FEB Broch.

Blue Care Network of Michigan

A Health Maintenance Organization Serving: Most of Michigan

Enrollment in this Plan is limited; see page (9) for requirements.

Enrollment codes: East Region:

KN1 Self Only KN2 Self and Family K51 Self Only K52 Self and Family Southeast Region:

LX1 Self Only LX2 Self and Family Mid- Michigan Region:

LN1 Self Only LN2 Self and Family West Region:

KR1 Self Only KR2 Self and Family KF1 Self Only KF2 Self and Family G71 Self Only G72 Self and Family

1999

Visit the OPM website at http:// www. opm. gov/ insure and this Plans website at http:// www. bcbsm. com

United States Office of Personnel Management RI 73- 153

Authorized for distribution by the:

For changes in benefits

see page 24.

Blue Care Network of Michigan

Blue Care Network of Michigan, Inc., 25925 Telegraph Road, P. O. Box 5043, Southfield, Michigan 48086- 5043, has entered into a contract (CS 2011) 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 the Blue Care Network of Michigan, BCN, 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 the page (23) of this brochure.

Table of Contents Page Inspector General Advisory on Fraud. ................................................................................................................................................ 3

General Information. ........................................................................................................................................................................ 3- 6

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. ........................................................................................................................................................................ 6- 9

Information you have a right to know; Who provides care to Plan members? Role of a primary care doctor; Choosing your doctor; Referrals for specialty care; Authorizations; For new members; Hospital care; Out- of- pocket maximum; Deductible carryover; Submit claims promptly; Experimental/ investigational determinations; Other considerations; The Plans service and enrollment areas

General Limitations. ...................................................................................................................................................................... 10- 11 Important notice; Circumstances beyond Plan control; Other sources of benefits

General Exclusions. ............................................................................................................................................................................. 11

Benefits. .......................................................................................................................................................................................... 12- 20 Medical and Surgical Benefits; Hospital/ Extended Care Benefits; Emergency Benefits; Mental Conditions/ Substance Abuse Benefits; Prescription Drug Benefits

Other Benefits ...................................................................................................................................................................................... 21 Dental and Vision care

Non- FEHB Benefits ............................................................................................................................................................................. 22

How to Obtain Benefits ................................................................................................................................................................. 23- 24

How Blue Care Network of Michigan Changes January 1999 .................................................................................................. 24- 25

Summary of Benefits ........................................................................................................................................................................... 26

1999 Rate Information .................................................................................................................................................................. 27- 28

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 the Plan at:

West Michigan Region 1- 800- 775- BLUE (2583) East Michigan Region 1- 800- 890- 0871 Southeast Michigan Region 1- 800- 662- 6667 Mid- Michigan Region 1- 888- 227- 2345

and explain the situation. If the matter is not resolved after speaking to the 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

General Information Confidentiality

If you are a new member

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

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, coordination of benefit provisions with other plans, and subrogation of claims; 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 16. 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 4.

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.

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 provision), 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).

Generally, you must be continuously enrolled in the FEHB Program for the last five years before you retire to continue your enrollment for you and any eligible family members after you retire.

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 for 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. See page 22 for information on the Medicare prepaid plan offered by this 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.

NOTE: If there is a delay in processing the TCC enrollment, the effective date of the enrollment is still the 32nd day after regular coverage ends. The TCC enrollee is responsible for premium payments retroactive to the effective date and coverage may not exceed the 18 or 36 month period noted above.

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

Former spouse coverage

Temporary continuation of coverage (TCC)

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 rates under the individual contract may differ from those under the FEHB Program.

Under Federal law, if you lose coverage under the FEHB Progrm, 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 been 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.

Conversion to individual coverage

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.

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:

West Michigan Region 1- 800- 775- BLUE (2583) East Michigan Region 1- 800- 890- 0871 Southeast Michigan Region 1- 800- 662- 6667 Mid- Michigan Region 1- 888- 227- 2345 or you may write the Carrier at 25925 Telegraph, P. O. Box 5043, Southfield, MI 48086- 5043. You may also contact the Carrier by fax at:

West Michigan Region 1- 616- 957- 3476 East Michigan Region 1- 517- 249- 3730 Southeast Michigan Region 1- 248- 799- 6969 Mid- Michigan Region 1- 517- 322- 8270 or its website at http:// www. bcbsm. com.

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 non compliant, 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. Nearly 3,000 participating doctors currently provide health care services to enrollees in this Plan. These doctors are located in private offices and medical centers throughout the Service Area.

The first and most important decision each member must make is the selection of a primary care doctor. The decision is important since 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 there has been a referral by the members primary care doctor. Female members age 14 or older may select both an internist and an OB/ GYN as primary care doctors. In order to better coordinate care, we encourage females to choose an internist who admits to the same hospital as the OB/ GYN.

Services of other providers are covered only when you have been referred by your primary care doctor.

The Plans provider directory lists primary care doctors (family practitioners, obstetricians/ gynecologists, pediatricians, and internists), with their locations and phone numbers. It also notes whether or not the doctor is accepting new patients. Directories are updated and available at the time of enrollment or upon request by calling the Customer Services Department at:

West Michigan Region 1- 800- 775- BLUE (2583) East Michigan Region 1- 800- 890- 0871 Southeast Michigan Region 1- 800- 662- 6667 Mid- Michigan Region 1- 888- 227- 2345; 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.

If you decide to enroll, you will be asked to complete a primary care doctor selection form and send it directly to the Plan, indicating the name of the primary care doctor( s) selected for you and each member of your family. Members may change their doctor selection by notifying the Plan. Changes received by the Plan between the 1st and the 15th of the month will become effective on the first day of the following month. If the change is received from the 16th of the month to the end of the month, the change will become effective on the first day of the second month following the month in which the change is received.

If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services until the Plan can arrange with you for you to be seen by another participating doctor.

Choosing your doctor Who provides care

to Plan members? Role of a primary care doctor Information you

have a right to know

Facts about this Plan continued.

Except in a medical emergency, or when a primary care doctor has designated another doctor to see patients when he or she is unavailable, you must receive a referral from your primary care doctor 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 participating in the Plan, 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. All follow- up care must be provided or arranged by the primary care doctor. 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 the specialist unless your primary care doctor has arranged for and the Plan has issued an authorization for the referral in advance.

The primary care physician has the discretion by the Plan to authorize multiple direct access visits under an approved treatment plan without requiring the member to obtain an approval for each visit.

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, obtain certain services, or obtain follow- up care from a specialist.

If you are already under the care of a specialist who is a Plan participant, you must still obtain a referral from a Plan primary care doctor for the care to be covered by the Plan. If the doctor who originally referred you prior to your joining the Plan is now your Plan primary care doctor, you need to call and explain that you now belong to this Plan and ask that a referral form be sent to the specialist for your next appointment.

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 covered under this Plan are limited to the stated copayments which are required for a few benefits.

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 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 January 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.

Referrals for specialty care

Authorizations For new members

Hospital care Out- of- pocket maximum

Deductible carryover

Submit claims promptly

A product or procedure is considered not experimental or investigational if it meets all of the following conditions: It has final approval from the appropriate government regulatory bodies. The scientific evidence permits conclusions concerning the effect of the technology on health

outcomes. The technology improves the net health outcome. The technology is as beneficial as any established alternatives. The investigational setting may be eliminated if the research and experimental stage of development is completed, and the improvement in net health outcome is attainable outside the investigational settings.

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 in the service area to enroll in this Plan.

SOUTHEAST MICHIGAN REGION (248) 354- 7479 or 1- 800- 662- 6667

Serving these counties: Macomb, Monroe, Oakland, St. Clair, Washtenaw and Wayne. EAST MICHIGAN REGION (517) 249- 3222 or 1- 800- 890- 0871

Serving these counties: Arenac, Bay, Genesee, Gratiot, Isabella, Lapeer, Midland, Saginaw, Shiawassee and Tuscola.

MID- MICHIGAN REGION (517) 322- 4322 or 1- 888- 227- 2345

Serving these counties: Clinton, Eaton, Hillsdale, Ingham, Jackson, Livingston and parts of Shiawassee (the towns of Perry, Shaftsburg, and Morrice), Ionia (the towns of Danby and Portland) and Hillsdale (except for Somerset and Wright Townships, and Waldron Village).

WEST MICHIGAN REGION (616) 941- 6000 or 1- 800- 775- BLUE (2583)

Serving these counties: Alcona, Alpena, Antrim, Benzie, Charlevoix, Cheboygan, Crawford, Emmet, Grand Traverse, Iosco, Kalkaska, Leelanau, Mackinac, Manistee, Montmorency, Ogemaw, Oscoda, Ostego, Presque Isle, and Roscommon.

(616) 388- 9500 or 1- 800- 775- BLUE (2583)

Serving these counties: Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph and Van Buren Counties and the portions of Allegan, Barry and Eaton counties served by the following postal zip codes: 49010, 49020, 49046, 49060, 49073, 49078 and 49080.

(616) 957- 5057 or 1- 800- 775- BLUE (2583)

Serving these counties: Ionia, Kent, Mecosta, Montcalm, Muskegon, Newaygo, Oceana, and Ottawa and the portion of Allegan County served by the following postal zip codes: 49070, 49311, 49314, 49323, 49328, 49335, 49344, 49348, 49406, 49408, 49416, 49419, 49423, 49447, 49450 and 49543.

Benefits for care outside the service area are limited to emergency services, as described on page 16.

If you or a covered family member move outside the service area, 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.

Almost anywhere within the state of Michigan, urgent care and, in some cases, routine services, can be arranged through any one of the other Blue Care Network regions. Blue Care Network is also part of a national network of Blue Cross and Blue Shield HMOs- HMO USA. Through HMO- USA, urgent care can be obtained in areas served by other Blue Cross and Blue Shield HMOs affiliated with HMO- USA. If you would like more information about receiving care away from home, please call the Customer Services Department in your area. Please see How to obtain benefits for the phone number in your area.

Experimental or Investigational Determinations

Other considerations Facts about this Plan continued.

The Plans service and enrollment areas

Reciprocity

General Limitations Group health insurance and automobile insurance

CHAMPUS Important notice

Circumstances beyond Plan control

Other sources of benefits

Medicare

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, unless you use Plan providers or the services are covered under this Plans POS benefits. 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.

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. Medicaid

11 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS General Limitations continued.

Workers compensation

DVA facilities, DoD facilities, and Indian Health Service

Other Government agencies

Liability insurance and third party actions

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 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 law. If medical benefits provided under such law 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 the recovery, or that it be subrogated to the persons rights to the extent of the benefits received under the Plan, including the right to bring suit in the persons name. If you need more information about subrogation, the Plan will provide 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 8. The following are excluded:

Care by non- Plan doctors or hospitals except for authorized referrals or emergencies (see Emergency Benefits);

Expenses incurred while not covered by this Plan; Services furnished or billed by a provider or facility barred from the FEHB Program; Services not required according to accepted standards of medical, dental, or psychiatric

practice; 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.

Medical and Surgical Benefits CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS What is covered A comprehensive range of preventive, diagnostic and treatment services is provided by Plan

doctors and other Plan providers. This includes all necessary office visits; you pay a $5 office visit copay, 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 a $5 copay for home visits by nurses and health aides.

The following services are included and are subject to the office visit copay unless stated otherwise: Preventive care, including well- baby care and periodic check- ups Mammograms are covered as follows: for women age 35 through age 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 child during the covered portion of the mothers hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment; other care of the infant requiring definitive treatment will be covered only if the infant is covered under a Self and Family enrollment.

The following gynecological services are covered without a referral when the member has selected an internist as a primary care doctor and an OB/ GYN as her second primary care doctor: obstetrical procedures including associated diagnostic lab and radiology services; maternity ultrasounds; breast physical exams; mammograms; gynecological exams, with related lab work such as pap smears and nonsurgical treatment of gynecological disorders such as cystitis during pregnancy; hospital admissions for delivery and infertility studies.

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, kidney, liver, single lung, double lung, heart/ lung, and kidney/ pancreas

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 nonHodgkins lymphoma, advanced neuroblastoma, breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors. Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be subject to participation in non- randomized clinical trials, based on recommendations by the National Cancer Institute, and require the prior approval of the Plans Medical Director. Related medical and hospital expenses of the donor are covered.

13 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 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 Chemotherapy, radiation therapy, and inhalation therapy Surgical treatment of morbid obesity Home health services of nurses, health aides, physical, occupational and speech therapists

when prescribed by your Plan doctor, who will periodically review the program for continuing appropriateness and need. Medical supplies such as dressings and antiseptics are provided in conjunction with home health care services.

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.

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. Medical services and treatment (but not dental and orthodontic services, treatment or appliances) for temporomandibular joint syndrome (TMJ) and orthognathic surgery are both covered. You pay 50% of charges. All other procedures involving the teeth and intra- oral areas surrounding the teeth are not covered.

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, cardiac, speech and occupational) is provided on an inpatient or outpatient basis for up to 60 days per condition per year if significant improvement can be expected within 60 days. You pay a $5 copay per outpatient session. 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. Cardiac rehabilitation is limited to Phase I programs for inpatients and Phase II outpatient programs following a heart transplant, myocardial infarction or bypass surgery; Phase III and IV programs are not covered.

Prosthetics, such as artificial limbs and external lenses following cataract removal, orthopedic devices, such as braces, and durable medical equipment, such as wheelchairs and hospital beds are available when obtained from a Plan vendor. Diabetic equipment such as glucose test tablets and test tape, Benedicts solution or equivalent and acetone test tablets are provided under this benefit. You pay 50% of charges.

Vision and hearing examinations are limited to members up to age 17.

Diagnosis and treatment of infertility is covered. The following types of artificial insemination are covered: intravaginal (IVI); intracervical insemination (ICI) and intrauterine (IUI). Fertility drugs are covered. Cost of donor sperm is not covered. Other assisted reproductive technology (ART) procedures such as in vitro fertilization and embryo transfer are not covered.

Limited benefits

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Medical and Surgical Benefits continued.

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

Reversal of voluntary, surgically- induced sterility Surgery primarily for cosmetic purposes Transplants not listed as covered Foot orthotics Hearing aids Chiropractic services Homemaker services Long- term rehabilitative therapy Refractions (including lens prescriptions) and corrective eyeglasses and frames or contact

lenses and their fitting

Hospital/ Extended Care Benefits What is covered

Hospital care Extended care

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 are 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 The Plan provides a comprehensive range of benefits for up to 730 days per confinement when full- time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. You pay nothing. All necessary services are covered, including:

Bed, board and general nursing care Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled

nursing facility when prescribed by a Plan doctor. Supportive and palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and 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 approximately six months or less.

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

Hospice care Ambulance service

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 18 for nonmedical Substance Abuse Benefits.

Personal comfort items, such as telephone and television Custodial care, rest cures, domiciliary or convalescent care

Limited benefits Inpatient dental procedures

Acute inpatient detoxification

What is not covered CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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 should be notified within 24 hours unless it was not reasonably possible to do so. 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 care services to the extent the services would have been covered if received from Plan providers.

$25 per visit in a hospital emergency room, or $10 per visit in an urgent care facility, and $5 per visit in a doctors office for emergency care services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the emergency care copay is waived.

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

Benefits outside the Service Area

What is covered Plan pays...

You pay... CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Emergency Benefits

What is a medical emergency?

Emergencies within the service area

A medical emergency is 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 primary care doctor. 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 should notify the Plan within 24 hours unless it was not reasonably 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 should be notified within 24 hours unless it was not reasonably possible to do so. If you are hospitalized in non- Plan facilities and 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.

Benefits are available for care from non- Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability, 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 care services to the extent the services would have been covered if received from Plan providers.

Plan pays... You pay...

17 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Emergency Benefits continued.

What is not covered Filing claims for non- Plan providers

Elective care or nonemergency care Emergency care provided outside the Service Area if the need for care could have been

foreseen before departing 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. 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 23.

Mental Conditions/ Substance Abuse Benefits Mental Conditions

What is covered Outpatient care Inpatient care What is not covered

Substance Abuse What is covered

Outpatient care Inpatient care What is not covered

To the extent shown below, the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions, including treatment of mental illness or disorders:

Diagnostic evaluation Psychological testing Psychiatric treatment (including individual and group therapy) Hospitalization (including inpatient professional services)

Initial assessments and referrals must be arranged (by either the member or their primary care physician) by calling their Regional Plan Mental Health and Substance Abuse Department at :

West Michigan Region 1- 800- 733- 1525 East Michigan Region 1- 800- 280- 8708 Southeast Michigan Region 1- 800- 482- 5982 Mid- Michigan Region 1- 800- 823- 6369

Up to 20 outpatient visits to Plan doctors, consultants, or other psychiatric personnel each calendar year; you pay nothing for each covered visit - all charges thereafter.

Up to 45 days of hospitalization each calendar year; you pay nothing for the first 45 days all charges thereafter.

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 when not medically necessary to determine the appropriate treatment of a short- term psychiatric condition

This Plan provides medical and hospital services such as acute detoxification services for the medical, non- psychiatric aspects of substance abuse, including alcoholism and drug addiction, the same as for any other illness or condition, and, to the extent shown below, the services necessary for diagnosis and treatment. Initial assessments and referrals must be arranged (by either the member or their primary care physician) by calling their Regional Plan Mental Health and Substance Abuse Department at:

West Michigan Region 1- 800- 733- 1525 East Michigan Region 1- 800- 280- 8708 Southeast Michigan Region 1- 800- 482- 5982 Mid- Michigan Region 1- 800- 823- 6369

Up to 20 outpatient visits to Plan providers for treatment each calendar year; you pay nothing for each covered visit all charges thereafter.

The substance abuse benefit may be combined with the outpatient mental conditions benefit shown above, provided such treatment is necessary and is approved by the Plan, to permit an additional 20 outpatient visits per calendar year with the applicable mental conditions benefit copayments.

One substance abuse rehabilitation (intermediate care) program per 12- month period in an alcohol detoxification or rehabilitation center approved by the Plan; you pay nothing during the benefit period all charges thereafter.

Treatment that is not authorized by a Plan doctor or the Mental Health and Substance Abuse Case Management Department.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Prescription Drug Benefits

Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34- day supply. You pay a $5 copay per prescription unit or refill for generic drugs or for name brand drugs when generic substitution is not permissible. When generic substitution is permissible (i. e., a generic drug is available and the prescribing doctor does not require the use of a name brand drug), but you request the name brand drug, you pay the price difference between the generic and name brand drug as well as the $5 copay per prescription unit or refill. Emergency prescription drugs purchased within the Service Area from a non- Plan pharmacy are reimbursed at 75% of cost minus the $5 copay. Emergency prescription drugs filled outside of the Plans Service Area are reimbursed at 100% of cost, minus the $5 copay.

Blue Care Network currently has an open voluntary formulary which is maintained by the BCN Pharmacy and Therapeutics Committee. Generic substitution is mandatory where appropriate. Generic substitution is not mandatory for critical drugs. Critical drugs are products where clinical judgment recommends using the brand- name drug because the generic drug cannot be safely substituted. These drugs are: Lanoxin, Dilantin, Coumadin, Premarin, Theodur, Slophyllin, Tegretol, and Synthroid. A few select drugs on the formulary are part of the BCN Quality Interchange Program and may require prior authorization.

Maintenance drugs may be obtained through the Plans mail order drug program. Certain maintenance drugs may be obtained for up to a 90- day supply at the $5 copay. Call your regional health plan for more information.

West Michigan Region 1- 800- 775- BLUE (2583) East Michigan Region 1- 800- 890- 0871 Southeast Michigan Region 1- 800- 662- 6667 Mid- Michigan Region 1- 888- 227- 2345

Covered medications and accessories include: Formulary drugs for which a prescription is required by law Contraceptive devices including diaphragms and IUDs Oral contraceptive drugs - up to a three- cycle supply may be obtained for a single copay Injectable contraceptive drugs Smoking cessation drugs and medication Disposable needles and syringes needed to inject covered prescribed medications Intravenous fluids and medications for home use Insulin with a copay charge applied to each vial Diabetic supplies including insulin syringes and needles Fertility drugs are covered under the Plans infertility benefit . See page 13.

Drugs to treat sexual dysfunction are limited. Contact the plan for dose limits. You pay $5 copayment up to the dosage limits and all charges above that.

What is covered

Limited Benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Prescription Drug Benefits continued.

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available

Drugs obtained at a non- Plan pharmacy except for out- of- area emergencies Vitamins and nutritional substances that can be purchased without a prescription Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes Drugs to enhance athletic performance Implanted time- release medications, such as Norplant

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Dental care Other Benefits

What is covered

Restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth are covered. The need for these services must result from an accidental injury, not biting or chewing. You pay nothing.

Other dental services not shown as covered In addition to medical and surgical benefits provided for diagnosis and treatment of diseases of the eye, annual eye refractions (to provide a written lens prescription for eyeglasses) may be obtained from Plan optometrists. You pay a $5 copay per visit and charges above the Plans allowance for lenses and frames. Non- participating vision care professionals are paid at 75% of the reasonable charge for testing, less the $5 copay. For lenses and frames, the Plan pays a predetermined level.

You pay non- participating professional all other charges for visit and for lenses and frames. The following are also available from Plan providers: One pair of lenses every 24 months Up to $37.50 toward the cost of one pair of frames: a $7.50 copay per corrective lenses

prescribed by a Plan provider; a $7.50 copay per pair of corrective contact lenses if authorized by a Plan provider as medically necessary; costs above $35.00 per pair of corrective contact lenses if not medically necessary. The Plan provides regular glass lenses, tints #1 and #2, bifocals, trifocals, and standard frames.

Eye exercises Photo- sensitive lenses Non- medically necessary tinted lenses Safety glasses Repair or replacement of lost or broken lenses or frames

Vision care What is not covered Accidental injury

benefit What is not covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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 of the Plan. The cost of the benefits described on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out- of- pocket maximums. These benefits are not subject to the FEHB disputed claims procedure.

Medicare prepaid plan enrollment

Health Promotion and Education Programs

Dental Care Network Personal program Non- FEHB Benefits Available to Plan Members

This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare. As indicated on page 4, annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area. They may then later reenroll in the FEHB Program. Most Federal annuitants have Medicare Part A. Those without Medicare Part A may join this Medicare prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether the plan covers hospital benefits and, if so, what you will have to pay. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan. Contact us at 888- 333- 3129 for information on the Medicare prepaid plan and the cost of that enrollment.

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plans FEHB plan, please call 888- 333- 3129 for information on the benefits available under the Medicare HMO.

We offer you a host of wellness programs geared toward preventing illness and successfully dealing with certain chronic diseases. Some of these programs include:

An asthma management program thats been proven to reduce hospitalizations and visits to the emergency room.

A diabetes management program that teaches you, family members or caregivers how to control diabetes through basic self- monitoring procedures.

A smoking cessation program offering effective tools and tips to help you quit smoking. A program that addresses congestive heart failure. Youll work closely with your primary care

physician, using self- monitoring techniques and lifestyle adjustments to keep this condition under control.

For more information on Health Promotion and Education Programs in your region, call: West Michigan Region 1- 800- 775- BLUE (2583) East Michigan Region 1- 800- 890- 0871 Southeast Michigan Region 1- 800- 662- 6667 Mid- Michigan Region 1- 888- 227- 2345

Dental Care Network (DCN) is an affiliate of Blue Cross Blue Shield of Michigan. DCN is one of the most complete packages of individual dental benefits available to Michigan residents. Under DCN your dental care is provided, arranged and coordinated by a qualified participating dentist who practices from his or her own private office. All DCN participating dentists are licensed and carefully chosen by DCNs credentialing staff. Each dentist is reviewed periodically to ensure compliance with DCNs quality assurance guidelines and they also must uphold DCNs managed care standards. Enrollment in the DCN Personal program is offered twice a year. The first enrollment period begins May 1 and runs through May 31 for a July 1 effective date. The second enrollment period begins November 1 and runs through December 15 for a January 1 effective date. To receive an enrollment package with rates, benefit description, provider directory and an application, please call a DCN Customer Service Representative at 800- 321- 8077. Be sure to identify yourself as a Federal employee when calling during the Nov. - Dec. open season.

Benefits on this page are not part of the FEHB contract

How to Obtain Benefits Questions

Disputed claims review

Plan reconsideration

OPM review

If you have a question concerning Plan benefits or how to arrange for care, contact the Plans Member Services Department at:

West Michigan Region 1- 800- 775- BLUE (2583) East Michigan Region 1- 800- 890- 0871 Southeast Michigan Region 1- 800- 662- 6667 Mid- Michigan Region 1- 888- 227- 2345 or the Plans TDD number at 800- 257- 9980, or you may write to the Plan at Blue Care Network, 25925 Telegraph Road, Box 5043, Southfield, MI 48086- 5043.

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 provisions 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 4, P. O. Box 436, Washington, DC 20044.

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 to Obtain Benefits continued.

OPM review

continued

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

How Blue Care Network of Michigan Changes January 1999 ProgramWide Changes:

Changes to this Plan:

Several changes have been made to comply with the Presidents mandate to implement the recommendations of the Patient Bill of Rights. 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. The medical management of certain 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 20 outpatient Mental Conditions visit limit.) Women may see their Plan gynecologist for their annual routine examination without a

referral from their primary care doctor. 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.

Southeast Region

Prescription Drug copayment has changed from $2 to $5.

Enhanced Vision Benefit.

Most of St. Clair county has been added to the Southeast Region Service Area.

Coverage of drugs for sexual dysfunction is shown under the Prescription Drug Benefit.

Mid- Michigan Region

The 50% copayment for family planning services is now waived. A new dental care program through Dental Care Network (this is a non- FEHB benefit). Your

dental coverage with Blue Cross Blue Shield of Michigan will be cancelled effective January 1, 1999. 730 days of full- time skilled nursing care benefits. A $25 copayment applies to all emergency services. Coverage of drugs for sexual dysfunction is shown under the Prescription Drug Benefit.

East Region

Prescription Drug copayment has changed from $3 to $5. The 50% copayment for family planning services is now waived. The 50% copayment for allergy services is now waived. A new dental care program through Dental Care Network (this is a non- FEHB benefit). Enhanced Vision Benefit. 730 days of full- time skilled nursing care benefits. Coverage of drugs for sexual dysfunction is shown under Prescription Drug Benefit.

West Region

The 50% copayment for family planning services is now waived. The 50% copayment for allergy services is now waived. 730 days of full- time skilled nursing care benefits. A new dental care program through Dental Care Network (this is a non- FEHB benefit). Enhanced Vision Benefit. Coverage of drugs for sexual dysfunction is shown under Prescription Drug Benefit.

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

How Blue Care Network of Michigan Changes January 1999 Changes to this Plan:

continued continued

26 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, ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS.

Benefits Plan pays/ provides Page Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit. Includes .....

care 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 ................................................. 15

Extended Care All necessary services, for up to 730 days per confinement. You pay nothing ........................ 15

Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 45 days of inpatient care per . year. You pay nothing ............................................................................................................... 18

Substance Abuse One substance abuse rehabilitation program per 12- month period. You pay nothing .............. 18

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury, including

care 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 per . office visit; $5 per house call by a doctor ................................................................................. 12

Home Health Care All necessary visits by nurses and health aides. You pay a $5 copay per visit ......................... 13

Mental Conditions Up to 20 outpatient visits per year. You pay nothing ................................................................ 18

Substance Abuse Up to 20 outpatient visits per year. You pay nothing ................................................................ 18

Emergency Reasonable charges for services and supplies required because of a medical emergency. You care pay a $25 copay to the hospital, a $10 copay to an urgent care center and a $5 copay in a .........

doctors office for each emergency room visit and any charges for services that are not covered by the plan ............................................................................................................................ 16- 17

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy. You pay a $5 copay ......... per prescription unit or refill................................................................................................... 19- 20

Dental care Accidental injury benefit. You pay nothing................................................................................ 21

Vision care Lenses and Frames .................................................................................................................... 21

Out- of- pocket Your out- of- pocket expenses for benefits covered under this Plan are limited to the stated ........

limit copayments that are required for a few benefits ........................................................................... 8

Summary of Benefits for Blue Care Network of Michigan 1999

MID- MICHIGAN REGION Serving these counties: Clinton, Eaton, Hillsdale, Ingham, Jackson, Livingston and parts of Shiawassee (the towns of Perry, Shaftsburg, and Morrice), Ionia (the towns of Danby and Portland) and Hillsdale (except for Somerset and Wright Townships, and Waldron Village).

EAST MICHIGAN REGION Serving these counties: Genesee, Lapeer and Shiawassee

EAST MICHIGAN REGION Serving these counties: Arenac, Bay, Gratiot, Isabella, Midland, Saginaw and Tuscola.

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 KN1 $60.95 $20.31 $132.05 $44.01 $72.12 $9.14 Self and Family KN2 $160.39 $82.72 $347.51 $179.23 $183.29 $59.82

Self Only K51 $65.66 $21.89 $142.27 $47.42 $77.70 $9.85 Self and Family K52 $160.39 $59.01 $347.51 $127.86 $183.29 $36.11

Self Only LN1 $68.75 $22.91 $148.95 $49.65 $81.35 $10.31 Self and Family LN2 $160.39 $60.36 $347.51 $130.78 $183.29 $37.46

WEST MICHIGAN REGION Serving these counties: Ionia, Kent, Mecosta, Montcalm, Muskegon, Newaygo, Oceana, and Ottawa and the portion of Allegan County served by the following postal zip codes: 49070, 49311, 49314, 49323, 49328, 49335, 49344, 49348, 49406, 49408, 49416, 49419, 49423, 49447, 49450 and 49543.

WEST MICHIGAN REGION Serving these counties: Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph and Van Buren Counties and the portions of Allegan, Barry and Eaton counties served by the following postal zip codes: 49010, 49020, 49046, 49060, 49073, 49078 and 49080.

WEST MICHIGAN REGION Serving these counties: Alcona, Alpena, Antrim, Benzie, Charlevoix, Cheboygan, Crawford, Emmet, Grand Traverse, Iosco, Kalkaska, Leelanau, Mackinac, Manistee, Montmorency, Ogemaw, Oscoda, Ostego, Presque Isle, and Roscommon.

SOUTHEAST MICHIGAN REGION Serving these counties: Macomb, Monroe, Oakland, St. Clair, Washtenaw and Wayne.

Self Only LX1 $46.21 $15.40 $100.12 $33.37 $54.68 $6.93 Self and Family LX2 $152.86 $50.95 $331.19 $110.40 $180.88 $22.93

Self Only G71 $72.06 $41.24 $156.13 $89.35 $84.98 $28.32 Self and Family G72 $160.39 $126.22 $347.51 $273.48 $183.29 $103.32

Self Only KF1 $59.99 $19.99 $129.97 $43.32 $70.98 $9.00 Self and Family KF2 $160.39 $60.11 $347.51 $130.24 $183.29 $37.21

Self Only KR1 $58.86 $19.62 $127.53 $42.51 $69.65 $8.83 Self and Family KR2 $160.39 $66.69 $347.51 $144.50 $183.29 $43.79

Non- Postal Premium Postal Premium Biweekly Monthly Biweekly Type of Govt Your Govt Your USPS Your Enrollment Code Share Share Share Share Share Share