Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, contact us as follows:

High Option: Call us at 800/222-APWU or write to us at P.O. Box 3279, Silver Spring, MD 20918 or through our Web site at www.apwuhp.com.

Consumer-driven Option: Call Definity Health at 866/833-3463 or request replacement cards through the Web site at www.definityhealth.com.

Where you get covered care

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

Covered providers

We consider the following to be covered providers when they perform services within the scope of their license or certification:

1. Doctor � A licensed doctor of medicine (M.D.), a licensed doctor of osteopathy (D.O.), a licensed doctor of podiatry (D.P.M.), or, for certain specified services covered by this Plan, a licensed dentist, licensed chiropractor, or licensed clinical psychologist practicing within the scope of the license.

2. Alternate Provider � Alternate providers are covered when performing certain specified services covered by this Plan and when such treatment is within the scope of the provider�s license. Alternate providers are limited to licensed physical occupational and speech therapists licensed physician�s assistants; Registered Nurses (R.N.); Licensed Practical Nurses (L.P.N.); Licensed Vocational Nurses (L.V.N.); and Certified Registered Nurse Anesthetists (C.R.N.A.).

3. Other covered providers include a qualified clinical psychologist, clinical social worker, optometrist, audiologist, nurse midwife nurse practitioner /clinical specialist, and nursing school administered clinic. For purposes of this FEHB brochure, the term �doctor� includes all of these providers when the services are performed within the scope of their license or certification.

Medically underserved areas. Note: We cover any licensed medical practitioner for any covered service performed within the scope of that license in states OPM determines are �medically underserved.� For 2005, the states are: Alabama, Alaska, Idaho, Kentucky, Louisiana, Mississippi, Missouri, Montana, New Mexico, North Dakota, South Carolina, South Dakota, Texas, and Wyoming.

Covered facilities

Covered facilities include:

Freestanding ambulatory facility

An out-of-hospital facility such as a medical, cancer, dialysis, or surgical center or clinic, and licensed outpatient facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations for treatment of substance abuse.

Covered facilities (continued)

Hospital

1. An institution which is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations, or

2. Any other institution which is operated pursuant to law, under the supervision of a staff of doctors and twenty-four hour a day nursing service, and which is primarily engaged in providing:

a) general inpatient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities, all of which must be provided on its premises or under its control, or

b) specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized provider of those facilities.

The term �hospital� shall not include a skilled nursing facility, a convalescent nursing home or institution or part thereof which 1) is used principally as a convalescent facility, rest facility, residential treatment center, nursing facility or facility for the aged or 2) furnishes primarily domiciliary or custodial care, including training in the routines of daily living.

What you must do to
get covered care

It depends on the kind of care you want to receive. You can go to any provider you want, but we must approve some care in advance.

Transitional care

Specialty care: If you have a chronic or disabling condition and

lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or

lose access to your PPO specialist because we terminate our contract with your specialist for other than cause,

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

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

Hospital care

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our High Option begins, call our customer service department immediately at 800/222-APWU. For the Consumer-driven Option, please call Definity Health at 866/833-3463.

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

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

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

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

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

How to Get Approval for�

Your hospital stay

Precertification is the process by which � prior to your inpatient hospital admission � we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won�t change our decision on medical necessity.

In most cases, your physician or hospital will take care of precertification. Because you are still responsible for ensuring that we are asked to precertify your care, you should always ask your physician or hospital whether they have contacted us.

Warning

We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any benefits.

How to precertify an
admission

High Option: You, your representative, your doctor, or your hospital must call Spectera/CARE at 800/580-8771 at least 48 hours before admission. In Minnesota, call PreferredOne at 800/451-9597 to precertify. These numbers are available 24 hours every day.

Consumer-driven Option: You, your representative, your doctor, or your hospital must call Definity Health at 866/333-4648 at least 48 hours before admission. This number is available 24 hours every day.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the doctor, or the hospital must telephone the above number 48 hours following the day of the emergency admission, even if you have been discharged from the hospital.

Provide the following information:

- Enrollee�s name and Plan identification number

- Patient�s name, birth date, and phone number

- Reason for hospitalization, proposed treatment, or surgery

- Name and phone number of admitting doctor

- Name of hospital or facility; and

- Number of planned days of confinement

We will then tell the doctor and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the hospital.

Maternity care

You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.

If your hospital stay
needs to be extended

High Option: If your hospital stay -- including for maternity care -- needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days by calling Spectera/CARE at 800/580-8771 or in Minnesota, call PreferredOne at 800/451-9597.

Consumer-driven Option: If your hospital stay � including for maternity care - needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days by calling Definity Health at 866/333-4648.

What happens when you
do not follow the precertification rules

If no one contacted us, we will decide whether the hospital stay was medically necessary.

If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty.

If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.

If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.

When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then:

For the part of the admission that was medically necessary, we will pay inpatient benefits, but

For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.

Exceptions

You do not need precertification in these cases:

You are admitted to a hospital outside the United States and Puerto Rico.

You have another group health insurance policy that is the primary payer for the hospital stay.

Your Medicare Part A is the primary payer for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payer and you do need precertification.

Radiology/Imaging Procedures Precertification

High Option: Radiology precertification is required prior to scheduling specific imaging procedures. We evaluate the medical necessity of your proposed procedure to ensure that the appropriate procedure is being requested for your condition. In most cases your physician will take care of the precertification. Because you are responsible for ensuring that precertification is done, you should ask your doctor to contact us.

The following outpatient radiology services require precertification:

CAT/CT � Computerized Axial Tomography

MRI � Magnetic Resonance Imaging

MRA � Magnetic Resonance Angiography

NC � Nuclear Cardiology

PET � Positron Emission Tomography

How to precertify a radiology/imaging procedure

For these outpatient studies; you, your representative or doctor must call MedSolutions before scheduling the procedure. The toll free number is 888/693-3298.

Provide the following information:

- Patient's name, Plan identification number, and birth date

- Requested procedure and clinical support for request

- Name and phone number of ordering provider

- Name of requested imaging facility

Exceptions

You do not need precertification in these cases:

You have another health insurance policy that is primary including Medicare Parts A&B or Part B Only

The procedure is performed outside the United States or Puerto Rico

You are inpatient hospital

The procedure is performed as an emergency

Warning

We will reduce our benefits for these procedures by $100 if no one contacts us for precertification. If the procedure is not medically necessary, we will not pay any benefits.

Other services

Some services require prior approval (High Option) and some require pre-notification (Consumer-driven Option):

High Option: Call Spectera/CARE at 800/580-8771 if you need any of the services listed below:

Consumer-driven Option: Call Definity Health at 866/333-4648 if you need any of the services listed below:

Prior approval/pre-notification is required for organ transplantation. Call before your first evaluation as a potential candidate.

Prior approval/pre-notification is required for surgical procedures which may be cosmetic in nature such as eyelid surgery (blepharoplasty) or varicose vein surgery (sclerotherapy).

Prior approval/pre-notification is required for recognized surgery for morbid obesity or for organic impotence.

Prior approval/pre-notification is required for home health care such as nursing visits, infusion therapy, growth hormone therapy (GHT), rehabilitative therapy (physical, occupational or speech therapy) and pulmonary rehabilitation programs.

Prior approval/pre-notification is required for durable medical equipment such as wheelchairs, oxygen equipment and supplies, artificial limbs and braces and for Retin A, Botox or drugs for organic impotence.

Prior approval is also required for mental health and substance abuse benefits, inpatient or outpatient, in-network or out-of-network. Under the High Option and the Consumer-driven Option, call ValueOptions at 888/700-7965.

Copayments

High Option: A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: Under the High Option, when you see your PPO physician you pay a copayment of $18 per visit.

Consumer-driven Option: There are no copayments under the Consumer-driven Option.

Deductible

Adeductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

High Option

If you use PPO providers, the calendar year deductible is $275 per person. Under a family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $550. If you use non-PPO providers, your calendar year deductible increases to a maximum of $500 per person ($1,000 per family). Whether or not you use PPO providers, your calendar year deductible will not exceed $500 per person ($1,000 per family).

We also have a separate deductible for mental health and substance abuse benefits. The in-network deductible is $275 per person. Under a family enrollment, this deductible is satisfied for all family members when the combined in-network covered expenses applied to this deductible for all family members reach $550. The out-of-network deductible is $750 per person each calendar year with no family maximum.

Note: If you change plans during Open Season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

And, if you change from Self and Family to Self Only, or from Self Only to Self and Family during the year, we will credit the amount of covered expenses already applied toward the deductible of your old enrollment to the deductible of your new enrollment. However, if you change from High Option to Consumer-driven Option, or from Consumer-driven Option to High Option, during the year, expenses incurred as of the effective date of the option change are subject to the benefit provisions of your new option.

Consumer-driven Option: There is no calendar year deductible under the Consumer-driven Option. Also, there is no separate deductible for mental health and substance abuse benefits under the Consumer-driven Option.

Coinsurance

High Option: Coinsurance is thepercentage of our allowance that you must pay for your care. Coinsurance doesn�t begin until you meet your deductible (High Option) or your Member Responsibility (Consumer-driven Option).

Example: You pay 30% of our allowance for office visits to a non-PPO physician.

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

For example, if your physician ordinarily charges $100 for a service but routinely waives your 30% coinsurance, the actual charge is $70. We will pay $49 (70% of the actual charge of $70).

Consumer-driven Option: Coinsurance is the percentage of our allowance that you must pay for your care after you have used up your Personal Care Account (PCA) and paid your Member Responsibility.

Member Responsibility

High Option: Does not apply.

Consumer-driven Option: Your Member Responsibility is your bridge between your Personal Care Account (PCA) and your Traditional Health Coverage. After you have exhausted your PCA, you must pay your Member Responsibility before your Traditional Health Coverage begins. Your Member Responsibility is generally $600 for a Self Only enrollment or $1,200 for a Self and Family enrollment. Your Member Responsibility in subsequent years may be reduced by rolling over any unused portion of your Personal Care Account remaining at the end of the calendar year(s).

Differences between our allowance and the bill

High Option: Our �Plan allowance� is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in different ways, so their allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 11.

Often, the provider�s bill is more than a fee-for-service plan�s allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on the provider you use.

PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance or copayment.Here is an example about coinsurance: You see a PPO physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just -- 10% of our $100 allowance ($10). Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and his bill.

Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. When you use a non-PPO provider, you will pay your deductible and coinsurance -- plus any difference between our allowance and charges on the bill. Here is an example: You see a non-PPO physician who charges $150 and our allowance is again $100. Because you�ve met your deductible, you are responsible for your coinsurance, so you pay 30% of our $100 allowance ($30). Plus, because there is no agreement between the non-PPO physician and us, he can bill you for the $50 difference between our allowance and his bill.

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

Physician�s charge

$150

$150

Our allowance

We set it at:

100

We set it at:

100

We pay

90% of our allowance:

90

70% of our allowance:

70

You owe: Coinsurance

10% of our allowance:

10

30% of our allowance:

30

+Difference up to charge?

No:

0

Yes:

50

TOTAL YOU PAY

$10

$80

Consumer-driven Option:

PPO providers agree to accept our plan allowance so if you use a PPO Provider, you never have to worry about paying the difference between the plan allowance and the billed amount for covered services. If your covered expenses are being paid out of your Personal Care Account or if you are receiving in-network covered preventive services, the plan will pay 100%. If you have exhausted your Personal Care Account, you will be responsible for paying your Member Responsibility and also coinsurance under the Traditional Health Coverage.

Non PPO Providers: If you use a non-PPO provider, you will have to pay the difference between the plan allowance and the billed amount only if you use up your Personal Care Account for the year. Note that it usually makes sense to use PPO providers because it will make your Personal Care Account go much further since money left in your Personal Care Account can be rolled over to be used in the next year.

Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, copayments, and Member Responsibility

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

High Option:

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

Non-PPO benefit: Your out-of-pocket maximum is $10,000 for either a Self Only or a Self and Family enrollment if you are using non-PPO providers. Eligible expenses for network providers also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers.

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

The 10% you pay for PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services

The 30% you pay for non-PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services; and

The copayment of $18 for outpatient visits to PPO physicians

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

Expenses in excess of our allowance or maximum benefit limitations

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

Any amounts you pay because benefits have been reduced for non-compliance with this Plan's cost containment requirements (see pages 11, 12, 13 and 14)

Covered expenses applied to the $275 or $500 calendar year deductibles

Covered expenses applied to the $275 deductible for in-network mental health or substance abuse care

The $300 per admission deductible for non-PPO Inpatient hospital charges

Expenses for prescription drugs

Expenses in excess of visit maximums for physical, occupational and speech therapy (see page 26)

Expenses incurred in excess of the $90 per day provided under home nursing care (see page 29); and

Expenses in excess of hospice care and preventive care maximums

Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, copayments, and Member Responsibility (continued)

Consumer-driven Option:

If you have exceeded your Personal Care Account and met your Member Responsibility the following would apply:

In-network benefit: Your out-of-pocket maximum is $4,500 for either a Self Only or a Self and Family enrollment if you are using network providers. Only eligible expenses for network providers count toward this limit.

Out-of-network benefit: Your out-of-pocket maximum is $9,000 for either a Self Only or a Self and Family enrollment if you are using out-of-network providers. Eligible expenses for network providers also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers.

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

The 15% you pay for in-network Inpatient and outpatient hospital charges, Surgical, Medical, Maternity and Emergency services under the Traditional Health Coverage

The 40% you pay for out-of-network Inpatient and outpatient hospital charges, Surgical, Medical, Maternity and Emergency services under the Traditional Health Coverage

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

Any expenses paid by the Plan under your Personal Care Account

Any expenses paid by the Plan under your In-network Preventive Care benefit

Any expenses you must pay under your Member Responsibility

Expenses in excess of our allowance or maximum benefit limitations or expenses not covered under the Traditional Health Coverage

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

Expenses you pay for prescription drugs under your Traditional Health Coverage

Dental care or vision care expenses above the limitations provided under your Personal Care Account

Any amounts you pay because benefits have been reduced for non-compliance with this Plan�s cost containment requirements (see pages 11, 12, 13, 14 and 15)

Expenses in excess of hospice care maximums

Carryover

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

When Government facilities
bill us

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

If we overpay you

We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments. We will generally first seek recovery from the provider if we paid the provider directly, or from the person (covered family member, guardian, custodial parent, etc.) to whom we sent our payment.

If you�

are age 65 or over, and

do not have Medicare Part A, Part B, or both; and

have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and

are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)

Then, for your inpatient hospital care,

the law requires us to base our payment on an amount -- the �equivalent Medicare amount� -- set by Medicare�s rules for what Medicare would pay, not on the actual charge;

you are responsible for your applicable deductibles, coinsurance, or copayments you owe under this Plan;

you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you; and

the law prohibits a hospital from collecting more than the Medicare equivalent amount.

And, for your physician care, the law requires us to base our payment and your coinsurance on�

an amount set by Medicare and called the �Medicare approved amount,� or

the actual charge if it is lower than the Medicare approved amount.

Participates with Medicare or accepts Medicare assignment for the claim and is a member of our PPO network,

your deductibles, coinsurance, and copayments;

Participates with Medicare and is not in our PPO network,

your deductibles, coinsurance, copayments, and any balance up to the Medicare approved amount;

Does not participate with Medicare,

your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare approved amount

It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect only up to the Medicare approved amount.

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than allowed, ask for a refund. If you need further assistance, call us.

When you have the Original Medicare Plan
(Part A, Part B, or both)

We limit our payment to an amount that supplements the benefits that Medicare would pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital, that does not participate with Medicare and is not reimbursed by Medicare.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician accepts Medicare assignment for the claim.

High Option: If your physician accepts Medicare assignment, then you pay nothing for covered charges.

Consumer-driven Option: If your physician accepts Medicare assignment, then you pay nothing if you have unused benefits available under your Personal Care Account to pay the difference between the Medicare approved amount and Medicare�s payment. If your PCA is exhausted, you must pay either this full difference under your Member Responsibility or the lesser of your coinsurance or the full difference if your Member Responsibility has been met.

If your physician does not accept Medicare assignment, then you pay the difference between the "limiting charge" or the physician's charge (whichever is less) and our payment combined with Medicare�s payment.

It's important to know that a physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the �limiting charge.� The Medicare Summary Notice (MSN) that Medicare will send you will have more information about the limiting charge. If your physician tries to collect more than allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to your Medicare carrier who sent you the MSN form. Call us if you need further assistance.

Please see Section 10, Coordinating benefits with other coverage, for more information about how we coordinate benefits with Medicare.

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

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

The calendar year deductible is: PPO - $275 per person ($550 per family); Non-PPO - $500 per person ($1,000 per family). The calendar year deductible applies to almost all benefits in this Section. We added �(No deductible)� to show when the calendar year deductible does not apply.

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

When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists, may not all be preferred providers. If they are not, they will be paid by this Plan as non-PPO providers. However, if surgical services are rendered at a PPO hospital or a PPO freestanding ambulatory facility by a PPO primary surgeon, we will pay the services of anesthesiologists who are not preferred providers at the PPO rate, based on Plan allowance.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

YOU MUST GET PRECERTIFICATION OF CERTAIN OUTPATIENT IMAGING PROCEDURES. FAILURE TO DO SO WILL RESULT IN A MINIMUM OF $100 PENALTY. Please refer to precertification information in Section 3 to be sure which procedures require precertification.

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Note: The calendar year deductible applies to almost all benefits in this Section. We say �(No deductible)� when it does not apply.

Professional services of physicians

In physician�s office

One annual routine gynecological visit for pap test for women age 18 or over � PPO only

PPO: $18 copayment (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Professional services of physicians

In an urgent care center

During a hospital stay

In a skilled nursing facility

Initial examination of a newborn child covered under a family enrollment

Second surgical opinion

At home

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Routine physical checkups and related tests

Non-PPO annual routine gynecological visits

All charges

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT and CT Scans/MRI/MRA/NC/PET (Outpatient requires precertification � See Section 3)

Ultrasound

Electrocardiogram and EEG

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Note: If your PPO provider uses a non-PPO lab or radiologist, we will pay non-PPO benefits for any lab and X-ray charges.

Not covered: Professional fees for automated lab tests

All charges

Routine screenings, limited to:

Total Blood Cholesterol � once annually

Fasting lipoprotein profile, once every 5 years for adults age 20 or over

Osteoporosis screening, once every two years, for women age 65 and older

Chlamydial infection

Colorectal Cancer Screening, including

- Fecal occult blood test, once annually, ages 40 and older

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

- Colonoscopy, once every 10 years starting at age 50

- Double Contrast Barium Enema (DCBE), once every 5 years starting at age 50

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

Routine pap test, one annually, women age 18 and older

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Routine mammograms� covered for women age 35 and older, as follows:

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

From age 40 through 64, one every calendar year

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

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Routine immunizations, limited to:

Tetanus-diphtheria (Td) booster � once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually

Pneumococcal vaccine, age 65 and older

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Adult immunizations other than those listed above

Office visit associated with preventive care other than one annual routine PPO gynecological visit for pap test for women age 18 or over

All charges

Childhood immunizations recommended by the American Academy of Pediatrics up to age 22

Examinations, limited to:

- Well-child care charges for physical examinations and laboratory tests through age 12

- Examination for amblyopia and strabismus-limited to one screening examination (age 2 through 6)

PPO: Nothing (No deductible)

Non-PPO: Any difference between the Plan allowance and the billed charge (No deductible)

PPO: Nothing (No deductible)

Non-PPO: Any difference between the Plan allowance and the billed charge and any amount above $250 per child (ages 0 through 3) each year and any amount above $150 per child (ages 4 through 12) each year (No deductible)

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see page 11 for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary, but you, your representative, your doctor, or your hospital must precertify.

We cover routine nursery care of the newborn child during the covered portion of the mother�s maternity stay. We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self and Family enrollment. We cover circumcision of a covered newborn under Surgical benefits. See Surgery benefits (Section 5b).

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

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: Amniocentesis if for diagnosing multiple births

All charges

A range of voluntary family planning services, limited to:

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

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

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

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: Reversal of voluntary surgical sterilization and genetic counseling

All charges

Diagnosis and treatment of infertility, except as shown in Not covered.

PPO: 10% of the Plan allowance and any amount over $2,500

Non-PPO: 30% of the Plan allowance, any difference between our allowance and the billed amount and any amount over $2,500

Not covered:

Infertility services after voluntary sterilization

Assisted reproductive technology (ART) procedures, such as:

- artificial insemination (all procedures)

- in vitro fertilization

- embryo transfer and gamete intrafallopian transfer (GIFT)

- intravaginal insemination (IVI)

- intracervical insemination (ICI)

- intrauterine insemination (IUI)

Services and supplies related to ART procedures

Cost of donor sperm

Cost of donor egg

All charges

Testing and treatment, including materials (such as allergy serum)

Allergy injections

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: Provocative food testing and sublingual allergy desensitization

All charges

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on page 33.

Dialysis � hemodialysis and peritoneal dialysis

Intravenous (IV)/Infusion Therapy � Home IV and antibiotic therapy

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover IV/Infusion therapy and GHT when we preauthorize the treatment. Call Spectera/CARE at 800/580-8771 for preauthorization. Spectera/CARE will ask you to submit information that establishes that GHT is medically necessary. You should ask for preauthorization before you begin treatment. If you do not ask or if we determine GHT is not medically necessary, we will not cover GHT or related services and supplies. See Other services under How to get approval for... in Section 3.

Respiratory and inhalation therapies

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Physical therapy and occupational therapy provided by a licensed registered therapist up to a combined 60 visits per calendar year.

Note: Preauthorization of rehabilitative therapies is required. Call Spectera/CARE at 800/580-8771 for preauthorization.

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

1) Orders the care

2) Identifies the specific professional skills the patient requires and the medical necessity for skilled services; and

3) Indicates the length of time the services are needed

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Maintenance therapies

Exercise programs

Physical and occupational therapies without preauthorization

All charges

Speech therapy where medically necessary and provided by a licensed therapist

Note: Preauthorization of speech therapy is required. Call Spectera/CARE at 800/580-8771 for preauthorization.

Note: Speech therapy is combined with 60 visits per year for the services of physical therapy and/or occupational therapy (see above).

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Audiologist to diagnose a hearing problem

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Hearing aids, testing and examinations for them

All charges

Internal (implant) ocular lenses and/or the first contact lenses required to correct an impairment caused by accident or illness. The services of an optometrist are limited to the testing, evaluation and fitting of the first contact lenses required to correct an impairment caused by accident or illness.

Note: See Preventive care, children for eye exams for children

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Eyeglasses or contact lenses and examinations for them

Eye exercises and visual training

Radial keratotomy and other refractive surgery

All charges

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

See Orthopedic and prosthetic devices for information on podiatric shoe inserts

PPO: $18 copayment for the office visit (No deductible) plus 10% of the Plan allowance for other services performed during the visit

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

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

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

All charges

Artificial limbs and eyes; stump hose

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

Leg, arm, neck and back braces

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

Note: We recommend preauthorization of orthopedic and prosthetic devices. Call Spectera/CARE at 800/580-8771 for preauthorization.

Note: We will pay only for the cost of the standard item. Coverage for specialty items, such as bionics, is limited to the cost of the standard item.

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Orthopedic and corrective shoes

Arch supports

Foot orthotics

Heel pads and heel cups

Lumbosacral supports

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

All charges

Durable medical equipment (DME) is equipment and supplies that:

1) Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury)

2) Are medically necessary

3) Are primarily and customarily used only for a medical purpose

4) Are generally useful only to a person with an illness or injury

5) Are designed for prolonged use; and

6) Serve a specific therapeutic purpose in the treatment of an illness or injury

We cover rental or purchase, at our option, including repair and adjustment, of durable medical equipment, such as oxygen and dialysis equipment.

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Under this benefit, we also cover equipment such as:

Hospital beds

Wheelchairs

Ostomy supplies (including supplies purchased at a pharmacy)

Crutches; and

Walkers

Note: Call Spectera/CARE at 800/580-8771 as soon as your physician prescribes this equipment because prior approval is required. We arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Note: We will pay only for the cost of the standard item. Coverage for specialty equipment, such as all-terrain wheelchairs, is limited to the cost of the standard equipment.

(see above)

Not covered:

Whirlpool equipment

Sun and heat lamps

Light boxes

Heating pads

Exercise devices

Stair glides

Elevators

Air Purifiers

Computer �story boards,� �light talkers,� or other communication aids for communication-impaired individuals

All charges

Services for skilled nursing care up to 25 visits per calendar year, not to exceed a maximum plan payment of $90 per day, when preauthorized and:

A registered nurse (R.N.), licensed practical nurse (L.P.N.) or licensed vocational nurse (L.V.N.) provides the services

The attending physician orders the care

The physician identifies the specific professional skills required by the patient and the medical necessity for skilled services; and

The physician indicates the length of time the services are needed

Note: Skilled nursing care must be preauthorized. Call Spectera/CARE at 800/580-8771 for preauthorization.

PPO: 10%; all charges after we pay $90 per day

Non-PPO: 30%; all charges after we pay $90 per day

Not covered:

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

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

Nursing services without preauthorization

Services of nurses aides or home health aides

All charges

Chiropractic treatment limited to 12 visits and/or manipulations per year

PPO: $18 copayment (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Acupuncture � by a doctor of medicine or osteopathy

PPO: $18 copayment (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Services of any provider not listed as covered; see Covered providers on page 9

Note: Benefits of certain alternative treatment providers may be covered in medically underserved areas; see page 9.

All charges

Coverage is limited to:

Smoking Cessation � Up to $100 for one smoking cessation program per member per lifetime

PPO: Nothing

Non-PPO: Nothing

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

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

The calendar year deductible is: PPO - $275 per person ($550 per family); Non-PPO - $500 per person ($1,000per family). The calendar year deductible applies to almost all benefits in this Section. We added �(No deductible)� to show when the calendar year deductible does not apply.

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

When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists, may not all be preferred providers. If they are not, they will be paid by this Plan as non-PPO providers. However, if surgical services are rendered at a PPO hospital or a PPO freestanding ambulatory facility by a PPO primary surgeon, we will pay the services of anesthesiologists who are not preferred providers at the PPO rate, based on Plan allowance.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

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

YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification.

Precertification/preauthorization is required for:

- Organ transplantations

- Procedures which might be cosmetic in nature, such as eyelid surgery or varicose vein surgery

- Surgery for morbid obesity, or

- Surgery for organic impotence

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Note: The calendar year deductible applies to almost all benefits in this Section. We say �(No deductible)� when it does not apply.

A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Electroconvulsive therapy

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

Surgical treatment of morbid obesity

Insertion of internal prosthetic devices. See Section 5(a) for Orthopedic and prosthetic devices for device coverage information

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

Surgically implanted contraceptives

Intrauterine devices (IUDs)

Treatment of burns

Assistant surgeons - We cover up to 20% of our allowance for the surgeon�s charge

(see above)

When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to patient care, our benefits are:

For the primary procedure:

- PPO: 90% of the Plan allowance or

- Non-PPO: 70% of the Plan allowance

For the secondary procedure(s):

- PPO: 90% of one-half of the Plan allowance or

- Non-PPO: 70% of one-half of the Plan allowance

Note: Multiple or bilateral surgical procedures performed through the same incision are �incidental� to the primary surgery. That is, the procedure would not add time or complexity to patient care. We do not pay extra for incidental procedures.

PPO: 10% of the Plan allowance for the primary procedure and 10% of one-half of the Plan allowance for the secondary procedure(s)

Non-PPO: 30% of the Plan allowance for the primary procedure and 30% of one-half of the Plan allowance for the secondary procedure(s); and any difference between our payment and the billed amount

Not covered:

Cosmetic surgery and other related expenses if not preauthorized

Reversal of voluntary sterilization

Services of a standby surgeon, except during angioplasty or other high risk procedures when we determine standbys are medically necessary

Radial keratotomy and other refractive surgery

All charges

Surgery to correct a functional defect

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

- The condition produced a major effect on the member�s appearance and

- The condition can reasonably be expected to be corrected by such surgery

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

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

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

- Surgery to produce a symmetrical appearance of breasts

- Treatment of any physical complications, such as lymphedemas

- Breast prostheses; and surgical bras and replacements (see Prosthetic devices for coverage)

Note: We pay for internal breast prostheses as hospital benefits.

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

(see above)

Not covered:

Cosmetic surgery � any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury if repair is initiated within two years of the accident

Surgeries related to sex transformation, sexual dysfunction or sexual inadequacy except if preauthorized for organic impotence

All charges

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones

Surgical correction of cleft lip, cleft plate or severe functional malocclusion

Removal of stones from salivary ducts

Excision of leukoplakia or malignancies

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

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

Extraction of impacted (unerupted) teeth

Alveoplasty, partial ostectomy and radical resection of mandible with bone graft unrelated to tooth structure

Excision of bony cysts of the jaw unrelated to tooth structure

Excision of tori, tumors, and premalignant lesions, and biopsy of hard and soft oral tissues

Reduction of dislocations and excision, manipulation, arthrocentesis, aspiration or injection of temporomandibular joints

Removal of foreign body, skin, subcutaneous alveolar tissue, reaction-producing foreign bodies in the musculoskeletal system and salivary stones

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Incision/excision of salivary glands and ducts

Repair of traumatic wounds

Sinusotomy, including repair of oroantral and oromaxillary fistula and/or root recovery

Surgical treatment of trigeminal neuralgia

Frenectomy or frenotomy, skin graft or vestibuloplasty-stomatoplasty unrelated to periodontal disease

Incision and drainage of cellulitis unrelated to tooth structure

Note: We suggest you call us at 800/222-APWU to determine whether a procedure is covered.

(See above)

Not covered:

Oral implants and transplants

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

Dental bridges, replacement of natural teeth, dental/orthodontic/temporomandibular joint dysfunction appliances and any related expenses

Treatment of periodontal disease and gingival tissues, and abscesses

Charges related to orthodontic treatment

All charges

Limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

Lung: Single � only for the following end-stage pulmonary diseases: pulmonary fibrosis, primary pulmonary hypertension, or emphysema; Double � only for patients with cystic fibrosis

Pancreas

Allogeneic bone marrow transplants are limited to patients with leukemia, advanced Hodgkin�s lymphoma, advanced non-Hodgkin�s lymphoma, aplastic anemia, severe combined immuno-deficiency disease or Wiskott-Aldrich syndrome

Autologous bone marrow transplants and autologous peripheral stem cell support are limited to patients with acute leukemia in remission, relapsed non-Hodgkin�s lymphomas responding to treatment, resistant or recurrent neuroblastoma, relapsed Hodgkin�s disease responding to treatment, testicular cancer, mediastinal cancer, retroperitoneal cancer, ovarian germ cell tumors, epithelial ovarian cancer, breast cancer and multiple myeloma

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas only for those patients with irreversible intestinal failure who have failed TPN (total parenteral nutrition)

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $50,000 for kidney transplants or $100,000 for other listed transplants

The Plan uses specific Plan-designated organ/tissue transplant facilities. Before your initial evaluation as a potential candidate for a transplant procedure, you or your doctor must contact Spectera/CARE at 800/580-8771 and ask to speak to a Transplant Case Manager. You will be provided with information about transplant preferred providers. If you choose a Plan-designated transplant facility, you may receive prior approval for travel and lodging costs.

Limited Benefits � If you don�t use a Plan-designated transplant facility, benefits for pretransplant evaluation, organ procurement, inpatient hospital, surgical and medical expenses for covered transplants, whether incurred by the recipient or donor, are limited to a maximum of $50,000 for kidney transplants or $100,000 for each other listed transplant, including multiple organ transplants.

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

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $50,000 for kidney transplants or $100,000 for other listed transplants

Not covered:

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

Services or supplies for, or related to, surgical transplant procedures for artificial or human organ transplants not listed as specifically covered. Related services include administration of high dose chemotherapy when supported by autologous bone marrow transplant

Transplants not listed as covered

All charges

Professional services for administration of anesthesia

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Note: If surgical services are rendered at a PPO hospital or a PPO freestanding ambulatory facility by a PPO primary surgeon, we will pay the services of non-PPO anesthesiologists at the PPO rate, based on Plan allowance.

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

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

In this Section, unlike Sections 5(a) and 5(b), the calendar year deductible applies to only a few benefits. In that case, we added �(calendar year deductible applies).� The calendar year deductible is; PPO - $275 per person ($550 per family); Non-PPO - $500 per person ($1,000 per family).

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

When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists, may not all be preferred providers. If they are not, they will be paid by this Plan as non-PPO providers. However, if surgical services are rendered at a PPO hospital or a PPO freestanding ambulatory facility by a PPO primary surgeon, we will pay the services of anesthesiologists who are not preferred providers at the PPO rate, based on Plan allowance.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

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

YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification information shown in Section 3 to be sure which services require precertification.

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Note: The calendar year deductible applies ONLY when we say below: �(calendar year deductible applies).�

Room and board, such as:

Ward, semiprivate, or intensive care accommodations

General nursing care

Meals and special diets

Note: We only cover a private room when you must be isolated to prevent contagion. Otherwise, we will pay the hospital�s average charge for semiprivate accommodations. If the hospital only has private rooms, we base our payment on the average semiprivate rate of comparable hospitals in the area.

Note: When the non-PPO hospital bills a flat rate, we prorate the charges to determine how to pay them, as follows: 30% room and board and 70% other charges.

PPO: 10% of the covered charges

Non-PPO: $300 per admission and 30% of the covered charges

Note: If you use a PPO provider and a PPO facility, we may still pay non-PPO benefits if you receive treatment from a radiologist or pathologist who is not a PPO provider.

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Blood or blood plasma, if not donated or replaced

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Note: We cover appliances, medical equipment and medical supplies provided for take-home use under Section 5(a). We cover prescription drugs and medicines dispensed for take-home use under Section 5(f).

Note: We base payment on whether the facility or a health care professional bills for the services or supplies. For example, when the hospital bills for its nurse anesthetists� services, we pay Hospital benefits and when the anesthesiologist bills, we pay Surgery benefits.

(see above)

Not covered:

Any part of a hospital admission that is not medically necessary (see definition), such as when you do not need acute hospital inpatient (overnight) care, but could receive care in some other setting without adversely affecting your condition or the quality of your medical care. Note: In this event, we pay benefits for services and supplies other than room and board and in-hospital physician care at the level they would have been covered if provided in an alternative setting

Custodial care; see definition

Non-covered facilities, such as nursing homes, skilled nursingfacilities, residential treatment facilities, day and evening care centers, and schools

Personal comfort items such as radio, television, air conditioners, beauty and barber services, guest meals and beds

Services of a private duty nurse that would normally be provided by hospital nursing staff

All charges

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals

Blood and blood plasma, if not donated or replaced

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

Note: We cover outpatient services and supplies of a hospital or free-standing ambulatory facility the day of a surgical procedure (including change of cast), hemophilia treatment, hyperalimentation, rabies shots, cast or suture removal, oral surgery, foot treatment, chemotherapy for treatment of cancer, and radiation therapy.

PPO: 10% of the Plan allowance (calendar year deductible applies)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

No benefit

All charges

Hospice is a coordinated program of home and inpatient supportive care for the terminally ill patient and the patient�s family provided by a medically supervised specialized team under the direction of a duly licensed or certified Hospice Care Program.

We pay $3,000 annually for outpatient services and $2,000 annually for inpatient services

We pay a $200 annual bereavement benefit per family unit

Any amount over the annual maximums shown

Local professional ambulance service when medically appropriate immediately before or after an inpatient admission

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Ambulance service used for routine transport

All charges

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

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

The calendar year deductible is: PPO - $275 per person ($550 per family); Non-PPO - $500 per person ($1,000 per family). The calendar year deductible applies to almost all benefits in this Section. We added �(No deductible)� to show when the calendar year deductible does not apply.

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

When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists, may not all be preferred providers. If they are not, they will be paid by this Plan as non-PPO providers. However, if surgical services are rendered at a PPO hospital or a PPO freestanding ambulatory facility by a PPO primary surgeon, we will pay the services of anesthesiologists who are not preferred providers at the PPO rate, based on Plan allowance.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

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What is an accidental injury?

An accidental injury is a bodily injury sustained solely through violent, external, and accidental means, such as broken bones, animal bites, and poisonings.

What is a medical emergency?

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 we may determine are medical emergencies � what they all have in common is the need for quick action. If you are unsure of the severity of a condition in terms of this benefit, the Plan recommends that you first call its 24-hour nurse advisory advisory service (888/993-0333) or your physician.

Note: If you use an emergency room for other than a recognized medical emergency, facility fees and supplies will not be covered.

Note: The calendar year deductible applies to almost all benefits in this Section. We say �(No deductible)� when it does not apply.

If you receive care for your accidental injury within 24 hours, we cover:

Physician services and supplies

Related outpatient hospital services

Professional ambulance service

Air ambulance if medically necessary for transport to the closest appropriate facility for treatment

Note: We pay Hospital benefits if you are admitted.

PPO: Nothing (No deductible)

Non-PPO: Only the difference between
our allowance and the billed amount
(No deductible)

If you receive care for your accidental injury after 24 hours, we cover:

Physician services and supplies

Note: We pay Hospital benefits if you are admitted.

PPO: $18 copayment (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Outpatient facility charges in an Urgent Care Center

PPO: $40 copayment (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Outpatient medical or surgical services and supplies, other than an Urgent Care Center

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Professional ambulance service within 24 hours of a medical emergency

Air ambulance if medically necessary for transport to the closest appropriate facility for treatment within 24 hours of a medical emergency

Note: See Section 5(c) for non-emergency service.

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

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You may choose to get care In-network or Out-of-network. When you receive In-network care, you must get our approval for services and follow a treatment plan we approve. If you do, cost-sharing and limitations for In-network mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions.

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

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

The Mental health and substance abuse benefits have a separate calendar year deductible. The
In-network deductible is $275 per person, $550 per family.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits descriptions below.

In-network mental health and substance abuse benefits are below, then Out-of-network benefits begin on page 41.

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Note: The calendar year deductible applies to almost all benefits in this Section. We say �(No deductible)� when it does not apply.

All diagnostic and treatment services contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure.

Note: In-network benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve.

Your cost sharing responsibilities are no greater than for other illnesses or conditions

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, licensed social workers, or licensed intensive outpatient treatment centers

Medication management

$18 per visit (No deductible)

Diagnostic tests

10% of the Plan allowance

Inpatient services provided by a hospital or other facility

Services in approved partial hospitalization setting

10% of the covered charges (No deductible)

Not covered: Services we have not approved

Note: OPM will base its review of disputes about treatment plans on the treatment plan�s clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges

Preauthorization

To be eligible to receive these enhanced mental health and substance abuse benefits you must obtain a treatment plan and follow all of the following network authorization processes:

Inpatient care-You must get preauthorization of hospital stays; failure to do so will result in a minimum $500 penalty. Please refer to the precertification information shown in Section 3. To obtain preauthorization of an admission for mental conditions or substance abuse, call ValueOptions at 888/700-7965.

Outpatient care-You must get preauthorization of outpatient care for mental conditions or substance abuse. Preauthorization must be obtained by calling ValueOptions at 888/700-7965.

We do not make available provider directories for mental health or substance abuse providers. ValueOptions will provide you with a choice of network providers when you call to preauthorize your care.

Professional outpatient care to treat mental conditions and substance abuse

After a $750 mental conditions/substance abuse calendar year deductible, 50% of our allowance for up to 15 visits; all charges after 15 visits

Inpatient care to treat mental conditions includes ward or semiprivate accommodations and other hospital charges

After a $750 mental conditions/substance abuse calendar year deductible, 50% of charges for up to 30 days per calendar year; all charges after 30 days

Inpatient care to treat substance abuse includes room and board and ancillary charges for confinements in a treatment facility for rehabilitative treatment of alcoholism or substance abuse

After a $750 mental conditions/substance abuse calendar year deductible, 50% of charges for one treatment program up to $3,000; all charges over $3,000 per lifetime

Not covered out-of-network:

Treatment for learning disabilities and mental retardation

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

Phototherapy for treatment of Seasonal Affective Disorder (SAD)

All charges

Lifetime maximum

Out-of-network inpatient care for the treatment of alcoholism and drug abuse is limited to one treatment program per lifetime not to exceed $3,000.

Precertification

Inpatient care � You must get preauthorization of hospital stays; failure to do so will result in a minimum $500 penalty. Please refer to the precertification information shown in Section 3. To obtain preauthorization of an admission for mental conditions or substance abuse, call ValueOptions at 888/700-7965.

Outpatient care � You must get preauthorization of outpatient care for mental conditions or substance abuse. Preauthorization must be obtained by calling ValueOptions at 888/700-7965.

See these sections of the brochure for more valuable information about these benefits:

Section 4, Your costs for covered services, for information about catastrophic protection for these benefits.

Section 8, Filing a claim for covered services, for information about submitting out-of-network claims

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

We cover prescribed drugs and medications, as described in the chart on the next page.

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

The calendar year deductible does not apply to prescription drug benefits.

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

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

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There are important features you should be aware of. These include:

Who can write your prescription. Any covered provider licensed to prescribe drugs may write your prescription.

Where can you obtain them. You can fill the prescription at a Medco Health network pharmacy, a non-network pharmacy, or by mail. We pay our highest level of benefits for mail order and you should use the mail order program to obtain your maintenance medications.

We use a formulary. Our formulary is open and voluntary. A formulary is a list of medications we have selected based on their clinical effectiveness and lower cost. By asking your doctor to prescribe formulary medications, you can help reduce your costs while maintaining high-quality care. Use of a formulary drug is voluntary; there is no financial penalty if your physician does not prescribe a formulary drug.

Brand/Generic Drugs

Why use generic drugs? A generic drug is a chemical equivalent of a corresponding name brand drug. The US Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand name drugs. Generic drugs are less expensive than brand drugs, therefore, you may reduce your out-of-pocket-expenses by choosing to use a generic drug.

A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not received a preauthorization, you have to pay the difference in cost between the name brand drug and the generic, in addition to your coinsurance. However, if your doctor obtains preauthorization because it is medically necessary that a brand name drug be dispensed, you will not be required to pay this cost difference. Your doctor may seek preauthorization by calling 800/841-5409.

These are the dispensing limitations.

- The Medco Health Retail Network �you may obtain up to a 30-day supply plus one 30-day refill for each prescription purchased from a Medco Health network pharmacy. After one 30-day refill, you must obtain a new prescription and submit it to the mail order program. If you do not, we will pay the non-network pharmacy benefit level. To receive maximum savings you must present your card at the time of each purchase, and your enrollment information must be current and correct. In most cases, you simply present the card together with the prescription to the pharmacist. Refills cannot be obtained until 75% of the drug has been used.

- Exceptions for special circumstances � The Plan will authorize up to a 90-day supply at a network pharmacy for covered persons called to active military service. Also, the Plan will authorize an extra 30-day supply, either at network retail or Home Delivery, for civilian Government employees who are relocated for assignment in the event of a national emergency. Authorization may be obtained from Medco Health at 800/841-2734 or from the Plan at 800/222-APWU.

- Non-network pharmacy � if you do not use your identification card, if you elect to use a non-network pharmacy, or if a Medco Health network pharmacy is not available, you will need to file a claim and we will pay at the non-network retail pharmacy benefit level.

- Mail order � through this program, you may receive up to a 90-day supply of maintenance medications for drugs which require a prescription, diabetic supplies and insulin, syringes and needles for covered injectable medications, and oral contraceptives. Some medications may not be available in a 90-day supply from Medco Health Home Delivery Pharmacy Service even though the prescription is for 90 days.

- Refills for maintenance medications are not considered new prescriptions except when the doctor changes the strength or 180 days has elapsed since the previous purchase. Refill orders submitted too early after the last one was filled are held until the right amount of time has passed. As part of the administration of the prescription drug program, we reserve the right to maximize your quality of care as it relates to the utilization of pharmacies.

- You may fill your prescription at any pharmacy participating in the Medco Health system. For the names of participating pharmacies, call 800/841-2734.

Certain controlled substances and several other prescribed medications may be subject to other dispensing limitations, such as quantities dispensed, and to the judgment of the pharmacist.

When you have to file a claim. Use a Prescription Drug Claim Form to claim benefits for prescription drugs and supplies purchased from a non-network pharmacy. You may obtain forms by calling 800/222-APWU or from our Web site at www.apwuhp.com. Your claim must include receipts that show the prescription number, the National Drug Code (NDC) number, name of the drug, prescribing physician�s name, date of purchase and charge for the drug. Mail the claim form and receipt(s) to:

APWU Health Plan

P.O. Box 967

Silver Spring, MD 20910

Note: The calendar year deductible does not apply to this section.

Covered medications and supplies

Each new enrollee will receive a description of our prescription drug program, a combined prescription drug/Plan identification card, a mail order form/patient profile and a preaddressed reply envelope.

You may purchase the following medications and supplies prescribed by a physician from either a pharmacy or by mail:

Drugs and medicines, including those for smoking cessation, for use at home that are obtainable only upon a doctor�s prescription and listed in official formularies

Drugs and medicines (including those administered during a non-covered admission or in a non-covered facility) that by Federal law of the United States require a physician�s prescription for their purchase, except those listed as Not covered

Insulin and reagent strips for known diabetics

Needles and syringes for the administration of covered medications

Full range of FDA-approved drugs, prescriptions, and devices for birth control

Approved drugs for organic impotence subject to prior Plan approval and limitations on dosage and quantity

Retin A, Botox, Growth Hormones and approved drugs for organic impotence such as Viagra and Levitra must have prior approval from Spectera/CARE at 800/580-8771

Network Retail: $8 generic/25% brand name with an $8 minimum coinsurance for brand name

Network Retail Medicare: $8 generic/25% brand name with an $8 minimum coinsurance for brand name

Non-network Retail: 50% of cost with an $8 minimum coinsurance

Non-network Retail Medicare: 50% of cost with an $8 minimum coinsurance

Network Mail Order: $12 generic/25% brand name with a $12 minimum coinsurance for brand name

Network Mail Order Medicare: $12 generic/
25% brand name with a $12 minimum coinsurance for brand name

Not covered:

Drugs and supplies for cosmetic purposes

Vitamins, minerals, nutritional supplements, and enteral formulas (liquid food supplements)

Medical supplies such as dressings and antiseptics

Nonprescription medicines

All charges

Flexible benefits option

Under the flexible benefits option, we determine the most effective way to provide services.

We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit

Alternative benefits are subject to our ongoing review

By approving an alternative benefit, we cannot guarantee you will get it in the future

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits

Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process

24 hour nurse line

We offer a 24-hour nurse advisory service for your use. This program is strictly voluntary and confidential. You may call toll-free at 888/993-0333 and reach registered nurses to discuss an existing medical concern or to receive information about numerous health care issues.

Services for deaf and hearing impaired

We offer a toll-free TDD line for customer service. The number is 800/622-2511. TDD equipment is required.

Wellness benefit

We reimburse you up to $250 per Self Only enrollment and $350 per Self and Family enrollment per calendar year for non-covered expenses such as vision, eyeglasses, hearing aids, if received in 2005 and no other benefits for 2005 have been paid. If we paid claims of less than $350 for a Self and Family enrollment, the difference up to $350 will be paid.

We will notify you in November if you are eligible for the Wellness benefit. Submit Wellness claims after January 1, 2006. Wellness claims are paid after March 1, 2006. If, after Wellness benefits have been paid, subsequent claims are received for hospital, medical or dental expenses, payments made under the Wellness benefit will be deducted from allowable charges.

Disease Management Program

A voluntary program that provides a variety of services to help you manage a chronic condition with outpatient treatment and avoid unnecessary emergency care or impatient admissions. Some examples of conditions that can be managed through this program are: diabetes, coronary artery disease and heart failure. We use medical and/or pharmacy claims data as well as interactions with you and your physician(s). If you have a chronic condition and would like additional information, call CorSolutions at 866/676-0740.

Review and reward program

If you send us a corrected hospital billing, we will credit 20% of any hospital charge over $20 for covered services and supplies that were not actually provided to a covered person. The maximum amount payable under this program is $100 per person per calendar year.

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

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

The calendar year deductible is: PPO - $275 per person ($550 per family); Non-PPO - $500 per person ($1,000 per family). The calendar year deductible applies to almost all benefits in this Section. We added �(No deductible)� to show when the calendar year deductible does not apply.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

Note: We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. We do not cover the dental procedure. See Section 5(c) for inpatient hospital benefits.

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We cover restorative services and supplies necessary to repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury (a blow or fall) and must be performed within two years of the accident. See also Section 5(d), Accidental Injury.

Within 24 hours of accident:

PPO: Nothing (No deductible)

Non-PPO: Only the difference between our allowance and the billed amount (No deductible)

More than 24 hours after accident:

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Dental benefits

Office visits

Restorative care
(fillings)

Simple extractions

Note: Office visits include examinations, prophylaxis (cleanings), x-rays of all types and fluoride treatment

$25 per visit (limit 2 visits per year)

$13 per tooth (single surface)
$18 per tooth (two or more surfaces)

$13 per tooth

All charges in excess of the scheduled amounts listed to the left (No deductible)

Voluntary Benefits Plan Dental Plan

The Voluntary Benefits Plan Dental program is an optional program with an additional premium that supplements the dental benefits in your APWU Health Plan coverage. All participants of the APWU Health Plan, either High Option or Consumer-driven Option, who enroll in the Voluntary Benefits Plan Dental Plan through this offer will receive a discount in the regular premiums for that program. To enroll in this additional coverage, complete and sign the Voluntary Benefits Plan Dental Plan enrollment form, which you can obtain from your APWU Health Plan representative or by calling the Voluntary Benefits Plan office at the toll-free number listed below. Please specify that you are an APWU Health Plan participant.

Availability

The Voluntary Benefits Plan Dental Plan is available to all Active, Retired, Associate and Transitional Employee APWU Members in all States and Territories of the United States.

Coverage Description

This optional dental plan is an indemnity insurance plan underwritten by the United States Life Insurance Company. You may use any dentist you choose. Covered services are reimbursed as a percentage of the �Reasonable and Customary� charges for that service in the state where the charge is incurred. Once you have satisfied the continuous coverage limitations of the program, there are no further waiting periods as long as you remain continuously insured under the plan. Both you and your eligible dependents (spouse and unmarried children to age 19 - full-time students to age 25) can be insured under this plan.

Coverage Schedule

Calendar Year Deductible: $50 per person - Type I benefits

$100 per person - Type II and Type III benefits, combined

Calendar Year Maximum: $1,500 per person for all covered services

$500 per person for all eligible Orthodontic services, if Optional Orthodontic Coverage is selected

Lifetime Maximum: $1,000 for Orthodontic services, if Optional Orthodontic Coverage is selected

Type I Benefits

Preventive Services

Exams

X-rays

Cleanings

100%
of the Reasonable and Customary charges

100%
of the Reasonable and Customary charges

Type II Benefits

Basic Services

Fillings

Oral Surgery

Extractions

80%
of the Reasonable and Customary charges
(6 month waiting period)

50%
of the Reasonable and Customary charges
(6 month waiting period)

Type III Benefits

Major Services

Crowns

Bridges

Dentures

Periodontics

50%
of the Reasonable and Customary charges
(12 month waiting period)

50%
of the Reasonable and Customary charges
(18 month waiting period)

Type IV Benefits

(Optional Coverage)

Orthodontic

50%
of the Reasonable and Customary charges
(24 month waiting period)

50%
of the Reasonable and Customary charges
(24 month waiting period)

Voluntary Benefits Plan

P.O. Box 1471

Waterbury, CT 06721

800/422-4492

800/237-5536 (In CT)

203/754-4410 (TDD)

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Here are some important things you should keep in mind about these in-network preventive care benefits:

Under the Consumer-driven Option, the plan pays 100% for the preventive care services listed in this Section as long as you use a network (PPO) provider.

For preventive care not listed in this Section or for preventive care from a non-network provider, please see Section 6(b) � Personal Care Account (PCA).

For all other covered expenses, please see Section 6(b) � Personal Care Account and
Section 6(c) � Traditional Health Coverage.

Note that the in-network preventive care paid under this Section does NOT count against or use up your Personal Care Account (PCA).

Under the Consumer-driven Option, there is no calendar year deductible.

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

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

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Note: There is no calendar year deductible under the Consumer-driven Option.

One annual routine office visit and examination per person after age 18

Nothing

Routine immunizations:

Tetanus-diphtheria (Td) Booster once every 10 years

Influenza Vaccination (flu shot) annually

Pneumococcal Vaccination (Pneumovax) one dose for persons 65 and older

Nothing

Routine screenings:

Total Blood Cholesterol, once annually

Fasting lipoprotein profile, once every 5 years for adults age 20 or older

Osteoporosis screening, once every two years, for women age 65 and older

Chlamydial infection

Routine mammograms � covered for women age 35 and older, as follows:

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

- From age 40 through 64, one every calendar year

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

Pap Smear and Routine Pelvic Exam annually

Colorectal Cancer Screenings, member has the choice of the following:

- Fecal occult blood test (FOBT) annually and flexible sigmoidoscopy once every 5 years, both beginning at age 50; or

- Colonoscopy once every 10 years beginning at age 50; or

- Double contrast barium enema (DCBE) once every five years starting at age 50

Digital rectal examination (DRE) and prostate specific antigen (PSA) test annually starting at age 45

Nothing

Routine office visits, examinations and laboratory tests as follows:

Six visits the first year (to age 1)

Three visits the second year (age 1-2)

Annual visits from age 2 through age 18

Nothing

Routine immunizations:

Two doses of Hepatitis A

Three doses of Hepatitis B

Six doses of Diphtheria, Tetanus, Pertussis (DtaP)

Four doses of Haemophilus Influenza type b

Four doses of Polio

Four doses of Pneumococcal Conjugate

Two doses of Varicella

Two doses of Measles, Mumps, Rubella

Nothing

Routine screenings:

Lead level testing, one between ages 9 to 12 months and one between 12 and 24 months

Vision screening at ages 3, 4, 5, 6, 8, 10, 12, 15, and 18

Hearing screening at ages 4, 5, 6, 8, 10, 12, 15, and 18

Pap smear and routine pelvic exam annually beginning at age 18 or the onset of sexual activity, whichever comes first.

Nothing

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Here are some important things you should keep in mind about your Personal Care Account:

All eligible health care expenses (except in-network preventive care) are paid first from your Personal Care Account (PCA). Traditional Health Coverage (Section 6(c)) will only start once your Personal Care Account is exhausted.

Note that in-network preventive care covered under Section 6(a) does NOT count against your PCA.

The Personal Care Account provides full coverage for both in-network and out-of-network providers. However your Personal Care Account will generally go much further when you use network providers because network providers agree to discount their fees.

You have flexibility about how to spend your PCA, and the Plan provides you with the resources to manage your PCA. You can track your PCA on your personal private Web site, by telephone at 866/333-4648 (toll-free), or with monthly statements mailed directly to you at home.

If you join this Plan during Open Season, you receive the full PCA ($1,200 per Self Only or $2,400 per Self and Family enrollment) as of your effective date of coverage. If you join at any other time during the year, your PCA for your first year will be prorated at a rate of $100 per month for Self Only or $200 per month for Self and Family for each full month of coverage remaining in that calendar year.

Unused PCA benefits are forfeited when leaving this Plan.

If PCA benefits are available in your account at the time a claim is processed, out-of-pocket expenses will be paid from your PCA regardless of the date the expense was incurred.

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

Under the Consumer-driven Option, there is no calendar year deductible.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.

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Note: There is no calendar year deductible under the Consumer-driven Option.

A Personal Care Account (PCA) is provided by the plan for each enrollment. Each year the plan adds to your account:

$1,200 per year for a Self Only enrollment or

$2,400 per year for a Self and Family enrollment

The Personal Care Account covers eligible expenses at 100%. For example, if you are ill and go to a network doctor for a $60 visit, the doctor will submit your claim and the cost of the visit will be deducted automatically from your PCA; you pay nothing.

In-network and Out-of-Network: Nothing up to $1,200 for a Self Only enrollment or $2,400 for a Self and Family enrollment

There are two types of eligible expenses covered by your PCA.

Basic PCA Expenses are the same medical, surgical, hospital, emergency, mental health and substance abuse, and prescription drug services and supplies covered under the Traditional Health Coverage (see Section 6(c) for details)

Extra PCA Expenses include:

- Dental and/or vision services up to a combined maximum of $400 per Self Only enrollment or $800 per Self and Family enrollment each calendar year, including:

- Vision exam performed by an optometrist or ophthalmologist

- Eyeglasses and contact lenses

- Dental treatment (including examinations, cleanings, fillings, restorative treatment, endodontics, and periodontics

- Costs for in-network preventive care services not included under Section 6(a) � In-network Preventive Care benefits

- Costs for out-of-network preventive care including amounts in excess of the Plan allowance, limited to services shown as covered under Section 6(a)

- Amounts in excess of the Plan allowance for services received out-of-network and covered under Basic PCA Expenses

Note: Both Basic and Extra PCA Expenses are covered at 100% as long as you have not used up your Personal Care Account.

Note: Extra PCA Expenses are covered under your PCA only and are combined with your Basic PCA Expenses up to the PCA account limit. These expenses do not count toward reducing your Member Responsibility and are not covered under Traditional Health Coverage.

To make the most of your Personal Care Account, you should:

Use the network providers wherever possible;

Use generic prescriptions wherever possible; and

Only use your PCA for Extra PCA Expenses if you expect to have an unused balance in your PCA at the end of the calendar year.

(see above)

Not covered:

Orthodontia

Dental treatment for cosmetic purposes including teeth whitening

Out-of-network preventive care services not included under Section 6(a)

Services or supplies shown as not covered under Traditional Health Coverage (see Section 6(c)) and not included under Extra PCA Expenses above

All charges

PCA Rollover

Any unused, remaining balance in your PCA at the end of the calendar year may be rolled over to subsequent years, as long as you remain in this Plan, up to a maximum PCA account of $5,000 per Self Only enrollment or $10,000 per Self and Family enrollment, thereby increasing your PCA in the following year(s).

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

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

In-network preventive care is covered at 100% under Section 6(a) and does not count against your Personal Care Account.

Your Personal Care Account must be used first for eligible health care expenses.

If your Personal Care Account has been exhausted, you must pay your Member Responsibility before your Traditional Health Coverage may begin. Your Member Responsibility applies to all benefits in this section

The Consumer-driven Option provides coverage for both in-network and out-of-network providers. The out-of-network benefits are the standard benefits under the Traditional Health Coverage. In-network benefits apply only when you use a provider from the large, national network. When a network provider is not available, out-of-network benefits apply.

If you join at any time during the year other than Open Season, your Member Responsibility for your first year will be prorated at a rate of $50 per month for Self Only or $100 per month for Self and Family for each full month of coverage remaining in that calendar year.

When you use a network hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists, may not all be network providers. If they are not, they will be paid by this Plan as out-of-network providers under the Traditional Health Coverage. However, if surgical services are rendered at a PPO hospital or a PPO freestanding ambulatory facility by a PPO primary surgeon, we will pay the services of anesthesiologists who are not preferred providers at the PPO rate, based on Plan allowance.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 10 about coordinating benefits with other coverage, including with Medicare.

YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification information shown in Section 3 to confirm which services require precertification.

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Note: There is no calendar year deductible under the Consumer-driven Option.

If your Personal Care Account has been exhausted, you are responsible to pay your Member Responsibility before your Traditional Health Coverage begins.

Traditional Health Coverage benefits begin after covered eligible expenses total $1,800 for Self Only or $3,600 for Self and Family (the combination of eligible expenses paid out of your PCA and your Member Responsibility) each calendar year.

Note: You must use any available PCA benefits, including any amounts rolled over from previous years, before Traditional Health Coverage begins.

In-network/Out-of-network: $600 per Self Only enrollment or $1,200 per Self and Family enrollment

In year one, therefore, the member responsibility is $600 for Self Only and $1,200 for Self and Family enrollment.

Any PCA dollars that you rollover at the end of the year will reduce your Member Responsibility next year.

In future years, the amount of your Member Responsibility may be lower if you rollover PCA dollars at the end of the year. For example, if you rollover $300 at the end of the year:

If you decide to use your PCA for Extra PCA Expenses for other than covered dental and/or vision services, you may increase your Member Responsibility.

For example, if you have out-of-network preventive care for $150 and later have an accident that leads to a hospital stay, you will have to pay your Member Responsibility plus �make up� the $150 dollars you spent on Extra PCA Expenses.

(see above)

Note: The services listed below are Covered Expenses under Traditional Health Coverage

Professional services of physicians

In physician�s office

At home

In an urgent care center

During a hospital stay

Initial examination of a newborn child covered under a family enrollment

In a skilled nursing facility

Second surgical opinion

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI/PET

Ultrasound

Electrocardiogram and EEG

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Note: If your network provider uses an out-of-network lab or radiologist, we will pay out-of-network benefits for any lab and
X-ray charges.

Not covered: Professional fees for automated lab tests

All charges

Maternity care

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see pages 11 and 12 for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary, but you, your representative, your doctor, or your hospital must precertify.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

We cover routine nursery care of the newborn child during the covered portion of the mother�s maternity stay. We will cover the initial examination of the infant and other care of an infant who requires non-routine treatment if we cover the infant under a Self and Family enrollment. We cover circumcision of a covered newborn under Surgical benefits. See Surgery benefits below.

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

(see above)

Not covered: Amniocentesis if for diagnosing multiple births

All charges

A range of voluntary family planning services, limited to:

Voluntary sterilization (See Surgical procedures below)

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

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

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: Reversal of voluntary surgical sterilization and genetic counseling

All charges

Diagnosis and treatment of infertility, except as shown in Not covered

In-network: 15% of the Plan allowance and any amount over $2,500

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $2,500

Not covered:

Infertility services after voluntary sterilization

Assisted reproductive technology (ART) procedures, such as:

- artificial insemination (all procedures)

- in vitro fertilization

- embryo transfer and gamete intrafallopian transfer (GIFT)

- intravaginal insemination (IVI)

- intracervical insemination (ICI)

- intrauterine insemination (IUI)

Services and supplies related to ART procedures

Cost of donor sperm

Cost of donor egg

All charges

Testing and treatment, including materials (such as allergy serum)

Allergy injections

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: Provocative food testing and sublingual allergy desensitization

All charges

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on page 66.

Dialysis � hemodialysis and peritoneal dialysis

Intravenous (IV)/Infusion Therapy � Home IV and antibiotic therapy

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover IV/Infusion therapy and GHT when we are
pre-notified of the treatment. Call Definity Health at 866/333-4648 for pre-notification. Definity Health will ask you to submit information that establishes that GHT is medically necessary. You should pre-notify before you begin treatment. If you do not ask or if we determine GHT is not medically necessary, we will not cover GHT or related services and supplies. See Services requiring our prior approval in Section 3.

Respiratory and inhalation therapies

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Physical therapy and occupational therapy provided by a licensed registered therapist up to a combined 60 visits per calendar year

Note: Pre-notification of rehabilitative therapies is required. Call Definity Health at 866/333-4648 for pre-notification.

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

1) Orders the care

2) Identifies the specific professional skills the patient requires and the medical necessity for skilled services; and

3) Indicates the length of time the services are needed

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Maintenance therapies

Exercise programs

Physical and occupational therapies without preauthorization

All charges

Speech therapy where medically necessary and provided by a licensed therapist

Note: Pre-notification of speech therapy is required. Call Definity Health at 866/333-4648 for pre-notification.

Note: Speech therapy is combined with 60 visits per year for the services of physical therapy and/or occupational therapy (see above).

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Audiologist to diagnose a hearing problem

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Hearing aids, testing and examinations for them

All charges

Internal (implant) ocular lenses and/or the first contact lenses required to correct an impairment caused by accident or illness. The services of an optometrist are limited to the testing, evaluation and fitting of the first contact lenses required to correct an impairment caused by accident or illness.

Note: See page 51 - Preventive care, children, for eye exams for children

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Eyeglasses or contact lenses and examinations for them except under PCA

Eye exercises and visual training

Radial keratotomy and other refractive surgery

All charges

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

See Orthopedic and prosthetic devices for information on podiatric shoe inserts

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

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

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

All charges

Artificial limbs and eyes; stump hose

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

Leg, arm, neck and back braces

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

Note: We recommend pre-notification of orthopedic and prosthetic devices. Call Definity Health at 866/333-4648 for pre-notification.

Note: We will pay only for the cost of the standard item. Coverage for specialty items, such as bionics, is limited to the cost of the standard item.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Orthopedic and corrective shoes

Arch supports

Foot orthotics

Heel pads and heel cups

Lumbosacral supports

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

All charges

Durable medical equipment (DME) is equipment and supplies that:

1) Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury)

2) Are medically necessary

3) Are primarily and customarily used only for a medical purpose

4) Are generally useful only to a person with an illness or injury

5) Are designed for prolonged use; and

6) Serve a specific therapeutic purpose in the treatment of an illness or injury

We cover rental or purchase, at our option, including repair and adjustment, of durable medical equipment, such as oxygen and dialysis equipment. Under this benefit, we also cover equipment such as:

Hospital beds

Wheelchairs

Ostomy supplies (including supplies purchased at a pharmacy)

Crutches; and

Walkers

Note: Call Definity Health at 866/333-4648 as soon as your physician prescribes this equipment because pre-notification is required.

Note: We will pay only for the cost of the standard item. Coverage for specialty equipment, such as all-terrain wheelchairs, is limited to the cost of the standard equipment.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Whirlpool equipment

Sun and heat lamps

Light boxes

Heating pads

Exercise devices

Stair glides

Elevators

Air Purifiers

Computer �story boards,� �light talkers,� or other communication aids for communication-impaired individuals

All charges

Services for skilled nursing care up to 25 visits per calendar year, not to exceed a maximum plan payment of $90 per day, when preauthorized and:

A registered nurse (R.N.), licensed practical nurse (L.P.N.) or licensed vocational nurse (L.V.N.) provides the services

The attending physician orders the care

The physician identifies the specific professional skills required by the patient and the medical necessity for skilled services; and

The physician indicates the length of time the services are needed

Note: Skilled nursing care must be preauthorized. Call Definity Health at 866/333-4648 for pre-notification.

In-network: 15% of the Plan allowance; all charges after we pay $90 per day

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount; all charges after we pay $90 per day

Not covered:

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

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

Services of nurses aides or home health aides

All charges

Chiropractic treatment limited to 12 visits and/or manipulations per year

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Acupuncture � by a doctor of medicine or osteopathy

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Services of any provider not listed as covered; see Covered providers on page 9

Note: Benefits of certain alternative treatment providers may be covered in medically underserved areas; see page 9.

All charges

Coverage is limited to:

Smoking Cessation � Up to $100 for one smoking cessation program per member per lifetime

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Electroconvulsive therapy

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

Surgical treatment of morbid obesity

Insertion of internal prosthetic devices (see Orthopedic and prosthetic devices above for device coverage information)

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

Surgically implanted contraceptives

Intrauterine devices (IUDs)

Treatment of burns

Assistant surgeons - We cover up to 20% of our allowance for the surgeon�s charge

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to patient care, our benefits are:

For the primary procedure:

- In-network: 85% of the Plan allowance or

- Out-of-network: 60% of the Plan allowance

For the secondary procedure(s):

- In-network: 85% of one-half of the Plan allowance or

- Out-of-network: 60% of one-half of the Plan allowance

Note: Multiple or bilateral surgical procedures performed through the same incision are �incidental� to the primary surgery. That is, the procedure would not add time or complexity to patient care. We do not pay extra for incidental procedures.

In-network: 15% of the Plan allowance for the primary procedure and 15% of one-half of the Plan allowance for the secondary procedure(s)

Out-of-network: 40% of the Plan allowance for the primary procedure and 40% of one-half of the Plan allowance for the secondary procedure(s); and any difference between our payment and the billed amount

Not covered:

Cosmetic surgery and other related expenses if not preauthorized

Reversal of voluntary sterilization

Services of a standby surgeon, except during angioplasty or other high risk procedures when we determine standbys are medically necessary

Radial keratotomy and other refractive surgery

All charges

Surgery to correct a functional defect

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

- The condition produced a major effect on the member�s appearance and

- The condition can reasonably be expected to be corrected by such surgery

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

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

- Surgery to produce a symmetrical appearance of breast

- Treatment of any physical complications, such as lymphedemas

- Breast prostheses; and surgical bras and replacements (see Prosthetic devices for coverage)

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Note: We pay for internal breast prostheses as hospital benefits.

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

(see above)

Not covered:

Cosmetic surgery� any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury if repair is initiated within two years of the accident

Surgeries related to sex transformation, sexual dysfunction or sexual inadequacy except if preauthorized for organic impotence

All charges

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones

Surgical correction of cleft lip, cleft plate or severe functional malocclusion

Removal of stones from salivary ducts

Excision of leukoplakia or malignancies

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

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

Extraction of impacted (unerupted) teeth

Alveoplasty, partial ostectomy and radical resection of mandible with bone graft unrelated to tooth structure

Excision of bony cysts of the jaw unrelated to tooth structure

Excision of tori, tumors, and premalignant lesions, and biopsy of hard and soft oral tissues

Reduction of dislocations and excision, manipulation, arthrocentesis, aspiration or injection of temporomandibular joints

Removal of foreign body, skin, subcutaneous alveolar tissue, reaction-producing foreign bodies in the musculoskeletal system and salivary stones

Incision/excision of salivary glands and ducts

Repair of traumatic wounds

Sinusotomy, including repair of oroantral and oromaxillary fistula and/or root recovery

Surgical treatment of trigeminal neuralgia

Frenectomy or frenotomy, skin graft or vestibuloplasty-stomatoplasty unrelated to periodontal disease

Incision and drainage of cellulitis unrelated to tooth structure

Note: We suggest you call us at 866/333-4648 to determine whether a procedure is covered.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Oral implants and transplants

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

Dental bridges, replacement of natural teeth, dental/orthodontic/temporomandibular joint dysfunction appliances and any related expenses

Treatment of periodontal disease and gingival tissues, and abscesses

Charges related to orthodontic treatment

All charges

Limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

Lung: Single � only for the following end-stage pulmonary diseases: pulmonary fibrosis, primary pulmonary hypertension, or emphysema; Double � only for patients with cystic fibrosis

Pancreas

Allogeneic bone marrow transplants are limited to patients with leukemia, advanced Hodgkin�s lymphoma, advanced non-Hodgkin�s lymphoma, aplastic anemia, severe combined immuno-deficiency disease or Wiskott-Aldrich syndrome

Autologous bone marrow transplants and autologous peripheral stem cell support are limited to patients with acute leukemia in remission, relapsed non-Hodgkin�s lymphomas responding to treatment, resistant or recurrent neuroblastoma, relapsed Hodgkin�s disease responding to treatment, testicular cancer, mediastinal cancer, retroperitoneal cancer, ovarian germ cell tumors, epithelial ovarian cancer, breast cancer and multiple myeloma

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas only for those patients with irreversible intestinal failure who have failed TPN (total parenteral nutrition)

The Plan uses specific Plan-designated organ/tissue transplant facilities. Before your initial evaluation as a potential candidate for a transplant procedure, you or your doctor must contact Definity Health at 866/333-4648 and ask to speak to a Transplant Case Manager. You will be provided with information about transplant preferred providers. If you choose a Plan-designated transplant facility, you may receive prior approval for travel and lodging costs.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $100,000

Limited Benefits � If you don�t use a Plan-designated transplant facility, benefits for pretransplant evaluation, organ procurement, inpatient hospital, surgical and medical expenses for covered transplants, whether incurred by the recipient or donor, are limited to a maximum of $100,000 for each listed transplant, including multiple organ transplants.

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

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $100,000

Not covered:

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

Services or supplies for, or related to, surgical transplant procedures for artificial or human organ transplants not listed as specifically covered. Related services include administration of high dose chemotherapy when supported by autologous bone marrow transplant

Transplants not listed as covered

All charges

Professional services for administration of anesthesia

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Note: If surgical services are rendered at an in-network hospital or an in-network freestanding ambulatory facility by an in-network primary surgeon, we will pay the services of out-of-network anesthesiologists at the in-network rate, based on Plan allowance.

Room and board, such as:

Ward, semiprivate, or intensive care accommodations

General nursing care

Meals and special diets

Note: We only cover a private room when you must be isolated to prevent contagion. Otherwise, we will pay the hospital�s average charge for semiprivate accommodations. If the hospital only has private rooms, we base our payment on the average semiprivate rate of comparable hospitals in the area.

Note: When the out-of-network hospital bills a flat rate, we prorate the charges to determine how to pay them, as follows: 30% room and board and 70% other charges.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Note: If you use a network provider and a network facility, we may still pay out-of-network benefits on any services received from a radiologist or pathologist who is not a network provider.

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Blood or blood plasma, if not donated or replaced

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Note: We base payment on whether the facility or a health care professional bills for the services or supplies. For example, when the hospital bills for its nurse anesthetists� services, we pay Hospital benefits and when the anesthesiologist bills, we pay Surgery benefits.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Any part of a hospital admission that is not medically necessary (see definition), such as when you do not need acute hospital inpatient (overnight) care, but could receive care in some other setting without adversely affecting your condition or the quality of your medical care. Note: In this event, we pay benefits for services and supplies other than room and board and in-hospital physician care at the level they would have been covered if provided in an alternative setting

Custodial care; see definition

Non-covered facilities, such as nursing homes, skilled nursing facilities, residential treatment facilities, day and evening care centers, and schools

Personal comfort items such as radio, television, air conditioners, beauty and barber services, guest meals and beds

Services of a private duty nurse that would normally be provided by hospital nursing staff

All charges

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals

Blood and blood plasma, if not donated or replaced

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

Note: We cover outpatient services and supplies of a hospital or free-standing ambulatory facility the day of a surgical procedure (including change of cast), hemophilia treatment, hyperalimentation, rabies shots, cast or suture removal, oral surgery, foot treatment, chemotherapy for treatment of cancer, and radiation therapy.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

No benefit

All charges

Hospice is a coordinated program of home and inpatient supportive care for the terminally ill patient and the patient�s family provided by a medically supervised specialized team under the direction of a duly licensed or certified Hospice Care Program.

We pay $3,000 annually for outpatient services and $2,000 annually for inpatient services

We pay a $200 annual bereavement benefit per family unit

Any amount over the annual maximums shown

Local professional ambulance service when medically appropriate immediately before or after an inpatient admission

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

Ambulance service used for routine transport

All charges

What is an accidental injury?

An accidental injury is a bodily injury sustained solely through violent, external, and accidental means, such as broken bones, animal bites, and poisonings.

What is a medical emergency?

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 we may determine are medical emergencies � what they all have in common is the need for quick action.

Note: If you use an emergency room for other than a recognized medical emergency, facility fees and supplies will not be covered.

If you receive care for your accidental injury within 24 hours, we cover:

Physician services and supplies

Related outpatient hospital services

Note: We pay Hospital benefits if you are admitted.

If you receive care for your accidental injury after 24 hours, we cover:

Physician services and supplies

Note: We pay Hospital benefits if you are admitted.

In-network: 15% of the Plan allowance

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

Outpatient facility charges in an Urgent Care Center

Outpatient medical or surgical services and supplies, other than an Urgent Care Center

In-network: 15% of the Plan allowance

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

Professional ambulance service within 24 hours of an accidental injury or medical emergency

Air ambulance if medically necessary for transport to the closest appropriate facility for treatment within 24 hours of an accidental injury

Note: See Hospital benefits above for non-emergency service.

In-network: 15% of the Plan allowance

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount

All diagnostic and treatment services contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure.

Note: In-network benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve.

Your cost sharing responsibilities are no greater than for other illnesses or conditions

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, licensed social workers, or licensed intensive outpatient treatment centers

Medication management

15% of the Plan allowance

Diagnostic tests

15% of the Plan allowance

Inpatient services provided by a hospital or other facility

Services in approved partial hospitalization setting

15% of the Plan allowance

Not covered: Services we have not approved

Note: OPM will base its review of disputes about treatment plans on the treatment plan�s clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges

Preauthorization

To be eligible to receive these enhanced mental health and substance abuse benefits you must obtain a treatment plan and follow all of the following network authorization processes:

Inpatient care-You must get preauthorization of hospital stays; failure to do so will result in a minimum $500 penalty. Please refer to the precertification information shown in Section 3. To obtain preauthorization of an admission for mental conditions or substance abuse, call ValueOptions at 888/700-7965.

Outpatient care-You must get preauthorization of outpatient care for mental conditions or substance abuse. Preauthorization must be obtained by calling ValueOptions at 888/700-7965.

We do not make available provider directories for mental health or substance abuse providers. ValueOptions will provide you with a choice of network providers when you call to preauthorize your care.

Professional outpatient care to treat mental conditions and substance abuse

40% of our allowance for up to 15 visits; all charges after 15 visits

Inpatient care to treat mental conditions includes ward or semiprivate accommodations and other hospital charges

40% of charges for up to 30 days per calendar year; all charges after 30 days

Inpatient care to treat substance abuse includes room and board and ancillary charges for confinements in a treatment facility for rehabilitative treatment of alcoholism or substance abuse

40% of charges for one treatment program up to $3,000; all charges over $3,000 per lifetime

Not covered out-of-network:

Treatment for learning disabilities and mental retardation

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

Phototherapy for treatment of Seasonal Affective Disorder (SAD)

All charges

Lifetime maximum

Out-of-network inpatient care for the treatment of alcoholism and drug abuse is limited to one treatment program per lifetime not to exceed $3,000.

Precertification

Inpatient care � You must get preauthorization of hospital stays; failure to do so will result in a minimum $500 penalty. Please refer to the precertification information shown in Section 3. To obtain preauthorization of an admission for mental conditions or substance abuse, call ValueOptions at 888/700-7965

Outpatient care � You must get preauthorization of outpatient care for mental conditions or substance abuse. Preauthorization must be obtained by calling ValueOptions at 888/700-7965

See these sections of the brochure for more valuable information about these benefits:

Section 4, Your costs for covered services, for information about catastrophic protection for these benefits.

Section 8, Filing a claim for covered services, for information about submitting out-of-network claims.

Each new enrollee will receive a description of our prescription drug program administered by Medco Health, a combined prescription drug/Plan identification card, a mail order form/patient profile and a reply envelope.

You may purchase the following medications and supplies prescribed by a physician from either a network pharmacy or by mail:

Drugs and medicines, including those for smoking cessation, for use at home that are obtainable only upon a doctor�s prescription

Drugs and medicines (including those administered during a non-covered admission or in a non-covered facility) that by Federal law of the United States require a physician�s prescription for their purchase, except those listed as Not covered

Insulin and reagent strips for known diabetics

Needles and syringes for the administration of covered medications

Full range of FDA-approved drugs, prescriptions, and devices for birth control

Approved drugs for organic impotence subject to prior Plan approval and limitations on dosage and quantity

Note: If you do not use your identification card at a network pharmacy, or if you use a non-network pharmacy, the Plan provides no benefit and you must pay the full cost of your purchases. Non-network retail drugs will be covered under the in-network benefit only if necessary and prescribed for sudden illness while traveling outside of the United States (including Puerto Rico).

Network Retail: 25% of charge with a minimum of $10 per prescription

Network Retail Medicare: 25% of charge with a minimum of $10 per prescription

Network Mail Order: 25% of charge with a minimum of $15 per prescription

Network Mail Order Medicare: 25% of charge with a minimum of $15 per prescription

Not covered:

Drugs and supplies for cosmetic purposes

Vitamins, minerals, nutritional supplements, and enteral formulas (liquid food supplements)

Medical supplies such as dressings and antiseptics

Nonprescription medicines

Non-network retail drugs (unless for a sudden illness while traveling outside the United States or Puerto Rico)

All charges

Online tools and resources

Your personal, private Web site accessible by Internet or telephone (866/333-4648) featuring:

Your Personal Care Account balance and activity (also mailed quarterly)

Your complete claims payment history

A consumer health encyclopedia and interactive services

Online health risk assessment to help determine your risk for certain conditions and steps to manage them

Consumer choice information

Each member is provided access by Internet or telephone (866/333-4648) to information which you may use to support your important health and wellness decisions, including:

Online provider directory with complete national network and provider information (i.e., address, telephone, specialty, practice hours, languages spoken)

Network provider discounted pricing for comparative shopping

Pricing information for prescription drugs

General cost information for surgical and diagnostic procedures and for comparison of different treatment options

Provider quality information

Health calculators on medical and wellness topics

Care support

A 24-hour nurse advisory service for your use. This program is strictly voluntary and confidential. You may call toll-free at 866/333-4648 to discuss an existing medical concern or to receive information about numerous health care and self-care issues. This also includes health coaching with a registered nurse when you want to discuss significant medical decisions. TTY/TDD callers, please call the National Relay Center at 800/855-2880 and ask for 866/333-4648.

Identification and notification of potential patient safety issues (e.g., drug interactions).

Individual support with a health care professional for numerous medical conditions including maternity, asthma, diabetes, congestive heart failure, and more.

How to claim benefits

High Option: to obtain claim forms or other claims filing advice or answers about our benefits, contact us at 800/222-APWU, or at our Web site at www.apwuhp.com.

Consumer-driven Option: contact Definity Health at 866/333-4648 or visit their Web site at www.definityhealth.com. User ID: APWUHP Password: HPINFO

In most cases, providers and facilities file claims for you. Your physician must file on the form HCFA-1500, Health Insurance Claim Form. Your facility will file on the UB-92 form. For claims questions and assistance, call us at 800/222-APWU.

When you must file a claim, such as when you use non-PPO providers, for services you receive overseas or when another group health plan is primary, submit it on the HCFA-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

Name of patient and relationship to enrollee

Plan identification number of the enrollee

Name, address and taxpayer identification number of person or firm providing the service or supply

Dates that services or supplies were furnished

Diagnosis

Type of each service or supply; and

The charge for each service or supply

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

In addition:

You must send a copy of the explanation of benefits (EOB) from any primary payer (such as the Medicare Summary Notice (MSN)) with your claim

Bills for home nursing care must show that the nurse is a registered nurse, licensed practical nurse or licensed vocational nurse

Claims for rental or purchase of durable medical equipment; private duty nursing; and physical, occupational, and speech therapy require a written statement from the physician specifying the medical necessity for the service or supply and the length of time needed

Claims for prescription drugs and supplies that are not obtained from a network pharmacy or through the Mail Service Prescription Drug Program must include receipts that include the prescription number, the National Drug Code (NDC) number, name of drug or supply, prescribing physician�s name, date, and charge

You should provide an English translation and currency conversion rate at the time of services for claims for overseas (foreign) services

Records

Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements.

Deadline for filing your claim

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible. Once we pay benefits, there is a three-year limitation on the reissuance of uncashed checks.

Overseas claims

For covered services you receive in hospitals outside the United States and Puerto Rico and performed by physicians outside the United States, send a completed Claim Form and the itemized bills to the following address. Also send any written inquiries concerning the processing of overseas claims to:

- High Option: APWU Health Plan, P.O. Box 967, Silver Spring, MD 20910.

- Consumer-driven Option: Definity Health at the claims address shown on the back of your Definity Health ID card.

When we need more information

Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.

1

Ask us in writing to reconsider our initial decision. You must:

(a) Write to us within 6 months from the date of our decision; and

(b) Send your High Option request to us at: APWU Health Plan, P.O. Box 3279, Silver Spring, MD 20918 or send your Consumer-driven Option request to: Definity Health, Attn: Appeals, 1600 Utica Ave., So., Suite 900, St. Louis Park, MN 55416; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians� letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

2

We have 30 days from the date we receive your request to:

(a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or

(b) Write to you and maintain our denial -- go to step 4; or

(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request -- go to step 3.

3

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have.

We will write to you with our decision.

4

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

90 days after the date of our letter upholding our initial decision; or

120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or

120 days after we asked for additional information

Write to OPM at: United States Office of Personnel Management, Insurance Services Programs, Health Insurance Group 2, 1900 E Street, NW, Washington, D.C. 20415-3620.

Send OPM the following information:

A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure

Copies of documents that support your claim, such as physicians� letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms

Copies of all letters you sent to us about the claim

Copies of all letters we sent to you about the claim; and

Your daytime phone number and the best time to call

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

The disputed claims process (continued)

5

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM�s decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and

(a) We haven�t responded yet to your initial request for care or preauthorization/prior approval under the High Option, then call us at 800/222-APWU or under the Consumer-driven Option, call 866/333-4648 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/prior approval, then:

If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM�s Health Insurance Group 2 at 202/606-3818 between 8 a.m. and 5 p.m. Eastern Time.

When you have other health coverage

You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to fault. This is called �double coverage.�

When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners� guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance. When we are secondary payer, we will not waive specified visit limits.

Please see Section 4, Your costs for covered services, for more information about how we pay claims.

What is Medicare ?

Medicare is a Health Insurance Program for:

People 65 years of age and older

Some people with disabilities, under 65 years of age

People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant)

Medicare has two parts:

Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 800/MEDICARE (800/633-4227) for more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.

Should I enroll in
Medicare?

The decision to enroll in Medicare is yours. We encourage you to apply for Medicare benefits 3 months before you turn age 65. It�s easy. Just call the Social Security Administration toll-free number 1-800-772-1213 to set up an appointment to apply. If you do not apply for one or both Parts of Medicare, you can still be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal employees and annuitants are entitled to Medicare Part A at age 65 without cost. When you don�t have to pay premiums for Medicare Part A, it makes good sense to obtain the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social Security Administration can provide you with premium and benefit information. Review the information and decide if it makes sense for you to buy the Medicare Part B coverage.

If you are eligible for Medicare, you may have choices in how you get your health care. Medicare Advantage is the term used to describe the various private health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on whether you are in the Original Medicare Plan or a private Medicare Advantage plan.

The Original Medicare Plan
(Part A or Part B)

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. Some things are not covered under Original Medicare, such as most prescription drugs (but coverage through private prescription drug plans will be available starting in 2006).

When you are enrolled in Original Medicare, along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan: You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan:

When we are the primary payer, we process the claim first. In this case, we do not waive any out-of-pocket costs

When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 800/222-APWU or contact us at our Web site at www.apwuhp.com

We waive some costs if the Original Medicare Plan is your primary payer.

Under the High Option, we will waive some out-of-pocket costs as follows:

Inpatient hospital service. If you are enrolled in Medicare Part A, we will waive the deductible, copayment and coinsurance

Medical services and supplies provided by physicians and other health care professionals. If you are enrolled in Medicare Part B, we will waive the deductible and coinsurance

Under the Consumer-driven Option, when Original Medicare (either Medicare Part A or Medicare Part B) is the primary payer, we will not waive any out-of-pocket costs.

Note: We do not waive our deductible, copayments or coinsurance for prescription drugs or for services and supplies that Medicare does not cover. Also, we do not waive benefit limitations, such as the 12-visit limit for chiropractic services or the 60-visit limit for physical, occupational or speech therapy.

Primary Payer Chart

1) Have FEHB coverage on your own as an active employee or through your spouse who is an active employee

2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant

3) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB
(your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #1 above

4) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and�

You have FEHB coverage on your own or through your spouse who is also an active employee

You have FEHB coverage through your spouse who is an annuitant

5) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #1 above

6) Are enrolled in Part B only, regardless of your employment status

for Part B services

for other services

7) Are a former Federal employee receiving Workers� Compensation and the Office of Workers� Compensation Programs has determined that you are unable to return to duty)

*

1) Have Medicare solely based on end stage renal disease (ESRD) and�

It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and�

This Plan was the primary payer before eligibility due to ESRD

for 30-month coordination period

Medicare was the primary payer before eligibility due to ESRD

1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee

2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant

Medicare Advantage

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs) in some areas of the country. In most Medicare Advantage plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare Advantage plans provide all the benefits that Original Medicare covers. Some cover extras, like prescriptions drugs. To learn more about enrolling in a Medicare Advantage plan, contact Medicare at 800/MEDICARE (800/633-4227) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan�s Medicare Advantage plan: You may enroll in another plan�s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan�s network and/or service area, but we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan�s service area.

Private contract with your physician

A physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after Original Medicare�s payment.

TRICARE AND CHAMPVA

TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the program.

Workers� Compensation

We do not cover services that:

You need because of a workplace-related illness or injury that the Office of Workers� Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.