Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

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. This could 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 or pharmacy, 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 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 Plan at 1- 800- 305- 1992 and explain the situation. If the matter is not resolved after speaking to your Plan (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, D. C. 20415

The inappropriate use of membership identification cards, e. g., to obtain services 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.

General Information

Medical and other information provided to the Plan, including claim files, is kept confidential and will be used only: 1) by the Plan and its subcontractors for internal administration of the Plan and coordination of benefit provisions with other plans 2) by law enforcement officials with authority to investigate and prosecute alleged civil or criminal actions; 3) by OPM to review a disputed claim or perform its contract administration functions; 4) by OPM and the General Accounting Office when conducting audits as required by the FEHB law; or 5) for bona fide medical research or education. Medical data that does not identify individual members may be disclosed as a result of the bona fide medical research or education.

Use this brochure as a guide to coverage and obtaining benefits. There may be a delay before you receive your identification card and member information from the Plan. Until you receive your ID card, you may show your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM to a provider or Plan facility as proof of enrollment in this Plan. If you do not receive your ID card within 60 days after the effective date of your enrollment, you should contact the Plan.

If you made your open season change by using Employee Express and have not received your new ID card by the effective date of your enrollment, call the Employee Express HELP number to request a confirmation letter. Use that letter to confirm your new coverage with Plan providers.

If you are a new member of this Plan, benefits and rates begin on the effective date of your enrollment, as set by your employing office or retirement system. As a member of this Plan, once your enrollment is effective, you will be covered only for services provided or arranged by a Plan doctor except in the case of emergency as described on page 15. If you are confined in a hospital on the effective date, you must notify the Plan so that it may arrange for the transfer of your care to Plan providers. See If you are hospitalized on page 3.

FEHB plans may not refuse to provide benefits for any condition you or a covered family member may have solely on the basis that it was a condition that existed before you enrolled in a plan under the FEHB Program.

Confidentiality If you are a new member

General Information continued

If you change plans or options, benefits under your prior plan or option cease on the effective date of your enrollment in your new plan or option, unless you or a covered family member are confined in a hospital or other covered facility or are receiving medical care in an alternative care setting on the last day of your enrollment under the prior plan or option. In that case, the confined person will continue to receive benefits under the former plan or option until the earliest of (1) the day the person is discharged from the hospital or other covered facility (a move to an alternative care setting does not constitute a discharge under this pr ovision), or (2) the day after the day all inpatient benefits have been exhausted under the prior plan or option, or (3) the 92nd day after the last day of coverage under the prior plan or option. However, benefits for other family members under the new plan will begin on the effective date. If your plan terminates participation in the FEHB Program in whole or in part, or if the Associate Director for Retirement and Insurance orders an enrollment change, this continuation of coverage provision does not apply; in such case, the hospitalized family members benefits under the new plan begin on the effective date of enrollment.

It is your responsibility to be informed about your health benefits. Your employing office or retirement system can provide information about: when you may change your enrollment; who family members are; what happens when you transfer, go on leave without pay, enter military service, or retire; when your enrollment terminates; and the next open season for enrollment. Your employing office or retirement system will also make available to you an FEHB Guide, brochures and other materials you need to make an informed decision.

The benefits in this brochure are effective on January 1 for those already enrolled in this Plan; if you changed plans or plan options, see If you are a new member above. In both cases, however, the Plans new rates are effective the first day of the enrollees first full pay period that begins on or after January 1 (January 1 for all annuitants).

G e n e ra l ly, you must be continu o u s ly enrolled in the FEHB Program for the last five ye a rs befo re you re t i re to continue your enrollment for you and any eligi ble fa m i ly members after you re t i re.

The FEHB Program provides Self Only coverage for the enrollee alone or Self and Family coverage for the enrollee, his or her spouse, and unmarried dependent children under age 22. Under certain circumstances, coverage will also be provided under a family enrollment for a disabled child 22 years of age or older who is incapable of self- support.

An enrollee with Self Only coverage who is expecting a baby or the addition of a child may change to a Self and Family enrollment up to 60 days after the birth or addition. The effective date of the enrollment change is the first day of the pay period in which the child was born or became an eligible family member. The enrollee is responsible for his or her share of the Self and Family premium for that time period; both parent and child are covered only for care received from Plan providers except emergency benefits.

You will not be informed by your employing office (or your retirement system) or your Plan when a family member loses eligibility.

You must direct questions about enrollment and eligibility, including whether a dependent age 22 or older is eligible for coverage, to your employing office or retirement system. The Plan does not determine eligibility and cannot change an enrollment status without the necessary information from the employing agency or retirement system.

An employee, annuitant, or family member enrolled in one FEHB plan is not entitled to receive benefits under any other FEHB plan.

Report additions and deletions (including divorces) of covered family members to the Plan promptly.

If you are an annuitant or former spouse with FEHB coverage and you are also covered by Medicare Part B, you may drop your FEHB coverage and enroll in a Medicare prepaid plan when one is available in your area. If you later change your mind and want to reenroll in FEHB, you may do so at the next open season, or whenever you involuntarily lose coverage in the Medicare prepaid plan or move out of the area it serves.

Most Federal annuitants have Medicare Part A. If you do not have Medicare Part A, you may enroll in a Medicare prepaid plan, but you will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether they will provide hospital benefits and, if so, what you will have to pay.

If you are hospitalized

Your responsibility Things to keep in mind

General Information continued

You may also remain enrolled in this Plan when you join a Medicare prepaid plan. Contact your local Social Security Administration (SSA) office for information on local Medicare prepaid plans (also known as Coordinated Care Plans or Medicare HMOs) or request it from SSA at 1- 800- 638- 6833. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan.

Federal annuitants are not required to enroll in Medicare Part B (or Part A) in order to be covered under the FEHB Program nor are their FEHB benefits reduced if they do not have Medicare Part B (or Part A).

When an employees enrollment terminates because of separation from Federal service or when a family member is no longer eligible for coverage under an employee or annuitant enrollment, and the person is not otherwise eligible for FEHB coverage, he or she generally will be eligible for a free 31- day extension of coverage. The employee or family member may also be eligible for one of the following:

When a Federal employee or annuitant divorces, the former spouse may be eligible to elect coverage under the spouse equity law. If you are recently divorced or anticipate divorcing, contact the employees employing office (personnel office) or retirees retirement system to get more facts about electing coverage.

If you are an employee whose enrollment is terminated because you separate from service, you may be eligible to temporarily continue your health benefits coverage under the FEHB Program in any plan for which you are eligible. Ask your employing office for RI 79- 27, which describes TCC, and for RI 70- 5, the FEHB Guide for individuals eligible for TCC. Unless you are separated for gross misconduct, TCC is available to you if you are not otherwise eligible for continued coverage under the Program. For example, you are eligible for TCC when you retire if you are unable to meet the five- year enrollment requirement for continuation of enrollment after retirement.

Your TCC begins after the initial free 31- day extension of coverage ends and continues for up to 18 months after your separation from service (that is, if you use TCC until it expires 18 months following separation, you will only pay for 17 months of coverage). Generally, you must pay the total premium (both the Government and employee shares) plus a 2 percent administrative charge. If you use your TCC until it expires, you are entitled to another free 31- day extension of coverage when you may convert to nongroup coverage. If you cancel your TCC or stop paying premiums, the free 31- day extension of coverage and conversion option are not available.

Children or former spouses who lose eligibility for coverage because they no longer qualify as family members (and who are not eligible for benefits under the FEHB Program as employees or under the spouse equity law) also may qualify for TCC. They also must pay the total premium plus the 2 percent administrative charge. TCC for former family members continues for up to 36 months after the qualifying event occurs, for example, the child reaches age 22 or the date of the divorce. This includes the free 31- day extension of coverage. When their TCC ends (except by cancellation or nonpayment of premium), they are entitled to another free 31- day extension of coverage when they may convert to nongroup coverage.

N OT E : If there is a delay in processing the TCC enro l l m e n t , the effe c t ive date of the enro l l m e n t is still the 32nd day after regular cove rage ends. The TCC enrollee is re s p o n s i ble for pre m i u m p ayments re t ro a c t ive to the effe c t ive date and cove rage may not exceed the 18 or 36 month p e riod noted ab ove.

Separating employees Within 61 days after an employees enrollment terminates because of separation from service, his or her employing office must notify the employee of the opportunity to elect TCC. The employee has 60 days after separation (or after receiving the notice from the employing office, if later) to elect TCC.

Children You must notify your employing office or retirement system when a child becomes eligible for TCC within 60 days after the qualifying event occurs, for example, the child reaches age 22 or marries.

Coverage after enrollment ends

Te m p o ra ry c o n t i nu ation of c ove rage (TCC)

Former spouse coverage

Notification and election requirements

General Information continued

Former spouses You or your former spouse must notify the employing office or retirement system of the former spouses eligibility for TCC within 60 days after the termination of the marriage. A former spouse may also qualify for TCC if, during the 36- month period of TCC eligibility, he or she loses spouse equity eligibility because of remarriage before age 55 or loss of the qualifying court order. This applies even if he or she did not elect TCC while waiting for spouse equity coverage to begin. The former spouse must contact the employing office within 60 days of losing spouse equity eligibility to apply for the remaining months of TCC to which he or she is entitled.

The employing office or retirement system has 14 days after receiving notice from you or the former spouse to notify the child or the former spouse of his or her rights under TCC. If a child wants TCC, he or she must elect it within 60 days after the date of the qualifying event (or after receiving the notice, if later). If a former spouse wants TCC, he or she must elect it within 60 days after any of the following events: the date of the qualifying event or the date he or she receives the notice, whichever is later; or the date he or she loses coverage under the spouse equity law because of remarriage before age 55 or loss of the qualifying court order.

Important: The employing office or retirement system must be notified of a childs or former spouses eligibility for TCC within the 60- day time limit. If the employing office or retirement system is not notified, the opportunity to elect TCC ends 60 days after the qualifying event in the case of a child and 60 days after the change in status in the case of a former spouse.

When none of the above choices are available or chosen when coverage as an employee or family member ends, or when TCC coverage ends (except by cancellation or nonpayment of premium), you may be eligible to convert to an individual, nongroup contract. You will not be required to provide evidence of good health and the plan is not permitted to impose a waiting period or limit coverage for preexisting conditions. If you wish to convert to an individual contract, you must apply in writing to the carrier of the plan in which you are enrolled within 31 days after receiving notice of the conversion right from your employing agency. A family member must apply to convert within the 31- day free extension of coverage that follows the event that terminates coverage, e. g., divorce or reaching age 22. Benefits and r ates under the individual contract may differ from those under the FEHB Program.

Under Federal law, if you lose coverage under the FEHB Program, you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB Plan to cover you. This certificate, along with any certificates you receive from other FEHB plans you may have enrolled in, may reduce or eliminate the length of time a preexisting condition clause can be applied to you by a new non- FEHB insurer. If you do not receive a certificate automatically, you must be given one on request.

Facts about this Plan

This Plan is a comprehensive medical plan, sometimes called a health maintenance organization (HMO). When you enroll in an HMO, you are joining an organized system of health care that arranges in advance with specific doctors, hospitals and other providers to give care to members and pays them directly for their services. Benefits are available only from Plan providers except during a medical emergency. Members are required to select a personal doctor from among participating Plan primary care doctors. Services of a specialty care doctor can only be received by referral from the selected primary care doctor. There are no claim forms when Plan doctors are used.

Your decision to join an HMO should be based on your preference for the Plans benefits and delivery system, not because a particular provider is in the Plans network. You cannot change plans because a provider leaves the HMO.

Because the Plan provides or arranges your care and pays the cost, it seeks efficient and effective delivery of health services. By controlling unnecessary or inappropriate care, it can afford to offer a comprehensive range of benefits. In addition to providing comprehensive health services and benefits for accidents, illness and injury, the Plan emphasizes preventive benefits such as office visits, physicals, immunizations and well- baby care. You are encouraged to get medical attention at the first sign of illness.

Conversion to individual coverage

Certificate of Creditable Coverage

Facts about this Plan continued

All carriers in the FEHB Program must provide certain information to you. If you did not receive information about this Plan, you can obtain it by calling the Carrier at 1- 800- 638- 0668 or you may write the Carrier at Kaiser Foundation Health Plan of Connecticut, Inc., 200 Corporate Place, Suite 300, Rocky Hill, Connecticut 06067. You may also contact the Carrier by fax at (518) 785- 2741 or at its website at http:// www. kaiserpermanente. org.

Information that must be made available to you includes: Disenrollment rates for 1997. Compliance with State and Federal licensing or certification requirements and the dates met. If noncompliant, the reason for noncompliance.

Accreditations by recognized accrediting agencies and the dates received. Carriers type of corporate form and years in existence. Whether the carrier meets State, Federal and accreditation requirements for fiscal solvency, confidentiality and transfer of medical records.

Kaiser Permanente is a mixed model Plan that offers comprehensive health care coverage on a prepaid group practice basis at six Plan facilities, selected network locations and through referral specialists, hospitals and other providers in the community. All care should be received from these providers, except in a medical emergency. Health Plan contracts with the Northeast Permanente Medical Group, P. C., an independent multi- specialty group of physicians ( Plan doctors), to provide or arrange all necessary physician care for Plan members. These doctors are members of American Specialty Boards or are Board eligible. Medical care is provided through doctors, nurse practitioners, and other skilled medical personnel working as medical teams at Kaiser Permanente facilities and selected network locations. Specialists in most major specialties are available as part of the medical teams for consultation and treatment. Other necessary medical services, such as physical therapy, laboratory and X- ray services, are available at Kaiser Permanente contracting providers. Plan doctors also arrange any necessary specialty care. Hospital care is provided through the Plan at several local community hospitals.

The first and most important decision each member must make is the selection of a primary care doctor. Primary care doctors include internists, family practitioners, gynecologists and pediatricians. It is through this doctor that all other health services, particularly those of specialists, are obtained. It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only when you have been referred by your primary care doctor, except for covered follow- up and continuing care and care received from other Kaiser Permanente Plans.

The Plans provider directory lists Plan facilities and the services available at each facility (generally family practitioners, pediatricians, gynecologists, and internists), with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Customer Service Department at 1- 800- 305- 1992; you can also find out if your doctor participates with this Plan by calling this number. If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in this plan, services (except for emergency benefits) are provided through the Plans delivery system; the continued availability and/ or participation of any one doctor, hospital, or other provider, cannot be guaranteed.

Should you decide to enroll, you will be asked to select a primary care doctor for you and each member of your family and inform your Plan of your selection. Members may change their doctor selection at the same Medical Office or Network location by notifying the Plan at any time. Members may also change Medical Office or Network locations with a 30- day notice to the Plan.

In the event a member is receiving services from a Plan doctor who terminates his or her association with the Plan, the Plan will provide payment for covered services until the Plan can make reasonable and medically appropriate provisions for the assumption of such services by another Plan doctor.

Who provides care to Plan members? Information you

have a right to know

Role of a primary care doctor

Choosing your doctor

Facts about this Plan continued

Except in a medical emergency, you must contact your primary care doctor for a referral before seeing any other doctor or obtaining special services. Referral to a participating specialist is given at the primary care doctors discretion; if specialists or consultants are required beyond those who are Plan doctors, the primary care doctor will make arrangements for appropriate referrals.

When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation. On referrals, the primary care doctor will give specific instructions to the consultant as to what services are authorized. If additional services or visits are suggested by the consultant, you must first check with your primary care doctor. Do not go to the specialist unless your primary care doctor has arranged for and the Plan has issued an authorization for the referral in advance.

If you have a chronic, complex, or serious medical condition that causes you to see a Plan specialist frequently, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist. The treatment plan will permit you to visit your specialist without the need to obtain further referrals.

The Plan will provide benefits for covered services only when the services are medically necessary to prevent, diagnose or treat your illness or condition. Your Plan doctor must obtain the Plans determination of medical necessity before you may be hospitalized, referred for specialty care or obtain follow- up care from a specialist.

If you are already under the care of a specialist who is a Plan doctor, you must still obtain a referral from a Plan primary care doctor for the care to be covered by the Plan.

If you are selecting a new primary care doctor, you must schedule an appointment so the primary care doctor can decide whether to treat the condition directly or refer you back to the specialist.

If you require hospitalization, your primary care doctor or authorized specialist will make the necessary arrangements and continue to supervise your care.

Your out- of- pocket expenses for benefits under this Plan are limited to the stated copays required for a few benefits.

If you ch a n ged to this Plan during open season from a plan with a deductible and the effe c t ive d ate of the ch a n ge was after Ja nu a ry 1, a ny expenses that would have applied to that plans d e d u c t i ble will be cove red by your old plan if they are for care you got in Ja nu a ry befo re the e ffe c t ive date of your cove rage in this Plan. If you have alre a dy met the deductible in full, yo u r old plan will re i m bu rse these cove red expenses. If you have not met it in full, your old plan will fi rst ap p ly your cove red expenses to satisfy the rest of the deductible and then re i m bu rse you fo r a ny additional cove red expenses. The old plan will pay these cove red expenses according to this ye a r s benefits; benefit ch a n ges are effe c t ive Ja nu a ry 1.

When you are required to submit a claim to this Plan for covered expenses, submit your claim promptly. The Plan will not pay benefits for claims submitted later than December 31 of the calendar year following the year in which the expense was incurred, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

A service is experimental or investigational if it is: (1) not approved by the FDA; (2) the subject of a new drug or new device application on file with FDA; or (3) part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial; or is intended to evaluate the safety, toxicity, or efficacy of the service; or (4) provided pursuant to a written protocol that evaluates the services safety, toxicity, or efficacy; or (5) subject to the approval or review of an Institutional Review Board; or (6) provided pursuant to informed consent documents that describe the service as experimental or investigational. The Plan and its Medical Group carefully evaluate if a particular therapy is either proven to be safe and effective or offers a degree of promise with respect to improving health outcomes. The primary source of evidence about health outcomes of any intervention is peer- reviewed medical literature.

Referrals for specialty care

Authorizations For new members

Hospital care Out- of- pocket maximum Deductible carryover

Submit claims promptly

Experimental/ Investigational determinations

Facts about this Plan continued

Plan providers will follow generally accepted medical practice in prescribing any course of treatment. Before you enroll in this Plan, you should determine whether you will be able to accept treatment or procedures that may be recommended by Plan providers.

The service area for this Plan, where Plan providers and facilities are located, is described below. You must live or work in the service area to enroll in this Plan.

The service area for this Plan includes the following areas: Fairfield, Hartford, Litchfield, Middlesex, New Haven, and Tolland counties Windham County: Ashford, Brooklyn, Canterbury, Central Village, Chaplin, Eastford, Hampton, North Windham, Plainfield, Scotland, South Windham, Williamantic, Windham, Woodstock Valley.

New London County: Baltic, Bozrah, Colchester, East Lyme, Gilman, Glasgo, Hadlyme, Hanover, Jewett City, Lebanon, Montville, North Franklin, North Westchester, Norwick, Oakdale, Old Lyme, Quaker Hill, South Lyme, Taftville, Uncasville, Versaille, Yantic

Benefits for care outside the service area are limited to emergency services received at Kaiser Permanente facilities in other Kaiser Permanente Regions (see the Plan for further details on services available in other Kaiser Permanente Service areas.)

If you or a covered family member move outside the service area, or you no longer work there, you may enroll in another approved Plan. It is not necessary to wait until you move or for the open season to make such a change; contact your employing office or retirement system for information if you are anticipating a move.

General Limitations

Although a specific service may be listed as a benefit, it will be covered for you only if, in the judgment of your Plan doctor, it is medically necessary for the prevention, diagnosis, or treatment of your illness or condition. 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 this Plan or be used in the prosecution or defense of a claim under this Plan. This brochure is the official statement of benefits on which you can rely.

In the event of major disaster, epidemic, war, riot, civil insurrection, disability of a significant number of Plan providers, complete or partial destruction of facilities, or other circumstances beyond the Plans control, the Plan will make a good faith effort to provide or arrange for covered services. However, the Plan will not be responsible for any delay or failure in providing service due to lack of available facilities or personnel.

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 Plan and complete all necessary documents and authorizations requested by the Plan.

If you or a covered family member is enrolled in this Plan and Medicare Part A and/ or Part B, the Plan will coordinate benefits according to Medicares determination of which coverage is primary. However, this Plan will not cover services, except those for emergencies, follow- up or continuing care, unless you use Plan providers. You must tell your Plan that you or your family member is eligible for Medicare. Generally, that is all you will need to do, unless your Plan tells you that you need to file a Medicare claim.

This coordination of benefits (double coverage) provision 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 Plan.

Other considerations

The Plans service areas

Important notice Circumstances beyond Plan control

Other sources of benefits

Medicare Group health insurance and automobile insurance

General Limitations continued

When there is double coverage for covered benefits, other than emergency services from non- Plan providers, this Plan will continue to provide its benefits in full, but is entitled to receive payment for the services and supplies provided, to the extent that they are covered by the other coverage, no- fault or other automobile insurance or any other primary Plan.

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 which, when added to the benefits payable by the other coverage, will not exceed reasonable charges. 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. 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 plan 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. As a member of a prepaid plan, special limitations on your CHAMPUS coverage apply; your primary care provider must authorize all care. See your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.

If you are covered by both this Plan and Medicaid, this Plan will pay benefits first. The Plan will not pay for 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 workerscompensation (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 workerscompensation or similar laws. If medical benefits provided under such laws are exhausted, this Plan will be financially responsible for services or supplies that are otherwise covered by this Plan. The Plan is entitled to be reimbursed by OWCP (or the similar agency) for services it provided 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.

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

If a covered person is sick or injured as a result of the act or omission of another person or party, the Plan requires that it be reimbursed for the benefits provided in an amount not to exceed the amount of recovery, or that it be subrogated to the persons rights to the extent of the benefits received under this Plan, including the right to bring suit in the persons name. If you need more information about subrogation, the Plan will pr ovide you with its subrogation procedures.

General Exclusions

All benefits are subject to the limitations and exclusions in this brochure. Although a specific service may be listed as a benefit, it will not be covered for you unless your Plan doctor determines it is medically necessary to prevent, diagnose or treat your illness or condition as discussed under Authorizations on page 7. The following are excluded:

Care by non- Plan doctors or hospitals except for authorized referrals or emergencies and services received under the Travel Benefit (see Emergency Benefits and Benefits Available Away from Home);

CHAMPUS Medicaid Workers compensation

DVA facilities, DoD facilities, and Indian Health Service Other Government agencies

Liability insurance and third party actions

General Exclusions continued

Expenses incurred while not covered by this Plan; Services furnished or billed by a provider or facility barred from the FEHB Program; S e rvices not re q u i red according to accepted standards of medical, d e n t a l , or psych i at ric pra c t i c e ; Procedures, treatments, drugs or devices that are experimental or investigational; Procedures, services, drugs and supplies related to sex transformations; and 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.

Medical and Surgical Benefits

A comprehensive range of preventive, diagnostic and treatment services is provided by Plan doctors and other Plan providers. This includes all necessary office and outpatient surgery visits. You pay $5 per visit but no additional copay for laboratory tests and X- rays. Within the service area, house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate; you pay nothing for a doctors house call, home visit by nurses, health aides, physical therapists and speech pathologists.

The following services are included: Preventive care, including well- baby care Mammograms are covered as follows: for women age 35 through 39, one mammogram during these five years; for women age 40 through 49, one mammogram every one or two years; for women age 50 through 64, one mammogram every year; and for women age 65 and above, one mammogram every two years. In addition to routine screening, mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness.

Routine immunizations and boosters Consultations by specialists Diagnostic procedures, such as laboratory tests and X- rays Complete obstetrical (maternity) care for all covered females, including prenatal, delivery and postnatal care by a Plan doctor. The mother, at her option, may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery. Inpatient stays will be extended if medically necessary. If enrollment in the Plan is terminated during pregnancy, benefits will not be provided after coverage under the Plan has ended. Ordinary nursery care of the newborn during the covered portion of the mothers confinement for maternity will be covered under either a Self Only or Self and Family enrollment; other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment.

Voluntary sterilization and family planning services Diagnosis and treatment of diseases of the eye Allergy testing and treatment including testing and treatment materials (such as allergy serum) The insertion of internal prosthetic devices, such as pacemakers and artificial joints Cornea, heart, heart- lung, kidney, simultaneous pancreas- kidney, liver and lung (single and double) transplants; allogeneic (donor) bone marrow transplants; autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non- lymphocytic leukemia, advanced Hodgkins lymphoma, advanced non- Hodgkins lymphoma, advanced neuroblastoma, breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors. Transplants are covered when approved by the Medical Group. Related medical and hospital expenses of the donor are covered.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10

What is covered

Medical and Surgical Benefits continued

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

Dialysis (Office visit charges will be waived if you enroll in Medicare Part B and assign your Medicare benefits to the Plan).

Chemotherapy, radiation therapy, and respiratory therapy Surgical treatment of morbid obesity Home health services of nurses, health aides, including intravenous fluids and medications, when prescribed by your Plan doctor, who will periodically review the program for continuing appropriateness and need

Blood and blood products and the administration of blood All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers, at no additional cost to you

Cardiac rehabilitation following heart bypass surgery or a myocardial infarction Visits to receive injections Medical management of mental health conditions, including drug therapy evaluation and maintenance

If you do not pay any of the charges required for services at the time you receive the services, you will be billed for those charges. You will also be required to pay an administrative charge of $10 for each service for which a bill is sent.

Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects, such as cleft lip and cleft palate, and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including, but not limited to, treatment of fractures and excision of tumors and cysts. All other procedures involving the teeth or intra- oral areas surrounding the teeth are not covered, including shortening of the mandible or maxillae for cosmetic purposes, correction of malocclusion, and any dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the members appearance and if the condition can reasonably be expected to be corrected by such surgery.

Short- term rehabilitative therapy (physical, speech and occupational) is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement can be expected within two months. You pay nothing for inpatient care and $5 per outpatient visit. Rehabilitation is provided on an inpatient or outpatient basis as part of a specialized multidisciplinary therapy program in a specialized facility for up to two months per condition, when in the judgment of the Plan doctor significant improvement can be expected within two months. You pay nothing per outpatient session or inpatient session. This benefit is reduced by any covered inpatient rehabilitation days in a skilled nursing facility. Speech therapy is limited to treatment of certain speech impairments of organic origin. Occupational therapy is limited to services that assist the member to achieve and maintain self- care and improved functioning in other activities of daily living.

Diagnosis and treatment of infertility is covered. You pay $5 per visit. The following types of artificial insemination is covered: intravaginal insemination (IVI); intracervical insemination (ICI) and intrauterine insemination (IUI)). You pay $5 per visit. Cost of donor sperm and donor eggs and services related to their procurement and storage is not covered. Other assisted reproductive technology (ART) procedures such as in vitro fertilization, gamete and zygote intra fallopian transfers are not covered. Infertility services are not available when either member of the family has been voluntarily surgically sterilized. [Drugs used for covered infertility treatments are provided under the Prescription Drug Benefit at 50% of the over the counter charge to members who do not have a prescription drug benefit.] Drugs related to non- covered infertility treatments are not covered.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Limited benefits

Medical and Surgical Benefits continued

Orthopedic devices, prosthetic devices and durable medical equipment (such as braces, artificial limbs, wheelchairs and hospital beds) are provided; you pay the first $400 of costs for each prescribed item; the Plan pays a maximum of $1,500 per member per year for any combination of these items. Oxygen prescribed by a Plan doctor is covered; you pay 20% of the charges. Internal prosthetic devices prescribed by a Plan doctor following surgical procedures for treatment of tumors (such as maxillofacial prosthetic devices and internal breast prostheses) are provided at no charge. Neither oxygen nor internal prosthetic devices are subject to the $1,500 cap. The Plan will select the provider or vendor that will furnish covered devices and durable medical equipment.

Diagnosis and treatment for biologically based mental or nervous conditions caused by a biological disorder of the brain is covered, (schizophrenia, schizoaffective disorders, major depressive disorders, bipolar disorders, paranoia and other psychotic disorders, obsessivecompulsive disorders, panic disorders and pervasive development disorders or autism).

Physical examinations that are not necessary for medical reasons, such as those required for obtaining or continuing employment or insurance or governmental licensing, attending school or camp, or travel

Reversal of voluntary, surgically- induced sterility Surgery primarily for cosmetic purposes External and internally implanted hearing aids Homemaker services Long- term rehabilitative and cognitive therapy Transplants not listed as covered Lenses following cataract removal Foot orthotics Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as nearsightedness (myopia), farsightedness (hyperopia) and astigmatism.

Hospital/ Extended Care Benefits

The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor. You pay nothing. All necessary services ar e covered, including:

Semiprivate room accommodations; when a Plan doctor determines it is medically necessary, the doctor may prescribe private accommodations or private duty nursing care

Specialized care units, such as intensive care or cardiac care units Prescribed drugs and their administration, blood and blood products and the administration of blood, biologicals, supplies, and equipment ordinarily provided or arranged as part of inpatient services

The Plan provides a comprehensive range of benefits for up to 100 days benefit period when full- time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor. A benefit period begins when you enter a hospital or skilled nursing facility. A benefit period ends when you have not been a patient in either a hospital or a skilled nursing facility for 60 days. You pay nothing for the 100 days. All necessary services are covered, including:

Bed, board and general nursing care Prescribed drugs and their administration, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Wh at is not cove re d What is covered

Hospital care Extended care

Hospital/ Extended Care Benefits continued

Supportive and palliative care for a terminally ill member is covered in the home or Plan approved hospice facility. You pay nothing. Services include short- term inpatient care, limited to respite care and care for pain control and acute and chronic symptom management, outpatient care and family counseling; these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of six months or less.

Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor.

You pay nothing. Limited benefits

Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons totally unrelated to the dental procedure; the Plan will cover the hospitalization, but not the cost of the professional dental services. Conditions for which hospitalization would be covered include hemophilia and heart disease; the need for anesthesia, by itself, is not such a condition.

Hospitalization for medical treatment of substance abuse is limited to emergency care, diagnosis, treatment of medical conditions, and medical management of withdrawal symptoms (acute detoxification) if the Plan doctor determines that outpatient management is not medically appropriate. See page 17 for nonmedical substance abuse benefits.

Personal comfort items, such as telephone and television Custodial care, or care in an intermediate care facility When you are outside the service area of this Plan, you may still receive covered health care services. There are two types of coverage provided under your enrollment in this Plan.

When you are in the service area of another Kaiser Permanente plan, you are entitled to receive virtually all the benefits described in this brochure at Kaiser Permanente medical offices and medical centers and from Kaiser Permanente providers. You pay the charge required by the Plan you visit for services provided to federal enrollees in that Plans service area.

If the Kaiser Permanente plan in the area you are visiting has a benefit that is different from the benefits of this Plan, you are not entitled to receive that benefit. Some services covered by this Plan, such as artificial reproductive services and the services of specialized rehabilitation facilities, will not be available in other Kaiser Permanente service areas. If a benefit is limited to a specific number of days or visits, you are entitled to receive only the number of days or visits covered by the Plan in which you are enrolled.

If you are seeking routine, non- emergent or non- urgent services, you should call the Kaiser Permanente member services department in that service area and request an appointment. You may obtain routine follow- up or continuing care from these Plans, even when you have obtained the original services in the service area of this Plan. If you require emergency services as the result of an unexpected or unforeseen illness that requires immediate attention, you should go directly to the nearest hospital to receive care.

If you are outside the service area of this Plan by more than 100 miles, or outside the service area of any other Kaiser Permanente Plan, the following health care services will be covered:

Follow- up care - care necessary to complete a course of treatment following receipt of covered out- of- plan emergency care, or emergency care received from Plan facilities, if the care would otherwise be covered and is performed on an outpatient basis. Examples of covered follow- up care include the removal of stitches, a catheter or a cast.

Continuing care - care necessary to continue covered medical services normally obtained at Plan facilities, as long as care for the condition has been received at Plan facilities within the previous 90 days and the services would otherwise be covered. Services must be performed on an outpatient basis. Services include scheduled well- baby care, prenatal visits, drug monitoring, blood pressure monitoring and dialysis treatments. The following services are not covered: hospitalization, infertility treatments, childbirth services, and transplants. Prescription drugs are not covered. However, you may have prescriptions filled by mail through this Plans Prescription Drug Benefit.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Hospice care Ambulance service Inpatient dental procedures

Acute inpatient detoxification

Wh at is not cove re d Benefits Available Away From Home Services From Other Kaiser Permanente Plans

Benefits Available While You Travel

Hospital/ Extended Care Benefits continued

If you have any questions about how to use these benefits, call the Travel Benefit Information line at 1- 800- 390- 3509. You may obtain the Travel Benefits for Federal Employees brochure by calling this number.

You should pay the provider at the time you receive the service. Submit a claim to the Plan for the services on this Plans Claim for Follow- up/ Continuing Care Medical Form, with necessary supporting documentation. Submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card. Submit claims to Kaiser Foundation Health Plan of Connecticut, Inc., Claims Department, P. O. Box 15109, Albany, NewYork 12212- 5109. If the services are covered under this Travel Benefit, you will be reimbursed the reasonable charges for the care, up to a maximum of $1,200 per calendar year. You pay $25 for each follow- up or continuing care visit. This amount will be deducted from the payment the Plan makes to you.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Emergency Benefits

A medical emergency is an injury or the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life- threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that the Plan may determine are medical emergencies what they all have in common is the need for quick action.

If you are in an emergency situation, please call your Plan facility or the Plans after hours emergency phone number, 1- 800- 552- 1315 if your doctor is located in a medical office. If your doctor is located at a network location, call your primary care doctor directly.

In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member must notify the Plan within 48 hours, unless it was not reasona bly possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasona bly possible to notify the Plan within that time. If you are hospitalized in non- Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

B e n e fits are ava i l able for care from non- Plan prov i d e rs in a medical emerge n cy only if delay in re a ching a Plan provider would result in deat h , d i s ability or significant jeopardy to your condition.

To be covered by this Plan, any follow- up care recommended by non- Plan providers must be approved by the Plan or provided by Plan providers.

Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.

$25 per visit to a hospital or urgent care center for emerge n cy services that are cove red benefi t s of this Plan.

You may obtain emergency and urgent care services from Kaiser Permanente medical facilities and providers when you are in the service area of another Kaiser Permanente plan. The facilities will be listed in the local telephone book under Kaiser Permanente. You may also call the Customer Service Department at the following phone number: 1- 800- 552- 1315. This number is open 24 hours a day, 7 days a week.

Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow- up care recommended by non- Plan providers must be approved by the Plan or provided by Plan providers.

Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.

$25 per visit to a hospital or urgent care center visit for emergency services that are covered benefits of this Plan.

Emergency care at a doctors office or an urgent care center Emergency care as an outpatient or inpatient at a hospital, including doctorsservices Ambulance service approved by the Plan Elective care or nonemergency care

What is a medical emergency?

Emergencies within the service area

Plan pays... You pay... Emergencies outside the service area

Plan pays... You pay... What is covered

Wh at is not cove re d

Emergency Benefits continued

Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full- term delivery of a baby outside the Service Area

With your authorization, the Plan will pay benefits directly to the providers of your emergency care upon receipt of their claims. Physician claims should be submitted on the HCFA 1500 claim form. Submit claims to Kaiser Foundation Health Plan of Connecticut, Inc., Claims Department, P. O. Box 15109, Albany, NewYork 12212- 5109. If you are required to pay for the services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card.

Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the denial and the provisions of the contract on which denial was based. If you disagree with the Plans decision, you may request reconsideration in accordance with the disputed claims procedure described on page 22.

Filing claims for non- Plan providers

Mental Conditions/ Substance Abuse Benefits Mental conditions

To the extent shown below, the Plan provides the fo l l owing services necessary for the diag n o s i s and tre atment of acute psych i at ric conditions, i n cluding the tre atment of mental illness or disord e rs :

Diagnostic evaluation Psychological testing Psychiatric treatment (including individual and group therapy) Medical management visits, including drug evaluation and maintenance. You pay $5 per visit. (These visits are not charged as mental health outpatient visits.)

Hospitalization (including inpatient professional services) Up to 30 outpatient visits to Plan doctors, consultants or other psychiatric personnel each calendar year; You pay nothing for the first 10 visits, $25 per visit for visits 11- 20; 50% of charges or $50, whichever is less per visit, for visits 21- 30; all charges thereafter. Unless an appointment is canceled at least 24 hours in advance, the member must pay a charge of $25

for the broken appointment. Up to 60 days of hospitalization each calendar year; you pay nothing for first 60 days all charges thereafter (this limitation does not apply to admissions to treat biologically- based mental or nervous conditions).

If, in the professional judgment of a Plan doctor, a member would benefit from day care or night care services, up to 120 sessions of such prescribed care are provided without charge each calendar year. However, the number of such sessions is reduced by two for each day of hospitalization for inpatient Mental Conditions services received during the calendar year. Day care and night care sessions, of no less than four and no more than 12 hour duration, are provided in a hospital- based or residential treatment program. Such care includes all services of Plan doctors and mental health professionals. In addition, the following services and supplies as prescribed by a Plan doctor are covered: room and board, psychiatric nursing care, group therapy, drugs and medical supplies.

Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short- term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless determined by a Plan doctor to be necessary and appropriate

Psychological testing that is not medically necessary to determine the appropriate treatment of a short- term psychiatric condition

Substance abuse

This Plan provides medical and hospital services such as acute detox i fi c ation services for the m e d i c a l , n o n- p s y ch i at ric aspects of substance abu s e, i n cluding alcoholism and drug add i c t i o n , the same as for any other illness or condition. Services for the psych i at ric aspects are provided in conjunction with the mental conditions benefits shown ab ove. Outpatient visits to Plan mental health care prov i d e rs for fo l l ow- up care and counseling are cove re d, as well as inpatient serv i c e s n e c e s s a ry for diagnosis and tre atment. The mental conditions benefits visit/ day limitations and c o p ays ap p ly to the ab ove cove red substance abuse care. In add i t i o n , the Plan prov i d e s :

Up to 60 outpatient visits to Plan doctors, consultants or other substance abuse specialists each calendar year for the treatment of alcohol or drug abuse; you pay nothing. Unless an appointment is canceled at least 24 hours in advance, the member must pay a charge of $25 for the broken appointment.

In addition, the Plan provides up to 45 days of medical detoxification and rehabilitative treatment for substance abuse. You pay nothing for the first 45 days all charges thereafter.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Day and night care Wh at is not cove re d What is covered

Outpatient care Inpatient care Inpatient care

What is covered Outpatient care

Mental Conditions/ Substance Abuse Benefits continued

Treatment which is not authorized by a Plan doctor. All charges if the member does not complete the treatment program. Substance abuse treatment on court order or as a condition of parole or probation, unless determined by a Plan doctor to be necessary and appropriate

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Wh at is not cove re d

Prescription Drug Benefits

Prescription drugs prescribed by Plan doctors or any dentist and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply. If you choose a doctor in one of our medical offices as your primary care doctor, prescriptions must be filled at a medical office pharmacy. If you choose a network doctor as your primary care doctor, prescriptions can be filled at either a network pharmacy or a medical office pharmacy. You pay $5 per prescription or refill. It may be possible for you to receive refills by mail at no extra charge. Delivery may be made available at an additional charge. Ask for details at a Plan pharmacy.

The Plan uses a formulary to determine which prescribed drugs will be provided to members. If the doctor or dentist specifically prescribes a nonformulary drug, and does not prescribe a substitution, the nonformulary drug will be covered. If you request the nonformulary drug when your doctor or dentist has prescribed a substitution, the nonformulary drug is not covered. However, you may purchase the nonformulary drug from a Plan pharmacy at prices charged to members for non- covered drugs.

The fo l l owing drugs are provided at the $5 ch a rge (unless another ch a rge is specifi c a l ly identifi e d ) : Drugs for which a prescription is required by law Implanted time- release drugs and injectable contra c ep t ives. For Norp l a n t , you pay a one- time $ 2 0 0 per pre s c ription ch a rge. For Depo Prove ra , You pay $15. For all other intern a l ly implanted time- release drugs and injectable contra c ep t ive s , you pay a one- time payment equal to $5 per pre s c ription times the expected number of months the medication will be effe c t ive, not to exceed $200. Th e re will be no refund of any portion of these payments if the drug is re m ove d b e fo re the end of its expected life.

Insulin Glucose test strips Certain antacids Disposable needles and syringes needed for injecting covered prescribed drugs Injectable drugs for covered infertility treatments I n t ravenous fluids and medication for home use are cove red under Medical and Surgical Benefi t s . Drugs to treat sexual dysfunction have dispensing limitations. You pay 50% of charges.

Contact the Plan for details. D rugs ava i l able without a pre s c ription or for wh i ch there is a nonpre s c ription equivalent ava i l abl e Drugs obtained at a non- Plan pharmacy except for out- of- area emergencies Vitamins and nutritional substances which can be purchased without a prescription Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes Drugs to enhance athletic performance Smoking cessation drugs and medication, including nicotine patches Drugs related to non- covered infertility services

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

What is covered Limited Benefit Wh at is not cove re d

Other Benefits Dental care

The following preventive dental services are provided twice a year by participating dentists;

you pay $37 per visit.

Exams Prophylaxis (cleaning) X- rays Fluoride treatment Preventive dental instructions Dental services required due to accidental injury to sound natural teeth Other dental services not shown as covered

In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye, annual eye refractions (which include the written lens prescription for eyeglasses) may be obtained from Plan providers. You pay $5 per visit.

Corrective eyeglasses and frames or contact lenses (including the fitting of the lenses), except lenses for keracatous are covered at no charge

Eye exercises Lenses following cataract surgery

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

What is covered What is covered Wh at is not cove re d Wh at is not cove re d

Vision care

Non- FEHB Benefits Available to Plan Members

The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program, but are made available to all enrollees and family members who are members of this Plan. The cost of the benefits described on this page is not included in the FEHB premium; any charges for these services do not count toward any FEHB deductibles, out- of- pocket maximum copay charges, etc. These benefits are not subject to the FEHB disputed claims procedures.

In addition to the preventive dental services which are covered as a basic benefit under the FEHB Plan, you can also take advantage of our non- FEHB dental plan. Under this Plan, dental services such as restorative, endodontic, periodontic and prosthetic care are provided by participating plan dentists at discounted fees. For a complete listing of participating plan dentists, covered dental services and associated discounted fees, and dental services exclusions, please call our Customer Service Department at 1- 800- 305- 1992.

Kaiser Permanentes membership includes a variety of Health Education programs designed to improve, protect and maintain members health. Programs include smoking cessation, prenatal parenting, safety, weight management, stress reduction and there are many more. Most classes are available at no charge.

The Vision One Eyewear Discount Program is a non- FEHB benefit program. Under this Plan, eyeglass frames and lenses and contact lenses purchases are available at discounted fees. Call 1- 800- 424- 1155 to received an explanation of the program and locations of vision stores throughout the county.

The Kaiser Permanente Sports, Health and Fitness Discount Program is a non- FEHB benefit program featuring discounts on skiing, skating, tennis, fitness, sporting apparel and equipment and more. For more information call 1- 800- 597- 3872.

Benefits on this page are not part of the FEHB contract

Dental discount benefit

Health Education Program

Vision Discount Program

Sport Network Program

How to Obtain Benefits

If you have a question concerning Plan benefits or how to arrange for care, contact the Plans Customer Service Department at 1- 800- 305- 1992, (Hartford TDD number (203) 683- 0190, or in the Stamford area at TDD number (914) 949- 9845) or you may write to the Plan at Kaiser Foundation Health Plan of Connecticut, Inc. at the Customer Service Department at 200 Corporate Place, Suite 300, Rocky Hill, Connecticut 06067. You may also contact the Plan by fax at (518) 785- 2741 or at its website at http:// www. kaiserpermanente. org.

Disputed claims review

If a claim for payment or services is denied by the Plan, you must ask the Plan, in writing and within six months of the date of the denial, to reconsider its denial before you request a review by OPM. (This time limit may be extended if you show you were prevented by circumstances beyond your control from making your request within the time limit.) OPM will not review your request unless you demonstrate that you gave the Plan an opportunity to reconsider your claim. Your written request to the Plan must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided.

Within 30 days after receipt of your request for reconsideration, the Plan must affirm the denial in writing to you, pay the claim, provide the service, or request additional information reasonably necessary to make a determination. If the Plan asks a provider for information it will send you a copy of this request at the same time. The Plan has 30 days after receiving the information to give its decision. If this information is not supplied within 60 days, the Plan will base its decision on the information it has on hand.

If the Plan affirms its denial, you have the right to request a review by OPM to determine whether the Plans actions are in accordance with the terms of its contract. You must request the review within 90 days after the date of the Plans letter affirming its initial denial.

You may also ask OPM for a review if the Plan fails to respond within 30 days of your written request for reconsideration or 30 days after you have supplied additional information to the Plan. In this case, OPM must receive a request for review within 120 days of your request to the Plan for reconsideration or of the date you were notified that the Plan needed additional information, either from you or from your doctor or hospital.

This right is available only to you or the executor of a deceased claimants estate. Providers, legal counsel, and other interested parties may act as your representative only with your specific written consent to pursue payment of the disputed claim. OPM must receive a copy of your written consent with their request for review.

Your written request for an OPM review must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided. If the Plan has reconsidered and denied more than one unrelated claim, clearly identify the documents for each claim.

Your request must include the following information or it will be returned by OPM: A copy of your letter to the Plan requesting reconsideration; A copy of the Plans reconsideration decision (if the Plan failed to respond, provide instead (a) the date of your request to the Plan or (b) the dates the Plan requested and you provided additional information to the Plan);

Copies of documents that support your claim, such as doctors letters, operative reports, bills, medical records, and explanation of benefit (EOB) forms; and

Your daytime phone number. Medical documentation received from you or the Plan during the review process becomes a permanent part of the disputed claim file, subject to the pr ovisions of the Freedom of Information Act and the Privacy Act.

Send your request for review to: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, P. O. Box 436, Washington, DC 20044.

Questions Plan reconsideration

OPM review

How to Obtain Benefits continued

You (or a person acting on your behalf) may not bring a lawsuit to recover benefits on a claim for treatment, services, supplies or drugs covered by this Plan until you have exhausted the OPM review procedure, established at section 890.105, title 5, Code of Federal Regulations (CFR). If OPM upholds the Plans decision on your claim, and you decide to bring a lawsuit based on the denial, the lawsuit must be brought no later than December 31 of the third year after the year in which the services or supplies upon which the claim is predicated were provided. Pursuant to section 890.107, title 5, CFR, such a lawsuit must be brought against the Office of Personnel Management in Federal court.

Federal law exclusively governs all claims for relief in a lawsuit that relates to this Plans benefits or coverage or payments with respect to those benefits. Judicial action on such claims is limited to the record that was before OPM when it rendered its decision affirming the Plans denial of the benefit. The recovery in such a suit is limited to the amount of benefits in dispute.

Privacy Act statement If you ask OPM to review a denial of a claim for payment or service, OPM is authorized by chapter 89 of title 5, U. S. C., to use the information collected from you and the Plan to determine if the Plan has acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/ or the Plan in support of OPMs decision on the disputed claim.

How Kaiser Foundation Health Plan of Connecticut, Inc. Changes January 1999

Do not rely on this page; it is not an official statement of benefits.

Several changes have been made to comply with the Presidents mandate to implement the recommendations of the Patient Bill of Rights.

Women may see their Plan gynecologist as a primary care doctor. (See page 6.) If you have a chronic, complex, or serious medical condition that causes you to frequently see a Plan specialist, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist, without the need to obtain further referrals (See page 7 for details.)

A medical emergency is defined as the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care (See page 15.)

The medical management of mental conditions will be covered under this Plans Medical and Surgical Benefits provisions. Related drug costs will be covered under this Plans Prescription Drug Benefits, and any costs for psychological testing or psychotherapy will be covered under this Plans Mental Conditions Benefits. Office visits for the medical aspects of treatment do not count toward the 30 outpatient Mental Conditions visit limit.

Coverage of drugs to treat sexual dysfunction is shown under Prescription Drug Benefits. (See page 19.)

A travel benefit that covers follow- up medical services and continuing care services while you travel out of the Service Area has been added, subject to a maximum of $1,200 per year. (See page 13.)

If a member does not pay the applicable office visit charge at the time the services are provided, the member will be billed for the service. The Plan shall collect an administrative charge of $10 for every service for which payment was not made at the time the service was received. These charges will be included in the bill. (See page 11.)

Dialysis services will be provided at the office visit charge of $5. However, if a member is covered by Part B of Medicare and assigns to the Plan the right to collect payment from Medicare for these services, the office visit charge will be waived. (See page 11.)

The insertion of covered internal prosthetic devices such as pacemakers and artificial joints is covered. (See page 10.)

Program- wide changes:

Changes to this Plan:

Summary of Benefits for Kaiser Foundation Health Plan of Connecticut, Inc. 1999

Do not rely on this chart alone. All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure. This chart merely summarizes certain important expenses covered by the Plan. If you wish to enroll or change your enrollment in this Plan, be sure to indicate the correct enrollment code on your enrollment form (codes appear on the cover of this brochure). ALL SERVICES COVERED UNDER THIS PLAN, WITH THE EXCEPTION OF EMERGENCY CARE, FOLLOW UP AND CONTINUING CARE AND CARE RECEIVED FROM OTHER KAISER PERMANENTE PLANS, ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS.

Benefits Plan pays/ provides Page Inpatient care Hospital Comprehensive range of medical and surgical services without dollar

or day limit. Includes in- hospital doctor care, room and board, general nursing care, private room and private nursing care if medically necessary, diagnostic tests, drugs and medical supplies, use of operating room, intensive care and complete maternity care. You pay nothing . . . . . . . . . . . . . . . . . . . . 12

Extended care All necessary services, for up to 100 days per benefit period.

You pay nothing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 60 days

of inpatient care per year. You pay nothing. . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Substance abuse Up to 45 days per year in a substance abuse treatment program.

You pay nothing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Outpatient care Comprehensive range of services such as diagnosis and treatment of

illness or injury, including specialists care; preventive care, including well- baby care, periodic check- ups and routine immunizations; laboratory tests and X- rays; complete maternity care. You pay a $5 copay for office or outpatient surgery visit; copays are waived for maternity care;

You pay nothing for a house call by a doctor . . . . . . . . . . . . . . . . . . . . . . . . . 10 Home health care All necessary visits by nurses and health aides. You pay nothing . . . . . . . . . . 11

Mental conditions Up to 30 outpatient visits per year. You pay nothing for the first 10 visits; $25 per visit for visits 11- 20; $50 or 50% whichever is less, per visit for visits 21- 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Substance abuse Up to 60 outpatient visits per year. You pay nothing. . . . . . . . . . . . . . . . . . . . 17 Emergency care Reasonable charges for services and supplies required because of a

medical emergency. You pay a $25 copay to non- Plan providers and any charges for services that are not covered benefits of this Plan . . . . . . . . . . 15

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy.

You pay a copay of $5 per prescription unit or refill . . . . . . . . . . . . . . . . . . . . 19 Dental care Preventive dental care. You pay $37 per visit . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Vision care One refraction annually, including lens prescription.

You pay a copay of $5 per visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Out- of- pocket maximum Your out- of- pocket expenses for benefits covered under this Plan are

limited to the stated copays required for a few benefits . . . . . . . . . . . . . . . . . . . 7

1999 Rate Information for Kaiser Permanente

Non- Postal rates apply to most non- Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment.

Postal rates apply to most career U. S. Postal Service employees, but do not apply to non- career Postal employees, Postal retirees, certain special Postal employment categories or associate members of any Postal employee organization. If you are in a special Postal employment category, refer to the FEHB Guide for that category.

Non- Postal Premium Postal Premium Biweekly Monthly Biweekly

Type of Govt Your Govt Your USPS Your Enrollment Code Share Share Share Share Share Share

Self Only DM1 $72.06 $28.51 $156.13 $61.77 $84.98 $15.59 Self and Family DM2 $160.39 $81.19 $347.51 $175.91 $183.29 $58.29