Stop Health Care Fraud!

Preventing medical mistakes

Section 1. Facts about this fee-for-service Plan

Section 2. How we change for 2005

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 will need it whenever you receive services from a covered provider, or fill a prescription through a Preferred retail or internet pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call the Local Plan serving the area where you reside and ask them to assist you, or write to us directly at: FEP Enrollment Services, 840 First Street, NE, Washington, DC 20065.You may also request replacement cards through our Web site, www.fepblue.org.

Where you get covered care

Under Standard Option, you can get care from any "covered professional provider" or "covered facility provider." How much we pay � and you pay � depends on the type of covered provider you use. If you use our Preferred, Participating, or Member providers, you will pay less.

Under Basic Option, you must use those "covered professional providers" or "covered facility providers" that are Preferred providers for Basic Option in order to receive benefits. Please refer to page 12 for the exceptions to this requirement. Refer to page 7 for more information about Preferred providers.

For Basic Option, the term "primary care provider" includes family practitioners, general practitioners, medical internists, pediatricians, obstetricians/gynecologists, and physician assistants.

� Covered professional providers

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

Physicians � Doctors of medicine (M.D.); osteopathy (D.O.); dental surgery (D.D.S.); medical dentistry (D.M.D.); podiatric medicine (D.P.M.); and optometry (O.D.).

Other Covered Health Care Professionals � Professionals who provide additional covered services and meet the state's applicable licensing or certification requirements and the requirements of the Local Plan. Other covered health care professionals include:

- Audiologist � A professional who, if the state requires it, is licensed, certified, or registered as an audiologist where the services are performed.

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

- Clinical Social Worker � A social worker who (1) has a master's or doctoral degree in social work; (2) has at least two years of clinical social work practice; and (3) if the state requires it, is licensed, certified, or registered as a social worker where the services are performed.

- Diabetic educator � A professional who, if the state requires it, is licensed, certified, or registered as a diabetic educator where the services are performed.

- Dietician � A professional who, if the state requires it, is licensed, certified, or registered as a dietician where the services are performed.

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

- Nurse Midwife � A person who is certified by the American College of Nurse Midwives or, if the state requires it, is licensed or certified as a nurse midwife.

- Nurse Practitioner/Clinical Specialist � A person who (1) has an active R.N. license in the United States; (2) has a baccalaureate or higher degree in nursing; and (3) if the state requires it, is licensed or certified as a nurse practitioner or clinical nurse specialist.

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

- Nutritionist � A professional who, if the state requires it, is licensed, certified, or registered as a nutritionist where the services are performed.

- Physical, Speech, and Occupational Therapist � A professional who is licensed where the services are performed or meets the requirements of the Local Plan to provide physical, speech, or occupational therapy services.

- Physician Assistant � A person who is nationally certified by the National Commission on Certification of Physician Assistants in conjunction with the National Board of Medical Examiners or, if the state requires it, is licensed, certified, or registered as a physician assistant where the services are performed.

- Other professional providers specifically shown in the benefit descriptions in Section 5.

Medically underserved areas. In states that OPM determines are "medically underserved":

Under Standard Option, we cover any licensed medical practitioner for any covered service performed within the scope of that license.

Under Basic Option, we cover any licensed medical practitioner who is Preferred for any covered service performed within the scope of that license.

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 facility providers

Covered facilities include those listed below, when they meet the state's applicable licensing or certification requirements.

� Hospital � An institution, or a distinct portion of an institution, that:

(1) Primarily provides diagnostic and therapeutic facilities for surgical and medical diagnoses, treatment, and care of injured and sick persons provided or supervised by a staff of licensed doctors of medicine (M.D.) or licensed doctors of osteopathy (D.O.), for compensation from its patients, on an inpatient or outpatient basis;

(2) Continuously provides 24-hour-a-day professional registered nursing (R.N.) services; and

(3) Is not, other than incidentally, an extended care facility; a nursing home; a place for rest; an institution for exceptional children, the aged, drug addicts, or alcoholics; or a custodial or domiciliary institution having as its primary purpose the furnishing of food, shelter, training, or non-medical personal services.

Note: We consider college infirmaries to be Non-member hospitals. In addition, we may, at our discretion, recognize any institution located outside the 50 states and the District of Columbia as a Non-member hospital.

� Freestanding Ambulatory Facility � A freestanding facility, such as an ambulatory surgical center, freestanding surgi-center, freestanding dialysis center, or freestanding ambulatory medical facility, that:

(1) Provides services in an outpatient setting;

(2) Contains permanent amenities and equipment primarily for the purpose of performing medical, surgical, and/or renal dialysis procedures;

(3) Provides treatment performed or supervised by doctors and/or nurses, and may include other professional services performed at the facility; and

(4) Is not, other than incidentally, an office or clinic for the private practice of a doctor or other professional.

Note: We may, at our discretion, recognize any other similar facilities, such as birthing centers, as freestanding ambulatory facilities.

� Blue Quality Centers for Transplant (BQCT)

In addition to Preferred transplant facilities, you have access to the Blue Quality Centers for Transplant (BQCT), a centers of excellence program. BQCT institutions are selected based on their ability to meet defined clinical quality criteria that are unique for each type of transplant. BQCT negotiates a payment for transplant services performed during the transplant period (see page 114 for the definition of "transplant period").

Members who choose to use a BQCT facility for a covered transplant only pay the $100 per admission copayment under Standard Option, or the $100 per day copayment ($500 maximum) under Basic Option, for the transplant period. Members are not responsible for additional costs for included professional services. Regular Preferred benefits (subject to the regular cost-sharing levels for facility and professional services) are paid for pre- and post-transplant services performed in BQCT facilities before and after the transplant period.

BQCT institutions are available for seven types of transplants: heart; heart-lung; single or bilateral lung; liver; pancreas; simultaneous pancreas-kidney; and autologous or allogeneic bone marrow (see pages 53 through 55 for limitations).

All members (including those who have Medicare Part A or another group health insurance policy as their primary payer) must contact us at the customer service number listed on the back of their ID card before obtaining services. We will refer you to the designated Plan transplant coordinator for information about BQCT and approved facilities, and assistance in arranging for your transplant at a BQCT facility.

� Cancer Research Facility � A facility that is:

(1) A National Cooperative Cancer Study Group institution that is funded by the National Cancer Institute (NCI) and has been approved by a Cooperative Group as a bone marrow transplant center;

(2) An NCI-designated Cancer Center; or

(3) An institution that has a peer-reviewed grant funded by the National Cancer Institute (NCI) or National Institutes of Health (NIH) to study allogeneic or autologous bone marrow transplants and blood stem cell transplant support.

� Other facilities specifically listed in the benefits descriptions in Section 5(c).

What you must do to get covered care

Under Standard Option, you can go to any covered provider you want, but in some circumstances, we must approve your care in advance.

Under Basic Option, you must use Preferred providers in order to receive benefits, except under the special situations listed below. In addition, we must approve certain types of care in advance. Please refer to Section 4, Your costs for covered services, for related benefits information.

(1) Medical emergency or accidental injury care in a hospital emergency room and related ambulance transport as described in Section 5(d), Emergency services/accidents;

(2) Professional care provided at Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency room physicians, and assistant surgeons;

(3) Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred laboratories, radiologists, and outpatient facilities;

(4) Services of assistant surgeons;

(5) Special provider access situations (contact your Local Plan for more information);

or

(6) Care received outside the United States and Puerto Rico.

Unless otherwise noted in Section 5, when services of Non-preferred providers are covered in a special exception, benefits will be provided based on the Plan allowance. You are responsible for the applicable coinsurance or copayment, and may also be responsible for any difference between our allowance and the billed amount.

� 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 Preferred 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 Preferred 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 Preferred benefits will 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 Plan begins, call us immediately. If you have not yet received your Service Benefit Plan ID card, you can contact your Local Plan at the telephone number listed in your local telephone directory. If you already have your new Service Benefit Plan ID card, call us at the number on the back of the card. If you are new to the FEHB Program, we will reimburse you for your covered expenses while in the hospital.

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

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

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

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

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB 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 will not 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

� You, your representative, your doctor, or your hospital must call us at the telephone number listed on the back of your Service Benefit Plan ID card any time prior to admission.

� 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, your doctor, or your hospital must telephone us within two business days 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:

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.

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. [See Section 5(c) for payment information.]

� 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 or inpatient physician care 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 you 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 we will not pay inpatient benefits.

Exceptions:

You do not need precertification in these cases:

� You are admitted to a hospital outside the United States.

� You have another group health insurance policy that is the primary payer for the hospital stay. (See page 12 for special instructions regarding admissions to BQCT institutions.)

� Your Medicare Part A is the primary payer for the hospital stay. (See page 12 for special instructions regarding admissions to BQCT institutions.)

Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then you do need precertification.

� Other services

These services require prior approval under both Standard and Basic Option:

� Home hospice care � Contact us at the customer service number listed on the back of your ID card before obtaining services. We will request the medical evidence we need to make our coverage determination and advise you which home hospice care agencies we have approved.

� Partial hospitalization or intensive outpatient treatment for mental health/substance abuse � Contact us at the mental health and substance abuse number listed on the back of your ID card before obtaining services for intensive outpatient treatment or partial hospitalization from Preferred providers. We will request the medical evidence we need to make our coverage determination. We will also consider the necessary duration of either of these services.

� Organ/tissue transplants � Contact us at the customer service number listed on the back of your ID card before obtaining services. We will request the medical evidence we need to make our coverage determination. We will consider whether the facility is approved for the procedure and whether you meet the facility's criteria.

� Clinical trials for certain organ/tissue transplants � Contact our Clinical Trials Information Unit at 1-800-225-2268 for information or to request prior approval before obtaining services. We will request the medical evidence we need to make our coverage determination. Use this number only for prior approval of clinical trials for bone marrow and peripheral blood stem cell transplant support procedures for those conditions shown on pages 54 and 55 as covered only in clinical trials.

� Prescription drugs � Certain prescription drugs require prior approval. Contact our Retail Pharmacy Program at 1-800-624-5060 (TDD: 1-800-624-5077 for the hearing impaired) to request prior approval, or to obtain an updated list of prescription drugs that require prior approval. We will request the information we need to make our coverage determination. You must periodically renew prior approval for certain drugs. See page 85 for more about our prescription drug prior approval program, which is part of our Patient Safety and Quality Monitoring (PSQM) program.

Note: Benefits for drugs to aid smoking cessation that require a prescription by Federal law are limited to one course of treatment per calendar year. Prior approval is required before benefits will be provided for additional medication. To obtain approval, the physician must certify the patient is participating in a smoking cessation program that provides clinical treatment, including counseling and behavioral therapies.

Note: Until we approve them, you must pay for these drugs in full when you purchase them � even if you purchase them at a Preferred retail pharmacy or through an internet pharmacy � and submit the expense(s) to us on a claim form. Preferred pharmacies will not file these claims for you.

Under Standard Option, members may use our Mail Service Prescription Drug Program to fill their prescriptions. However, the Mail Service Prescription Drug Program also will not fill your prescription until you have obtained prior approval. Caremark, the administrator of the Mail Service Prescription Drug Program, will hold your prescription for you up to thirty days. If prior approval is not obtained within 30 days, your prescription will be returned to you along with a letter explaining the prior approval procedures.

The Mail Service Prescription Drug Program is not available under Basic Option.

In addition to the types of care listed above, these services also require prior approval under Basic Option:

� Outpatient mental health and substance abuse treatment � You must call us at the number listed on the back of your ID card for mental health and substance abuse before receiving any outpatient professional or facility care. We will then provide you with the names and phone numbers of several Preferred providers to choose from and tell you how many visits we are initially approving.

Section 4. Your costs for covered services

This is what you will pay out-of-pocket for your covered care:

Copayments

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

Example: If you have Standard Option when you see your Preferred physician, you pay a copayment of $15 for the office visit and we then pay the remainder of the amount billed for the office visit. (You may have to pay separately for other services you receive while in the physician's office.) When you go into a Preferred hospital, you pay a copayment of $100 per admission. We then pay the remainder of the hospital bill for the covered services you receive.

Copayments do not apply to services and supplies that are subject to a deductible and/or coinsurance amount.

Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than your copayment, you pay the lower amount.

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 and coinsurance amounts do not count toward your deductible. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply that you then pay counts toward meeting your deductible.

Under Standard Option, the calendar year deductible is $250 per person. Under a family enrollment, the calendar year deductible for each family member is satisfied and benefits are payable for all family members when the combined covered expenses of the family reach $500.

Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than the remaining portion of your deductible, you pay the lower amount.

Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you have not paid any amount toward meeting your Standard Option calendar year deductible, you must pay $80. We will apply $80 to your deductible. We will begin paying benefits once the remaining portion of your Standard Option calendar year deductible ($170) has been satisfied.

Note: If you change plans during Open Season and the effective date of your new plan is after January 1 of the next year, 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.

Under Basic Option, there is no calendar year deductible.

Coinsurance

Coinsurance is thepercentage of the Plan allowance that you must pay for your care. Your coinsurance is based on the Plan allowance, or billed amount, whichever is less. Under Standard Option only, coinsurance does not begin until you meet your deductible.

Example: You pay 10% of the Plan allowance under Standard Option for durable medical equipment obtained from a Preferred provider, after meeting your $250 calendar year deductible.

Note: If your provider routinely waives (does not require you to pay) your applicable deductible (under Standard Option only), coinsurance, or copayments, 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.

Example: If your physician ordinarily charges $100 for a service but routinely waives your 25% Standard Option coinsurance, the actual charge is $75. We will pay $56.25 (75% of the actual charge of $75).

Waivers

In some instances, a Preferred, Participating, or Member provider may ask you to sign a "waiver" prior to receiving care. This waiver may state that you accept responsibility for the total charge for any care that is not covered by your health plan. If you sign such a waiver, whether you are responsible for the total charge depends on the content of the contracts that the Local Plan has with its providers. If you are asked to sign this type of waiver, please be aware that, if benefits are denied for the services, you could be legally liable for the related expenses. If you would like more information about waivers, please contact us at the customer service number on the back of your ID card.

Differences between our allowance and the bill

Our "Plan allowance" is the amount we use to calculate our payment for certain types of covered services. Fee-for-service plans arrive at their allowances in different ways, so allowances vary. For information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10.

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 type of provider you use. In this Plan, we have the following types of providers:

� Preferred providers. These types of providers have agreements with the Local Plan to limit what they bill our members. Because of that, when you use a Preferred provider, your share of the provider's bill for covered care is limited.

Under Standard Option, your share consists only of your deductible and coinsurance or copayment. Here is anexample about coinsurance: You see a Preferred physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, under Standard Option, you pay just 10% of our $100 allowance ($10). Because of the agreement, your Preferred physician will not bill you for the $50 difference between our allowance and his/her bill.

Under Basic Option, your share consists only of your copayment or coinsurance amount, since there is no calendar year deductible. Here is anexample involving a copayment: You see a Preferred physician who charges $150 for covered services subject to a $20 copayment. Even though our allowance may be $100, you still pay just the $20 copayment. Because of the agreement, your Preferred physician will not bill you for the $130 difference between your copayment and his/her bill.

Remember, under Basic Option, you must use Preferred providers in order to receive benefits. See page 12 for the exceptions to this requirement.

� Participating providers. These types of Non-preferred providers have agreements with the Local Plan to limit what they bill our Standard Option members.

Under Standard Option, when you use a Participating provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an example: You see a Participating physician who charges $150, but the Plan allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, under Standard Option, you pay just 25% of our $100 allowance ($25). Because of the agreement, your Participating physician will not bill you for the $50 difference between our allowance and his/her bill.

Under Basic Option, there are no benefits for care performed by Participating providers; you pay all charges. See page 12 for the exceptions to this requirement.

� Non-participating providers. These Non-preferred providers have no agreement to limit what they will bill you.

Under Standard Option, when you use a Non-participating provider, you will pay your deductible and coinsurance � plus any difference between our allowance and the charges on the bill (except in certain circumstances � see page 114). For example, you see a Non-participating physician who charges $150. The Plan allowance is again $100, and you have met your deductible. You are responsible for your coinsurance, so you pay 25% of the $100 Plan allowance or $25. Plus, because there is no agreement between the Non-participating physician and us, the physician can bill you for the $50 difference between our allowance and his/her bill.

Under Basic Option, there are no benefits for care performed by Non-participating providers; you pay all charges. See page 12 for the exceptions to this requirement.

The following table illustrates examples of how much you have to pay out-of-pocket for services from a Preferred physician, a Participating physician, and a Non-participating physician. The table uses our example of a service for which the physician charges $150 and the Plan allowance is $100. For Standard Option, the table shows the amount you pay if you have met your calendar year deductible.

$150

$150

$150

$150

We set it at: 100

We set it at: 100

We set it at: 100

We set it at: 100

90% of our allowance: 90

Our allowance

less copay: 80

75% of our

allowance: 75

75% of our

allowance: 75

10% of our allowance: 10

Not applicable

25% of our

allowance: 25

25% of our

allowance: 25

Not applicable

20

Not applicable

Not applicable

No: 0

No: 0

No: 0

Yes: 50

$10

$20

$25

$75

*Under Basic Option, there are no benefits for care performed by Participating and Non-participating physicians. You must use Preferred providers in order to receive benefits. See page 12 for the exceptions to this requirement.

Note: Under Standard Option, had you not met any of your deductible in the above examples, only our allowance ($100), which you would pay in full, would count toward your deductible.

� Overseas providers. We pay overseas claims at Preferred benefit levels, using an Overseas Fee Schedule as our Plan allowance. Most overseas professional providers are under no obligation to accept our allowance, and you must pay any difference between our payment and the provider's bill. For facility care you receive overseas, we provide benefits in full after you pay the applicable copayment or coinsurance (and, under Standard Option, any deductible amount that may apply). See Section 5(i) for more information about our overseas benefits.

� Dental care. Under Standard Option, we pay scheduled amounts for routine dental services and you pay any balance. Under Basic Option, you pay $20 for any covered evaluation and we pay the balance for covered services. See Section 5(h) for a listing of covered dental services and additional payment information.

� Hospital care. You pay the coinsurance or copayment amounts listed in Section 5(c). Under Standard Option, you must meet your deductible before we begin providing benefits for certain hospital-billed services. Under Basic Option, you must use Preferred facilities in order to receive benefits. See page 12 for the exceptions to this requirement.

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

If the total amount of out-of-pocket expenses in a calendar year for you and your covered family members for deductibles (Standard Option only), coinsurance, and copayments (other than those listed below) exceeds $6,000 under Standard Option, or $5,000 under Basic Option, then you and any covered family members will not have to continue paying them for the remainder of the calendar year.

Standard Option Preferred maximum: If the total amount of these out-of-pocket expenses from using Preferred providers for you and your covered family members exceeds $4,000 in a calendar year under Standard Option, then you and any covered family members will not have to pay these expenses for the remainder of the calendar year when you continue to use Preferred providers. You will, however, have to pay them when you use Non-preferred providers, until your out-of-pocket expenses (for the services of both Preferred and Non-preferred providers) reach $6,000 under Standard Option, as shown above.

Basic Option maximum: If the total amount of these out-of-pocket expenses from using Preferred providers for you and your covered family members exceeds $5,000 in a calendar year under Basic Option, then you and any covered family members will not have to pay these expenses for the remainder of the calendar year.

The following expenses are not included under this feature. These expenses do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay them even after your expenses exceed the limits described above.

� The difference between the Plan allowance and the billed amount. See pages 17-19;

� Expenses for services, drugs, and supplies in excess of our maximum benefit limitations;

� Under Standard Option, your 30% coinsurance for inpatient care in a Non-member hospital;

� Under Standard Option, your 25% coinsurance for outpatient care by a Non-member facility;

� Your expenses for mental conditions and substance abuse care by a Non-preferred professional or facility provider;

� Your expenses for dental services in excess of our fee schedule payments under Standard Option. See Section 5(h);

� The $500 penalty for failing to obtain precertification, and any other amounts you pay because we reduce benefits for not complying with our cost containment requirements;

� Under Basic Option, coinsurance you pay for non-formulary brand-name drugs; and

� Under Basic Option, your expenses for care received from Participating/Non-participating professional providers or Member/Non-member facilities, except for coinsurance and copayments you pay in those special situations where we do pay for care provided by Non-preferred providers. Please see page 12 for the exceptions to the requirement to use Preferred providers.

Note: If you change to another plan during Open Season, we will continue to provide benefits between January 1 and the effective date of your new plan.

� If you had already paid the out-of-pocket maximum, we will continue to provide benefits as described on this page until the effective date of your new plan.

� If you had not yet paid the out-of-pocket maximum, we will apply any expenses you incur in January (before the effective date of your new plan) to our prior year's out-of-pocket maximum. Once you reach the maximum, you don't need to pay our deductibles, copayments, or coinsurance amounts (except as shown on this page) from that point until the effective date of your new plan.

Note: Because benefit changes are effective January 1, we will apply our next year's benefits to any expenses you incur in January.

Note: If you change options in this Plan during the year, we will credit the amounts already accumulated toward the catastrophic protection out-of-pocket limit of your old option to the catastrophic protection out-of-pocket limit of your new option. If you change from Self Only to Self and Family, or vice versa, during the calendar year, please call us about your out-of-pocket accumulations and how they carry over.

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.

Note: 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 deductible (Standard Option only), 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 equivalent Medicare amount.

And, for your physician care, the law requires us to base our payment and your applicable coinsurance or copayment 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 in our Preferred network

Standard Option:

your deductibles, coinsurance, and copayments

Basic Option:

your copayments and coinsurance

Participates with Medicare or accepts Medicare assignment and is not in our Preferred network

Standard Option:

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

Basic Option:

all charges

Does not participate with Medicare, and is in our Preferred network

Standard Option:

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

Basic Option:

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

Note: In many cases, your payment will be less because of our Preferred agreements. Contact your Local Plan for information about what your specific Preferred provider can collect from you.

Does not participate with Medicare and is not in our Preferred network

Standard Option:

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

Basic Option:

all charges

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 a facility 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.

� If your physician accepts Medicare assignment, then you pay nothing for covered charges (see note below for Basic Option).

� 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 (see note below for Basic Option).

Note: Under Basic Option, you must see Preferred providers in order to receive benefits. See page 12 for the exceptions to this requirement.

It is 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) form that you receive from Medicare 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 9, Coordinating benefits with other coverage, for more information about how we coordinate benefits with Medicare.

Section 5. Benefits � OVERVIEW
(See page 9 for how our benefits changed this year and pages 123-124 for a benefits summary.)

Section 5(a) Medical services and supplies provided by physicians
and other health care professionals

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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.

� Under Standard Option, the calendar year deductible is $250 per person ($500 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.

� Under Standard Option, we provide benefits at 90% of the Plan allowance for services provided in Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a physician's office). You are responsible for any difference between our allowance and the billed amount.

� Under Basic Option, there is no calendar year deductible.

� Under Basic Option, you must use Preferred providers in order to receive benefits. See below and page 12 for the exceptions to this requirement.

� Under Basic Option, we provide benefits at 100% of the Plan allowance for services provided in Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a physician's office). You are responsible for any difference between our allowance and the billed amount.

� Please refer to Section 3, How you receive benefits, for a list of providers we consider to be primary care providers (under Basic Option) and other health care professionals.

� 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 9 about coordinating benefits with other coverage, including Medicare.

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

� The amounts listed in this section are for the charges billed by a physician or other health care professional for your medical care. Look in Section 5(c) for charges associated with the facility

(i.e., hospital or other outpatient facility, etc.).

� PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

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Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Professional services of physicians and other health care professionals:

�Outpatient consultations

�Outpatient second surgical opinions

�Office visits

�Home visits

�Initial examination of a newborn needing definitive treatment when covered under a family enrollment

�Pharmacotherapy [see Section 5(f) for prescription drug coverage]

�Neurological testing

Preferred: $15 copayment for the office visit charge (No deductible)

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Inpatient professional services:

� During a hospital stay

� Services for nonsurgical procedures when ordered, provided, and billed by a physician during a covered inpatient hospital admission

� Medical care by the attending physician (the physician who is primarily responsible for your care when you are hospitalized) on days we pay inpatient hospital benefits

Note: A consulting physician employed by the hospital is not the attending physician.

� Consultations when requested by the attending physician

� Concurrent care � hospital inpatient care by a physician other than the attending physician for a condition not related to your primary diagnosis, or because the medical complexity of your condition requires this additional medical care

� Physical therapy by a physician other than the attending physician

� Initial examination of a newborn needing definitive treatment when covered under a family enrollment

� Pharmacotherapy [see Section 5(c) for prescription drug coverage]

� Neurological testing

� Second surgical opinion

� Nutritional counseling when billed by a covered provider for anorexia and bulimia

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: Nothing

Participating/Non-participating: You pay all charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Not covered:

� Routine services except for those Preventive care services described below, on pages

29-31, and page 46

� Inpatient private duty nursing

� Standby physicians

� Routine radiological and staff consultations required by hospital rules and regulations

� Inpatient physician care when your hospital admission or portion of an admission is not covered [see Section 5(c)]

Note: If we determine that a hospital admission is not covered, we will not provide benefits for inpatient room and board or inpatient physician care. However, we will provide benefits for covered services or supplies other than room and board and inpatient physician care at the level that we would have paid if they had been provided in some other setting.

All charges

All charges

Diagnostic tests provided, or ordered and billed by a physician, such as:

� Blood tests

� Bone density tests � screening or diagnostic

� CT scans/MRIs

� EKGs and EEGs

� Laboratory tests

� Pathology services

� Ultrasounds

� Urinalysis

� X-rays

Diagnostic services billed by an independent laboratory

Note: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Note: If your Preferred provider uses a Non-preferred laboratory or radiologist, we will pay Non-preferred benefits for any laboratory and X-ray charges.

Preferred primary care provider or other health care professional: Nothing

Preferred specialist: Nothing

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Other diagnostic tests provided, or ordered and billed by a physician, such as:

� Fecal occult blood tests

� Non-routine mammograms

� Non-routine Pap tests

� Prostate Specific Antigen (PSA) tests

� Sigmoidoscopies

Note: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.

Preferred: $15 copayment for associated office visits (No deductible); nothing for services or tests

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Note: If your Preferred provider uses a Non-preferred laboratory or radiologist, we will pay Non-preferred benefits for any laboratory and X-ray charges.

Preferred primary care provider or other health care professional: Nothing

Preferred specialist: Nothing

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

Home and office visits for routine (screening) physical examinations

Under Standard Option, benefits are limited to the following services when performed as part of a routine physical examination:

� History and risk assessment

� Chest X-ray

� EKG

� Urinalysis

� General health panel

� Basic or comprehensive metabolic panel test

� CBC

� Fasting lipoprotein profile (total cholesterol, LDL, HDL, and/or triglycerides) when performed by a Preferred provider or any independent laboratory

Note: The benefits listed above do not apply to children up to age 22. (See benefits under Preventive care, children, this section.)

� Chlamydial infection test

Under Basic Option, benefits are provided for all of the services listed above and for other appropriate screening tests and services.

Preferred: $15 copayment for the examination (No deductible); nothing for services or tests

Note: We provide benefits for adult routine physical examinations only when you receive these services from a Preferred provider.

Participating:

You pay all charges

Non-participating:

You pay all charges

Note:When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

Note:See Section 5(c) for our payment levels for these services when billed for by a facility, such as the outpatient department of a hospital.

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Cancer screening

� Colorectal cancer screening, including:

- Fecal occult blood test

- Sigmoidoscopy

- Double contrast barium enema

� Prostate cancer screening � Prostate Specific Antigen (PSA) test

� Cervical cancer screening

� Breast cancer screening (routine mammograms)

Preferred: $15 copayment for associated office visits (No deductible); nothing for services or tests

Note: We provide benefits in full for preventive (screening) tests and immunizations only when you receive these services from a Preferred provider on an outpatient basis. If these services are billed separately from the routine physical examination, you may be responsible for paying an additional copayment for each office visit billed.

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Note:When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

Note:See Section 5(c) for our payment levels for these services when billed for by a facility, such as the outpatient department of a hospital.

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Routine immunizations without regard to age, limited to:

� Hepatitis immunizations (Types A and B) for patients with increased risk or family history

� Influenza and pneumococcal vaccines, annually

� Tetanus-diphtheria (Td) booster � once every 10 years

Preferred: $15 copayment for associated office visits (No deductible); nothing for immunizations

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment for associated office visits; nothing for immunizations

Preferred specialist: $30 copayment for associated office visits; nothing for immunizations

Participating/Non-participating: You pay all charges

Not covered: Office visit charges associated with preventive services and routine immunizations performed by Participating and Non-participating providers

All charges

All charges

We provide benefits for the following services:

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

� The following routine services as recommended by the American Academy of Pediatrics for children up to the age of 22, including children living, traveling, or adopted from outside the United States:

- Routine physical examinations

- Routine hearing tests

- Laboratory tests

- Immunizations

- Related office visits

Preferred: Nothing (No deductible)

Participating: Nothing (No deductible)

Non-participating: Nothing (No deductible) up to the Plan allowance. You are responsible only for any difference between our allowance and the billed amount.

Note:When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Preferred primary care provider or other health care professional: Nothing

Preferred specialist: Nothing

Participating/Non-participating: You pay all charges

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

Note:When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Complete maternity (obstetrical) care including related conditions resulting in childbirth or miscarriage when provided, or ordered and billed by a physician or nurse midwife, such as:

� Prenatal care (including laboratory and diagnostic tests)

� Tocolytic therapy and related services (when provided and billed by a home infusion therapy company or a home health care agency)

Note: Benefits are not provided for oral tocolytic agents. Benefits for home nursing visits related to covered tocolytic therapy are subject to the visit limitations described on page 42.

� Delivery

� Postpartum care

� Assistant surgeons/surgical assistance by a physician if required because of the complexity of the delivery

� Anesthesia (including acupuncture) when requested by the attending physician and performed by a certified registered nurse anesthetist (CRNA) or a physician other than the operating physician (surgeon) or the assistant

Preferred: Nothing (No deductible)

Note: For facility care related to maternity, including care at birthing facilities, we waive the per admission copayment and pay for covered services in full when you use Preferred providers.

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: Nothing

Note: For facility care related to maternity, including care at birthing facilities, see Section 5(c).

Participating/Non-participating: You pay all charges

Note: For services billed by Participating and Non-participating laboratories and radiologists, you are responsible only for any difference between our allowance and the billed amount.

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Note: Here are some things to keep in mind:

� You do not need to precertify your normal delivery; see page 14 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 the extended stay. See Section 3 for information on requesting additional days.

� We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay, or if the child is covered under the father's Self and Family enrollment.

Note: When a newborn requires definitive treatment including incubation charges by reason of prematurity or evaluation for medical or surgical reasons during or after the mother's confinement, the newborn is considered a patient in his or her own right.

Note: Expenses of the newborn are eligible for benefits only if the child is covered by a Self and Family enrollment. For services such as circumcision, regular medical or surgical benefits apply rather than maternity benefits.

Note: See page 46 for our payment levels for circumcision.

Not covered: Procedures, services, drugs, and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

A range of voluntary family planning services, limited to:

� Depo-Provera

� Diaphragms and contraceptive rings

� Intrauterine devices (IUDs)

� Implantable contraceptives

� Oral and transdermal contraceptives

� Voluntary sterilization [see Surgical procedures in Section 5(b)]

Note: See Section 5(f) for prescription drug coverage.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay $100 for related surgical procedures. See Section 5(b) for our coverage for related surgical procedures.

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Not covered:

� Reversal of voluntary surgical sterilization

� Contraceptive devices not described above

All charges

All charges

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

Note: See Section 5(f) for prescription drug coverage.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Not covered:

� Assisted reproductive technology (ART) procedures, such as:

- artificial insemination (AI)

- in vitro fertilization (IVF)

- embryo transfer and Gamete Intrafallopian Transfer (GIFT)

- intravaginal insemination (IVI)

- intracervical insemination (ICI)

- intrauterine insemination (IUI)

� Services and supplies related to ART procedures, such as sperm banking

All charges

All charges

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

� Allergy injections

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment per visit; nothing for injections

Preferred specialist: $30 copayment per visit; nothing for injections

Participating/Non-participating: You pay all charges

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

Not covered: Provocative food testing and sublingual allergy desensitization

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Outpatient treatment therapies:

� Chemotherapy and radiation therapy

Note: We cover high dose chemotherapy and/or radiation therapy in connection with bone marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant procedures, only for those conditions listed as covered under Organ/tissue transplants in Section 5(b). See also, Other services under How to get approval for . . . in Section 3 (page 14).

� Renal dialysis � Hemodialysis and peritoneal dialysis

� Intravenous (IV)/infusion therapy � Home IV or infusion therapy

Note: Home nursing visits associated with Home IV/infusion therapy are covered as shown under Home health services on page 42.

� Outpatient cardiac rehabilitation

Note: See Section 5(c) for our payment levels for treatment therapies billed for by the outpatient department of a hospital.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Inpatient treatment therapies:

� Chemotherapy and radiation therapy

Note: We cover high dose chemotherapy and/or radiation therapy in connection with bone marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant procedures, only for those conditions listed as covered under Organ/tissue transplants in Section 5(b). See also, Other services under How to get approval for . . . in Section 3 (page 14).

� Renal dialysis � Hemodialysis and peritoneal dialysis

� Pharmacotherapy [see Section 5(c) for prescription drug coverage]

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: Nothing

Participating/Non-participating: You pay all charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

� Physical therapy, occupational therapy, and speech therapy when performed by a licensed therapist or physician

� Acupuncture when provided by a physician

Note: When billed by a skilled nursing facility, nursing home, or extended care facility, we pay benefits as shown here for professional care, according to the contracting status of the therapist.

Preferred: $15 copayment per visit (No deductible)

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Note: Benefits are limitedto 75 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.

Note: Visits that you pay for while meeting your calendar year deductible count toward the limit cited above.

Note:When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

Note: Benefits are limitedto 50 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.

Participating/Non-participating: You pay all charges

Note: See Section 5(c) for our payment levels for rehabilitative therapies billed for by the outpatient department of a hospital.

Not covered:

� Recreational or educational therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay

� Maintenance or palliative rehabilitative therapy

� Exercise programs

� Hippotherapy (exercise on horseback)

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Hearing tests related to illness or injury

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Not covered:

� Routine hearing tests (except as indicated under Preventive care, children)

� Hearing aids (including implanted bone conduction hearing aids)

� Testing and examinations for the prescribing or fitting of hearing aids

All charges

All charges

� One pair of eyeglasses, replacement lenses, or contact lenses to correct an impairment directly caused by a single instance of accidental ocular injury or intraocular surgery

Note: This benefit may also be used to obtain one pair of eyeglasses, replacement lenses, or contact lenses prescribed in lieu of surgery when the condition can be corrected by surgery, but surgery is precluded because of age or medical condition.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: 30% of the Plan allowance

Participating/Non-participating: You pay all charges

� Eye examinations related to a specific medical condition

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

Note: See Section 5(b), Surgical procedures, for coverage for surgical treatment of amblyopia and strabismus.

Preferred: $15 copayment (No deductible)

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Not covered:

� Eyeglasses, contact lenses, routine eye examinations, or vision testing for the prescribing or fitting of eyeglasses or contact lenses, except as described on page 38

� Eye exercises, visual training, or orthoptics, except for nonsurgical treatment of amblyopia and strabismus as described on page 38

� LASIK, radial keratotomy, and other refractive services

All charges

All charges

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

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

Note: See Section 5(b) for our coverage for surgical procedures.

Preferred: $15 copayment for the office visit (No deductible); 10% of the Plan allowance for all other services (deductible applies)

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Not covered: Routine foot care, such as 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

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Orthopedic braces and prosthetic appliances such as:

� Artificial limbs and eyes

� Functional foot orthotics when prescribed by a physician

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

� Replacement, repair, and adjustment of covered devices

� Following a mastectomy, breast prostheses and surgical bras, including necessary replacements

Note: A prosthetic appliance is a device that is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.

We provide hospital benefits for internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b).

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: 30% of the Plan allowance

Participating/Non-participating: You pay all charges

Not covered:

� Shoes and over-the-counter orthotics

� Arch supports

� Heel pads and heel cups

� Penile implants

� Wigs (including cranial prostheses)

� Implanted bone conduction hearing aids

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

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. Under this benefit, we cover:

� Home dialysis equipment

� Oxygen equipment

� Hospital beds

� Wheelchairs

� Crutches

� Walkers

� Continuous passive motion (CPM) and dynamic orthotic cranioplasty (DOC) devices

� Other items that we determine to be DME, such as compression stockings

Note: We cover DME at Preferred benefit levels only when you use a Preferred DME provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred DME providers.

Note: See Section 5(c) for our coverage of DME provided and billed by a facility.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: 30% of the Plan allowance

Participating/Non-participating: You pay all charges

Not covered:

� Exercise and bathroom equipment

� Lifts, such as seat, chair, or van lifts

� Car seats

� Air conditioners, humidifiers, dehumidifiers, and purifiers

� Breast pumps

� Computer equipment/devices such as "story boards" or other communication aids to assist communication-impaired individuals

� Equipment for cosmetic purposes

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

� Medical foods for children with inborn errors of amino acid metabolism

� Medical foods and nutritional supplements when administered by catheter or nasogastric tubes

� Ostomy and catheter supplies

� Oxygen, regardless of the provider

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

Note: We cover medical supplies at Preferred benefit levels only when you use a Preferred medical supply provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred medical supply providers.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: 30% of the Plan allowance

Participating/Non-participating: You pay all charges

Home nursing care for two (2) hours per day, up to 25 visits per calendar year, when:

� A registered nurse (R.N.) or licensed practical nurse (L.P.N.) provides the services; and

� A physician orders the care

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Note: Visits that you pay for while meeting your calendar year deductible count toward the annual visit limit.

Preferred: $20 copayment per visit

Participating/Non-participating: You pay all charges

Not covered:

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

� Services primarily for bathing, feeding, exercising, moving the patient, homemaking, giving medication, or acting as a companion or sitter

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

� Initial office visit

� Spinal manipulations

� Initial set of X-rays

All charges

Note: Benefits may be available for covered services you receive from chiropractors in medically underserved areas. See page 11 for additional information.

Preferred: $20 copayment per visit, up to 20 manipulations per calendar year

Participating/Non-participating: You pay all charges

Acupuncture � when performed and billed by a physician for:

� pain relief, and

� as a modality of physical therapy

Note: See page 37 for limitations.

Note:We may also cover services of certain alternative treatment providers in medically underserved areas. See page 11 for additional information.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Not covered:

� Services you receive from noncovered providers such as:

- naturopaths

- hypnotherapists

� Biofeedback (or other forms of self-care or self-help training)

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

� Smoking cessation

Note: See Section 5(e) for our coverage of individual and group psychotherapy for smoking cessation and Section 5(f) for our coverage of smoking cessation drugs.

Preferred: $15 copayment for the office visit charge (No deductible); 10% of the Plan allowance for all other services (deductible applies)

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Participating/Non-participating: You pay all charges

� Diabetic education when billed by a covered provider

Note:We cover diabetic educators, dieticians, and nutritionists who bill independently only as part of a covered diabetic education program.

� Nutritional counseling when billed by a covered provider for anorexia and bulimia

Note:We cover dieticians and nutritionists who bill independently for the treatment of anorexia and bulimia.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Participating/Non-participating: You pay all charges

Not covered:

� Marital, family, educational, or other counseling or training services when performed as part of an educational class or program

� Premenstrual syndrome (PMS), lactation, headache, eating disorder (except as described above), and other educational clinics

� Recreational or educational therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay

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

All charges

All charges

Section 5(b) Surgical and anesthesia services provided by physicians
and other health care professionals

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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.

� Under Standard Option, the calendar year deductible is $250 per person ($500 per family). The calendar year deductible applies to almost all Standard Option benefits in this Section. We say "(No deductible)" to show when the calendar year deductible does not apply.

� Under Standard Option, we provide benefits at 90% of the Plan allowance for services provided in Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a physician's office). You are responsible for any difference between our allowance and the billed amount.

� Under Basic Option, there is no calendar year deductible.

� Under Basic Option, you must use Preferred providers in order to receive benefits. See below and page 12 for the exceptions to this requirement.

� Under Basic Option, we provide benefits at 100% of the Plan allowance for services provided in Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency room physicians, and assistant surgeons (including assistant surgeons in a physician's office). You are responsible for any difference between our allowance and the billed amount.

� 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 9 about coordinating benefits with other coverage, including Medicare.

� We base payment on whether a facility or a health care professional bills for the services or supplies. You will find that some benefits are listed in more than one section of the brochure. This is because how they are paid depends on what type of provider bills for the service.

� The amounts listed in this section 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 PRIOR APPROVAL for all organ transplant surgical procedures (except kidney and cornea transplants); and if your surgical procedure requires an inpatient admission, YOU MUST GET PRECERTIFICATION. Please refer to the prior approval and precertification information shown in Section 3 to be sure which services require prior approval or precertification.

� PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

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Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

A comprehensive range of services provided, or ordered and billed by a physician, such as:

� Operative procedures

� Treatment of fractures and dislocations, including casting

� Normal pre- and post-operative care by the surgeon

� Correction of amblyopia and strabismus

� Colonoscopy � screening or diagnostic

� Other endoscopy procedures

� Biopsy procedures

� Removal of tumors and cysts

� Correction of congenital anomalies (see Reconstructive surgery on page 48)

� Treatment of burns

� Circumcision of newborn

� Insertion of internal prosthetic devices. See Section 5(a) � Orthopedic and prosthetic devices, and Section 5(c) � Other hospital services and supplies � for our coverage for the device.

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

� Assistant surgeons/surgical assistance by a physician if required because of the complexity of the surgical procedures

� Gastric bypass surgery or gastric stapling procedures for morbid obesity � a condition in which an individual weighs 100 pounds over, or 100% over, his or her normal weight according to current underwriting standards; eligible members must be age 18 or over

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: $100 copayment per performing surgeon

Note: If you receive the services of a co-surgeon, you pay a second $100 copayment for those services. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Note: When multiple surgical procedures that add time or complexity to patient care are performed during the same operative session, the Local Plan determines our allowance for the combination of multiple, bilateral, or incidental surgical procedures. Generally, we will allow a reduced amount for procedures other than the primary procedure.

Note: We do not pay extra for "incidental" procedures (those that do not add time or complexity to patient care).

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

Not covered:

� Reversal of voluntary sterilization

� Services of a standby physician

� Routine surgical treatment of conditions of the foot [see Section 5(a) � Foot care]

� Cosmetic surgery

� LASIK, radial keratotomy, and other refractive surgery

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

� Surgery to correct a functional defect

� Surgery to correct a congenital anomaly � 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; and webbed fingers and toes.

Note: Congenital anomalies do not include conditions related to the teeth or intra-oral structures supporting the teeth.

� Treatment to restore the mouth to a pre-cancer state

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

- surgery to produce a symmetrical appearance of the patient's breasts

- treatment of any physical complications, such as lymphedemas

Note: Internal breast prostheses are paid as orthopedic and prosthetic devices [see Section 5(a)]. See Section 5(c) when billed by a facility.

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.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: $100 copayment per performing surgeon

Note: If you receive the services of a co-surgeon, you pay a second $100 copayment for those services. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Not covered:

� Cosmetic surgery � any operative procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form � unless required for a congenital anomaly or to restore or correct a part of the body that has been altered as a result of accidental injury, disease, or surgery (does not include anomalies related to the teeth or structures supporting the teeth)

� Surgeries related to sex transformation, sexual dysfunction, or sexual inadequacy

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Oral surgical procedures, limited to:

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

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

� Excision of exostoses of jaws and hard palate

� Incision and drainage of abscesses and cellulitis

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

� Reduction of dislocations and excision of temporomandibular joints

� Removal of impacted teeth

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: $100 copayment per performing surgeon

Note: If you receive the services of a co-surgeon, you pay a second $100 copayment for those services. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Not covered:

� Oral implants and transplants

� Surgical procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone), except as shown above and in Section 5(h)

� Surgical procedures involving orthodontic care, dental implants, or preparation of the mouth for the fitting or the continued use of dentures, except as specifically shown above and in Section 5(h)

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

� Cornea

� Heart

� Heart-lung

� Kidney

� Liver

� Pancreas

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: $100 copayment per performing surgeon

Note: If you receive the services of a co-surgeon, you pay a second $100 copayment for those services. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

� Single or double lung: only for the following end-stage pulmonary diseases: pulmonary fibrosis, primary pulmonary hypertension, and emphysema

� Double lung: only for patients with end-stage cystic fibrosis

� Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas

Bone marrow and stem cell transplants, limited to:

� Allogeneic bone marrow transplants and allogeneic cord blood stem cell transplants (from related or unrelated donors) for:

- Advanced neuroblastoma

- Infantile malignant osteopetrosis

- Severe combined immunodeficiency

- Mucopolysaccharidosis (e.g., Hunter, Hurler's, Sanfilippo, Maroteaux-Lamy variants)

- Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)

- Severe or very severe aplastic anemia

- Thalassemia major (homozygous beta-thalassemia)

- Sickle cell anemia

- Phagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: $100 copayment per performing surgeon

Note: If you receive the services of a co-surgeon, you pay a second $100 copayment for those services. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Bone marrow and stem cell transplants, limited to: (continued)

� Allogeneic bone marrow transplants, allogeneic cord blood stem cell transplants (from related or unrelated donors) and allogeneic peripheral blood stem cell transplants for:

- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia

- Advanced Hodgkin's lymphoma

- Advanced non-Hodgkin's lymphoma

- Chronic myelogenous leukemia

- Advanced forms of myelodysplastic syndromes

� Autologous bone marrow transplants and autologous peripheral blood stem cell transplants (collectively referred to as autologous stem cell support) for:

- Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia

- Advanced Hodgkin's lymphoma

- Advanced non-Hodgkin's lymphoma

- Advanced neuroblastoma

- Amyloidosis

- Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

- Multiple myeloma

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: $100 copayment per performing surgeon

Note: If you receive the services of a co-surgeon, you pay a second $100 copayment for those services. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

� Extraction or reinfusion of bone marrow, blood stem cells, or cord blood as a source of stem cells as part of a covered allogeneic or autologous bone marrow transplant or blood stem cell transplant support procedure

� Marrow harvesting in anticipation of a covered autologous bone marrow transplant, for patients diagnosed at the time of harvesting with one of the conditions listed on page 51, 54, or 55

� Collection, processing, storage, and distribution of cord blood

� Storage of harvested bone marrow, blood stem cells, or cord blood as a source of stem cells, only when a covered transplant has already been scheduled

� Related medical and hospital expenses of the donor, as part of a covered transplant procedure

� Related services or supplies provided to the recipient

Note:See Section 5(a) for coverage for related services, such as chemotherapy and/or radiation therapy and drugs administered to stimulate or mobilize stem cells for covered transplant procedures.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: $100 copayment per performing surgeon

Note: If you receive the services of a co-surgeon, you pay a second $100 copayment for those services. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Organ/tissue transplants (continued)

Organ/Tissue Transplants at Blue Quality Centers for Transplant (BQCT)

We participate in the Blue Quality Centers for Transplant (BQCT), a centers of excellence program for the organ/tissue transplants listed below. You will receive enhanced benefits if you use a BQCT facility.

All members (including those who have Medicare Part A or another group health insurance policy as their primary payer) must contact us at the customer service number listed on the back of their ID card before obtaining services. You will be referred to the designated Plan transplant coordinator for information about BQCT and approved facilities.

� Heart

� Heart-lung

� Liver

� Pancreas

� Simultaneous pancreas-kidney

� Single or double lung: only for the following end-stage pulmonary diseases: pulmonary fibrosis, primary pulmonary hypertension, and emphysema

� Double lung: only available for patients with end-stage cystic fibrosis

� Bone marrow and stem cell transplants listed on pages 50, 51, 54, and 55

� Related transplant services listed on page 52

Note: Benefits for cornea, kidney-only, and intestinal transplants are not available through BQCT. See page 50 for benefit information for these transplants.

Note: See Section 5(c) for our benefits for facility care.

Note: Members will not be responsible for separate cost-sharing for the included professional services (see page 12).

Note: See below and pages 54 and 55 for limitations to bone marrow and stem cell transplant coverage.

Note: See page 12 for special instructions regarding all admissions to BQCT institutions.

Limitations for all transplants

(1) You must obtain prior approval (see page 15) from the Local Plan, for both the procedure and the facility, for the following transplant procedures:

� Bone marrow, cord blood stem cell, and peripheral blood stem cell transplant support procedures

� Heart

� Heart-lung

� Liver

� Lung (single/double)

� Pancreas

� Simultaneous pancreas-kidney

� Intestinal transplants (small intestine with or without other organs)

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

(2) For the following procedures, we provide benefits only when conducted at a Cancer Research Facility (see page 12) and performed as part of a clinical trial that meets the requirements shown below:

� Allogeneic bone marrow transplants, syngeneic bone marrow transplants, and allogeneic peripheral blood stem cell transplants for:

- Multiple myeloma

- Chronic lymphocytic leukemia

- Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

� Nonmyeloablative allogeneic stem cell transplants for:

- Chronic myelogenous leukemia

- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia

- Advanced Hodgkin's lymphoma

- Advanced non-Hodgkin's lymphoma

- Advanced forms of myelodysplastic syndromes

- Multiple myeloma

- Chronic lymphocytic leukemia

- Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

- Renal cell carcinoma

� Autologous bone marrow transplants and autologous peripheral blood stem cell transplants (collectively referred to as autologous stem cell support) for:

- Breast cancer

- Epithelial ovarian cancer

- Chronic myelogenous leukemia

- Chronic lymphocytic leukemia

- Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: $100 copayment per performing surgeon

Note: If you receive the services of a co-surgeon, you pay a second $100 copayment for those services. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

� Autologous bone marrow or peripheral blood stem cell transplants when performed in specific NIH-funded, randomized, multi-center, comparative trials for the following autoimmune diseases:

- Systemic sclerosis

- Systemic lupus erythematosus

- Multiple sclerosis

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

1. You must contact our Clinical Trials Information Unit at 1-800-225-2268 for prior approval (see page 15);

2. The clinical trial must be reviewed and approved by the Institutional Review Board of the Cancer Research Facility where the procedure is to be delivered; and

3. The patient must be properly and lawfully registered in the clinical trial, meeting all the eligibility requirements of the trial.

If a non-randomized clinical trial meeting these requirements is not available at a Cancer Research Facility where you are eligible, we will arrange for the transplant to be provided at another Plan-designated transplant facility.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: $100 copayment per performing surgeon

Note: If you receive the services of a co-surgeon, you pay a second $100 copayment for those services. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Not covered:

� Transplants for any diagnosis not listed as covered

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

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Anesthesia (including acupuncture) for covered surgical services when requested by the attending physician and performed by:

� a certified registered nurse anesthetist (CRNA), or

� a physician other than the operating physician (surgeon) or the assistant

Professional services provided in:

� Hospital (inpatient)

� Hospital outpatient department

� Skilled nursing facility

� Ambulatory surgical center

� Office

Anesthesia services consist of administration by injection or inhalation of a drug or other anesthetic agent (including acupuncture) to obtain muscular relaxation, loss of sensation, or loss of consciousness.

Note:See Section 5(c) for our payment levels for anesthesia services billed by a facility.

Preferred: 10% of the Plan allowance

Participating: 25% of the Plan allowance

Non-participating: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: Nothing

Participating/Non-participating: You pay all charges

Section 5(c) Services provided by a hospital or other facility,
and ambulance services

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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 Standard Option calendar year deductible applies to only a few benefits. In that case, we added "(calendar year deductible applies)" when it applies. The calendar year deductible is $250 per person ($500 per family) under Standard Option.

� Under Basic Option, there is no calendar year deductible.

� Under Basic Option, you must use Preferred providers in order to receive benefits. See page 12 for the exceptions to this requirement.

� 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 9 about coordinating benefits with other coverage, including Medicare.

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

� You should be aware that some PPO hospitals may have non-PPO professional providers on staff.

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

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

� PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

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Note: The Standard Option calendar year deductible applies ONLY when we say below:

"(calendar year deductible applies)." There is no calendar year deductible under Basic Option.

Room and board, such as:

� semiprivate or intensive care accommodations

� general nursing care

� meals and special diets

Note: We cover a private room only when you must be isolated to prevent contagion, when your isolation is required by law, or when a Preferred or Member hospital only has private rooms. Otherwise, we will pay the hospital's average semiprivate rate as determined by the Local Plan. If a Non-member hospital only has private rooms, we base our payment on the average semiprivate rate as determined by the Local Plan.

Preferred: $100 per admission copayment for unlimited days

Member: $300 per admission copayment for unlimited days

Non-member: $300 per admission copayment for unlimited days, plus 30% of the Plan allowance, and any remaining balance after our payment

Note: If you are admitted to a Non-member facility due to a medical emergency or accidental injury, you pay a $300 per admission copayment for unlimited days and we then provide benefits at 100% of the Plan allowance. You are responsible for any remaining balance after our payment.

Preferred: $100 per day copayment up to $500 per admission for unlimited days

Member/Non-member: You pay all charges

Note: The Standard Option calendar year deductible applies ONLY when we say below:

"(calendar year deductible applies)." There is no calendar year deductible under Basic Option.

Other hospital services and supplies, such as:

� Operating, recovery, maternity, and other treatment rooms

� Prescribed drugs

� Diagnostic laboratory tests, pathology services, MRIs, machine diagnostic tests, and X-rays

� Administration of blood or blood plasma

� Dressings, splints, casts, and sterile tray services

� Internal prosthetic devices

� Other medical supplies and equipment, including oxygen

� Anesthetics and anesthesia services

� Take-home items

� Pre-admission testing recognized as part of the hospital admissions process

� Nutritional counseling

Note: Here are some things to keep in mind:

� You do not need to precertify your normal delivery; see page 14 for other circumstances, such as extended stays for you or your baby.

� If you need to stay longer in the hospital than initially planned, we will cover an extended stay if it is medically necessary. However, you must precertify the extended stay. See Section 3 for information on requesting additional days.

� We pay inpatient hospital benefits for an admission in connection with dental procedures only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient. We provide benefits for dental procedures as shown in Section 5(h).

Note:See pages 32-33 for covered maternity services.

Note:See page 42 for coverage of blood and blood products.

Preferred: $100 per admission copayment for unlimited days

Member: $300 per admission copayment for unlimited days

Non-member: $300 per admission copayment for unlimited days, plus 30% of the Plan allowance, and any remaining balance after our payment

Preferred: $100 per day copayment up to $500 per admission for unlimited days

Member/Non-member: You pay all charges

Note: The Standard Option calendar year deductible applies ONLY when we say below:

"(calendar year deductible applies)." There is no calendar year deductible under Basic Option.

Not covered:

Hospital room and board expenses when, in our judgement, a hospital admission or portion of an admission is:

� Custodial care

� Convalescent care or a rest cure

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

� Not medically necessary, such as when services did not require the acute/subacute hospital inpatient (overnight) setting but could have been provided safely and adequately in a physician's office, the outpatient department of a hospital, or some other setting, without adversely affecting your condition or the quality of medical care you receive. Some examples are:

- Admissions for, or consisting primarily of, observation and/or evaluation that could have been provided safely and adequately in some other setting (such as a physician's office)

- Admissions primarily for diagnostic studies, laboratory and pathology services, X-rays, MRIs, or machine diagnostic tests that could have been provided safely and adequately in some other setting (such as the outpatient department of a hospital or a physician's office)

Note: If we determine that a hospital admission is one of the types listed above, we will not provide benefits for inpatient room and board or inpatient physician care. However, we will provide benefits for covered services or supplies other than room and board and inpatient physician care at the level that we would have paid if they had been provided in some other setting.

� Admission to noncovered facilities, such as nursing homes, extended care facilities, schools, residential treatment centers

� Personal comfort items, such as guest meals and beds, telephone, television, beauty and barber services

� Inpatient private duty nursing

All charges

All charges

Note: The Standard Option calendar year deductible applies ONLY when we say below:

"(calendar year deductible applies)." There is no calendar year deductible under Basic Option.

Outpatient medical services performed and billed for by a hospital or freestanding ambulatory facility, such as:

� Use of special treatment rooms

� Diagnostic tests, such as laboratory and pathology services, MRIs, machine diagnostic tests, and X-rays

� Chemotherapy and radiation therapy

� Intravenous (IV)/infusion therapy

� Cardiac rehabilitation

� Physical, occupational, and speech therapy

� Renal dialysis

� Visits to the outpatient department of a hospital for non-emergency medical care

� Administration of blood, blood plasma, and other biologicals

� Blood and blood plasma, if not donated or replaced, and other biologicals

� Dressings, splints, casts, and sterile tray services

� Other medical supplies, including oxygen

Note: See pages 29-31 for covered preventive services for adults and children.

Note: See pages 67-71 for our payment levels for care related to a medical emergency or accidental injury.

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

Member facilities: 25% of the Plan allowance (calendar year deductible applies)

Non-member facilities: 25% of the Plan allowance (calendar year deductible applies)

Note: See page 37 for our coverage of physical, occupational, and speech therapy.

Preferred: $40 copayment per day per facility

Member/Non-member: You pay all charges

Note: For outpatient diagnostic tests billed for by a Member or Non-member facility, you pay a $40 copayment.

Note: The Standard Option calendar year deductible applies ONLY when we say below:

"(calendar year deductible applies)." There is no calendar year deductible under Basic Option.

Outpatient surgery and related services performed and billed for by a hospital or freestanding ambulatory facility, such as:

� Operating, recovery, and other treatment rooms

� Anesthetics and anesthesia services

� Pre-surgical testing performed within one business day of the covered surgical services

� Facility supplies for hemophilia home care

� Diagnostic tests, such as laboratory and pathology services, MRIs, machine diagnostic tests, and X-rays

� Visits to the outpatient department of a hospital for non-emergency surgical care

� Administration of blood, blood plasma, and other biologicals

� Blood and blood plasma, if not donated or replaced, and other biologicals

� Dressings, splints, casts, and sterile tray services

� Other medical supplies, including oxygen

Note: See pages 67-71 for our payment levels for care related to a medical emergency or accidental injury.

Note: We cover outpatient hospital services and supplies related to dental procedures only when a non-dental physical impairment exists that makes the hospital setting necessary to safeguard the health of the patient. See Section 5(h), Dental benefits, for additional benefit information.

Note: See pages 32-33 for covered maternity services.

Preferred facilities: 10% of the Plan allowance

Member facilities: 25% of the Plan allowance

Non-member facilities: 25% of the Plan allowance

Preferred: $40 copayment per day per facility

Member/Non-member: You pay all charges

Note: For outpatient diagnostic tests billed for by a Member or Non-member facility, you pay a $40 copayment.

Note: The Standard Option calendar year deductible applies ONLY when we say below:

"(calendar year deductible applies)." There is no calendar year deductible under Basic Option.

Outpatient drugs, medical devices, and durable medical equipment billedfor by a hospital or freestanding ambulatory facility, such as:

� Prescribed drugs

� Orthopedic and prosthetic devices

� Durable medical equipment

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

Member facilities: 25% of the Plan allowance (calendar year deductible applies)

Non-member facilities: 25% of the Plan allowance (calendar year deductible applies)

Preferred: 30% of the Plan allowance

Note: You may also be responsible for paying a $40 copayment per day per facility for outpatient services.

Member/Non-member: You pay all charges

Note: The Standard Option calendar year deductible applies ONLY when we say below:

"(calendar year deductible applies)." There is no calendar year deductible under Basic Option.

Limited to the following benefits for Medicare Part A copayments:

When Medicare Part A is the primary payer (meaning that it pays first) and has made payment, Standard Option provides limited secondary benefits.

We pay the applicable Medicare Part A copayments incurred in full during the first through the 30^th day of confinement for each benefit period (as defined by Medicare) in a qualified skilled nursing facility. A qualified skilled nursing facility is a facility that specializes in skilled nursing care performed by or under the supervision of licensed nurses, skilled rehabilitation services, and other related care, and meets Medicare's special qualifying criteria, but is not an institution that primarily cares for and treats mental diseases.

If Medicare pays the first 20 days in full, Plan benefits will begin on the 21^st day (when Medicare Part A copayments begin) and will end on the 30^th day.

Note: See page 37 for benefits provided for outpatient physical, occupational, and speech therapy when billed by a skilled nursing facility. See Section 5(f) for benefits for prescription drugs.

Note: If you do not have Medicare Part A, we do not provide benefits for skilled nursing facility care.

Preferred: Nothing

Participating/Member: Nothing

Non-participating/Non-member: Nothing

Note: You pay all charges not paid by Medicare after the 30^th day.

All charges

Note: The Standard Option calendar year deductible applies ONLY when we say below:

"(calendar year deductible applies)." There is no calendar year deductible under Basic Option.

Hospice care is an integrated set of services and supplies designed to provide palliative and supportive care to terminally ill patients in their homes.

We provide the following home hospice care benefits for members with a life expectancy of six months or less when prior approval is obtained from the Local Plan and the home hospice agency is approved by the Local Plan:

� Physician visits

� Nursing care

� Medical social services

� Physical therapy

� Services of home health aides

� Durable medical equipment rental

� Prescription drugs

� Medical supplies

Nothing

Nothing

Inpatient hospice for members receiving home hospice care benefits:

Benefits are provided for up to five (5) consecutive days in a hospital or a freestanding hospice inpatient facility.

Each inpatient stay must be separated by at least 21 days.

These covered inpatient hospice benefits are available only when inpatient services are necessary to:

� control pain and manage the patient's symptoms; or

� provide an interval of relief (respite) to the family

Note: You are responsible for making sure that the home hospice care provider has received prior approval from the Local Plan (see page 14 for instructions). Please check with your Local Plan and/or your PPO directory for listings of approved agencies.

Preferred: $100 per admission copayment

Member: $300 per admission copayment

Non-member: $300 per admission copayment plus 30% of the Plan allowance, and any remaining balance after our payment

Preferred: $100 per day copayment up to $500 per admission

Member/Non-member: You pay all charges

Not covered: Homemaker or bereavement services

All charges

All charges

Note: The Standard Option calendar year deductible applies ONLY when we say below:

"(calendar year deductible applies)." There is no calendar year deductible under Basic Option.

Local professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically appropriate, and:

� Associated with covered hospital inpatient care

� Related to medical emergency

� Associated with covered hospice care

Preferred: 10% of the Plan allowance

Participating/Member: 10% of the Plan allowance

Non-participating/Non-member: 10% of the Plan allowance, plus any difference between our allowance and the billed amount

Preferred: $50 copayment per trip

Participating/Member or Non-participating/Non-member: $50 copayment per trip

Local professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically appropriate, and when related to accidental injury

Preferred: Nothing (No deductible)

Participating/Member: Nothing (No deductible)

Non-participating/Non-member: Any difference between the Plan allowance and the billed amount (No deductible)

Note: These benefit levels apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, see above.

Preferred: $50 copayment per trip

Participating/Member or Non-participating/Non-member: $50 copayment per trip

Section 5(d) Emergency services/accidents

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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.

� Under Standard Option, the calendar year deductible is $250 per person ($500 per family). The calendar year deductible applies to almost all Standard Option benefits in this Section. We added "(No deductible)" to show when the calendar year deductible does not apply.

� Under Basic Option, there is no calendar year deductible.

� Under Basic Option, you must use Preferred providers in order to receive benefits, except in cases of medical emergency or accidental injury. Refer to the guidelines appearing below for additional information.

� 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 9 about coordinating benefits with other coverage, including Medicare.

� You should be aware that some PPO hospitals may have non-PPO professional providers on staff.

� PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

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What is an accidental injury?

An accidental injury is an injury caused by an external force or element such as a blow or fall and which requires immediate medical attention, including animal bites and poisonings. [See Section 5(h) for dental care for accidental injury.]

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.

Basic Option benefits for emergency care

Under Basic Option, you are encouraged to seek care from Preferred providers in cases of accidental injury or medical emergency. However, if you need care immediately and cannot access a Preferred provider, we will provide benefits for the initial treatment provided in the emergency room of any hospital � even if the hospital is not a Preferred facility. We will also provide benefits if you are admitted directly to the hospital from the emergency room until your condition has been stabilized. In addition, we will provide benefits for emergency ambulance transportation provided by Preferred or Non-preferred ambulance providers if the transport is due to a medical emergency or accidental injury.

We provide emergency benefits when you have acute symptoms of sufficient severity � including severe pain � such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person's health, or with respect to a pregnant woman, the health of the woman and her unborn child.

Benefit Description

You Pay

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

� Physician services in the hospital outpatient department, urgent care center, or physician's office, including X-rays, MRIs, laboratory and pathology services, and machine diagnostic tests

� Related outpatient hospital services and supplies, including X-rays, MRIs, laboratory and pathology services, and machine diagnostic tests

Note: We pay Inpatient professional and hospital benefits if you are admitted [see Sections 5(a), 5(b), and 5(c)].

Note: See Section 5(h) for dental benefits for accidental injuries.

Preferred: Nothing (No deductible)

Participating/Member: Nothing (No deductible)

Non-participating/Non-member: Any difference between the Plan allowance and the billed amount (No deductible)

Note: These benefit levels apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, regular medical and outpatient hospital benefits apply. See Section 5(a), Medical services and supplies, Section 5(b), Surgical procedures, and Section 5(c), Outpatient hospital, for the benefits we provide.

Preferred emergency room:

$50 copayment per visit

Participating/Member emergency room:

$50 copayment per visit

Non-participating/Non-member emergency room: $50 copayment per visit

Note: You are responsible for the applicable copayment as shown above. If you use a Non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.

Note: If you are admitted directly to the hospital from the emergency room, you do not have to pay the $50 emergency room copayment. However, the $100 per day copayment for Preferred inpatient care still applies.

Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.

For the following places of service, you must receive care from a Preferred provider:

Preferred urgent care center:

$30 copayment per visit

Preferred primary care provider or other health care professional's office:

$20 copayment per visit

Preferred specialist's office:

$30 copayment per visit

Participating/Member (for other than emergency room): You pay all charges

Non-participating/Non-member (for other than emergency room): You pay all charges

Not covered:

� Oral surgery except as shown in Section 5(b)

� Injury to the teeth while eating

All charges

All charges

� Physician services in the hospital outpatient department, urgent care center, or physician's office, including X-rays, MRIs, laboratory and pathology services, and machine diagnostic tests

� Related outpatient hospital services and supplies, including X-rays, MRIs, laboratory and pathology services, and machine diagnostic tests

Note: We pay Inpatient professional and hospital benefits if you are admitted as a result of a medical emergency [see Sections 5(a), 5(b), and 5(c)].

Note: Please refer to Section 3 for information about precertifying emergency hospital admissions.

Preferred: 10% of the Plan allowance

Note: If you receive services in a Preferred physician's office, you pay a $15 copayment (No deductible) for the office visit, and 10% of the Plan allowance for all other services (deductible applies).

Participating/Member: 25% of the Plan allowance

Non-participating/Non-member: 25% of the Plan allowance, plus any difference between our allowance and the billed amount

Note: These benefit levels do not apply if you receive care in connection with, and within 72 hours after, an accidental injury. See Accidental Injury benefits on pages 67-69 for the benefits we provide.

Preferred emergency room:

$50 copayment per visit

Participating/Member emergency room:

$50 copayment per visit

Non-participating/Non-member emergency room: $50 copayment per visit

Note: You are responsible for the applicable copayment as shown above. If you use a Non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.

Note: If you are admitted directly to the hospital from the emergency room, you do not have to pay the $50 emergency room copayment. However, the $100 per day copayment for Preferred inpatient care still applies.

Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.

For the following places of service, you must receive care from a Preferred provider:

Preferred urgent care center:

$30 copayment per visit

Preferred primary care provider or other health care professional's office:

$20 copayment per visit

Preferred specialist's office:

$30 copayment per visit

Participating/Member (for other than emergency room): You pay all charges

Non-participating/Non-member (for other than emergency room): You pay all charges

Local professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically appropriate, and:

� Associated with covered hospital inpatient care

� Related to medical emergency

� Associated with covered hospice care

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

Preferred: 10% of the Plan allowance (No deductible)

Participating/Member: 10% of the Plan allowance (No deductible)

Non-participating/Non-member: 10% of the Plan allowance, plus any difference between our allowance and the billed amount (No deductible)

Preferred: $50 copayment per trip

Participating/Member or Non-participating/Non-member: $50 copayment per trip

Local professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically appropriate, and when related to accidental injury

Preferred: Nothing (No deductible)

Participating/Member: Nothing (No deductible)

Non-participating/Non-member: Any difference between the Plan allowance and the billed amount (No deductible)

Note: These benefit levels apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, see above.

Preferred: $50 copayment per trip

Participating/Member or Non-participating/Non-member: $50 copayment per trip

Section 5(e) Mental health and substance abuse benefits

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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.

� Under Standard Option, the calendar year deductible or, for facility care, the inpatient per admission copay, applies to almost all benefits in this Section. We added "(No deductible)" to show when the deductible does not apply.

� Under Standard Option, there is a maximum of 25 visits per year for office visits, partial hospitalization, intensive outpatient treatment, and other hospital outpatient treatment. The first 25 visits under Standard Option each calendar year by Preferred providers and Non-preferred providers count toward this maximum. This maximum may be waived for services received from Preferred providers.

� Under Standard Option, you may choose to get care In-Network (Preferred) or Out-of-Network (Non-preferred). When you use a Preferred provider, he or she must submit a treatment plan to us prior to your ninth outpatient visit in order to maximize the benefits you receive. Preferred benefits are payable when the care is clinically appropriate to treat your condition and when you receive the care as part of a treatment plan that we approve. Cost-sharing and limitations for In-Network (Preferred) mental health and substance abuse benefits are no greater than for similar benefits for other illnesses and conditions.

� Under Basic Option, you must call us for prior approval before receiving care. We will provide you with the names and phone numbers of several Preferred providers and tell you how many visits we are initially approving. You may then choose which of those providers you would like to see. You must use Preferred providers in order to receive Basic Option benefits.

� Under Basic 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 9 about coordinating benefits with other coverage, including Medicare.

� YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Pleaserefer to the precertification information listed in Section 3. Some other services also require prior approval. See the instructions after the benefits descriptions below.

� Standard Option and Basic Option benefits for Preferred (In-Network) mental health and substance abuse care begin below and are continued on the following pages. Standard Option benefits for Non-preferred (Out-of-Network) care begin on page 76.

� PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

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Benefit Description

You Pay

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

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

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

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

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, clinical social workers, or psychiatric nurses

� Office and home visits

� In a hospital outpatient department (except for emergency rooms)

� Psychotherapy for smoking cessation

Note: Additional types of licensed providers may be available to you for mental health and substance abuse services. Consult your PPO directory or contact your Local Plan at the mental health and substance abuse phone number on the back of your ID card.

$15 copayment for the visit, up to two hours per visit (No deductible)

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay a $40 copayment for outpatient services billed for by a facility.

Note: You pay 30% of the Plan allowance for drugs and supplies.

� Pharmacotherapy (medication management)

� Psychological testing (not subject to the two-hour limit)

Preferred: $15 copayment for the office visit charge (No deductible)

Preferred primary care provider or other health care professional: $20 copayment per visit

Preferred specialist: $30 copayment per visit

Note: You pay 30% of the Plan allowance for drugs and supplies.

� Inpatient professional visits

� Professional charges for facility-based intensive outpatient treatment

10% of the Plan allowance

Note: Intensive outpatient treatment is not limited to two hours per visit but you must obtain prior approval.

Nothing

� Professional charges for intensive outpatient treatment in a provider's office or other professional setting

10% of the Plan allowance

Note: Intensive outpatient treatment is not limited to two hours per visit but you must obtain prior approval.

Preferred: $30 copayment per visit

� Professional charges for outpatient diagnostic tests

10% of the Plan allowance

Nothing

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Inpatient services provided and billed by a hospital or other covered facility

� Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

� Diagnostic tests

Note: You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty.

$100 per admission copayment (No deductible)

$100 per day copayment up to $500 per admission

Outpatient services provided and billed by a hospital or other covered facility

� Diagnostic tests

� Services in the following approved treatment programs (must be prior approved):

- partial hospitalization

- facility-based intensive outpatient treatment

10% of the Plan allowance

$40 copayment per day per facility

Note: You pay 30% of the Plan allowance for drugs.

Not covered:

� Services we have not approved

� Educational or training services

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

All charges

All charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Preferred (In-Network) benefits (continued)

Authorization Procedures Standard Option: To be eligible to receive Preferred mental health and substance abuse benefits you must see a Preferred provider, obtain a treatment plan, and follow the applicable authorization processes.

To locate a Preferred provider, please refer to your PPO directory, visit our Web site at www.fepblue.org, or contact us at the mental health and substance abuse phone number shown on the back of your ID card.

Basic Option: To be eligible to receive mental health and substance abuse benefits, you must call us for prior approval at the mental health and substance abuse phone number on the back of your ID card before you receive care. We will then provide you with the names and phone numbers of several Preferred providers to choose from and tell you how many visits we are initially approving.

Precertification                                  You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty. Please refer to the precertification information listed in Section 3 for additional information.

Prior Approval Standard Option: Prior approval is required for partial hospitalization and intensive outpatient treatment programs.

Basic Option: Prior approval is required for all mental health and substance abuse services.

Prior to starting treatment, you, someone acting on your behalf, your physician, or your hospital must call us at the mental health and substance abuse phone number on the back of your ID card. We will not pay for mental health and substance abuse services under Basic Option or for partial hospitalization or intensive outpatient treatment programs under Standard Option, even at Preferred facilities, until you obtain prior approval.

Treatment Plans Standard Option: We provide Preferred benefits only when you receive care as part of a treatment plan that we have approved. In order to maximize your benefits, your provider must submit a treatment plan to us prior to your ninth outpatient visit. When we approve the treatment plan, we will give your provider authorization for additional visits or services. The services or number of additional visits authorized will depend on the treatment plan. We may need to request updated treatment plans as your treatment progresses. If a treatment plan is not submitted or approved, we will provide only Non-preferred (out-of-network) benefits. If you change providers, a new treatment plan must be submitted. We will be flexible in allowing additional visits while your treatment plan is being prepared or under review.

Basic Option: We will work directly with your provider and may request a treatment plan from your provider.

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.

Preferred Limitation Under Standard Option, if you do not obtain an approved treatment plan, we will provide only Non-preferred (out-of-network) benefits.

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Professional services, including individual or group therapy, by providers such as psychiatrists, psychologists, clinical social workers, or psychiatric nurses, for:

� Office and home visits

� In a hospital outpatient department (except for emergency rooms)

� Psychotherapy for smoking cessation

40% of the Plan allowance for up to two hours per visit and up to 25 outpatient visits per calendar year; all charges after 25 visits*. You may also be responsible for any difference between the Plan allowance and the billed amount.

*The 25-visit limit is a combined maximum for all outpatient professional care, partial hospitalization, intensive outpatient treatment, and outpatient facility care, whether performed by Preferred or Non-preferred providers, or applied to your calendar year deductible.

Participating/Non-participating: You pay all charges

Other services:

� Pharmacotherapy (medication management)

� Psychological testing

25% of the Plan allowance. You may also be responsible for any difference between the Plan allowance and the billed amount.

Note: Other services are not subject to the 25-visit limitation.

Participating/Non-participating: You pay all charges

Inpatient visits

40% of the Plan allowance up to 100 days per calendar year; all charges after 100 days. You may also be responsible for any difference between the Plan allowance and the billed amount.

Participating/Non-participating: You pay all charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

Inpatient services provided and billed by a hospital or other covered facility

� Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty.

$400 copayment per day (No deductible) up to 100 days per calendar year; all charges after 100 days

Member/Non-member: You pay all charges

Outpatient services provided and billed by a hospital or other covered facility

� Psychological testing

25% of the Plan allowance, plus any difference between the Plan allowance and the billed amount

Note: Psychological testing is not subject to the visit limitations.

Member/Non-member: You pay all charges

Partial hospitalization and intensive outpatient treatment

25% of the Plan allowance, plus any difference between the Plan allowance and the billed amount; all charges after 25 visits*

Note: Visits that you pay for while meeting your deductible count toward the limit cited above.

*The 25-visit limit is a combined maximum for all outpatient professional care, partial hospitalization, intensive outpatient treatment, and outpatient facility care, whether performed by Preferred or Non-preferred providers, or applied to your calendar year deductible.

Participating/Member or Non-participating/Non-member: You pay all charges

Note: The calendar year deductible applies to almost all Standard Option benefits in this Section.

We say "(No deductible)" when the Standard Option deductible does not apply.

There is no calendar year deductible under Basic Option.

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

Non-preferred facility: $400 copayment per day (No deductible); all charges after 28 days per lifetime

Non-preferred professional: 40% of the Plan allowance; all charges after 28 days per lifetime. You may also be responsible for any difference between the Plan allowance and the billed amount.

Note: Non-preferred inpatient care for the treatment of substance abuse is limited to one treatment program (28-day maximum) per lifetime.

Member/Non-member: You pay all charges

Participating/Non-participating: You pay all charges

Not covered:

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

� Services performed by a noncovered provider

� Testing and treatment for learning disabilities and mental retardation

� Services performed or billed by schools, residential treatment centers, halfway houses, or members of their staffs

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

All charges

All charges

Lifetime maximum Non-preferred inpatient care for the treatment of substance abuse is limited to one treatment program (28-day maximum) per lifetime under Standard Option.

Precertification                              You must get precertification of the medical necessity of your admission to a hospital or other covered facility. Report emergency admissions within two business days following the day of admission, even if you have been discharged. Otherwise, we will reduce the benefits payable by $500. See Section 3 for more information on precertification.

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 mental health and substance abuse benefits.

� Section 7, Filing a claim for covered services, for information about submitting Non-preferred claims.

Section 5(f) Prescription drug benefits

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

� We cover prescription drugs and supplies, as described in the chart beginning on page 81.

� 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 Standard Option, the calendar year deductible does not apply to prescriptions filled through the Retail Pharmacy Program or Mail Service Prescription Drug Program. We added "(calendar year deductible applies)" when it applies.

� Under Basic Option, there is no calendar year deductible.

� YOU MUST GET PRIOR APPROVAL FOR CERTAIN DRUGS, and prior approval must be renewed periodically. Please refer to the prior approval information shown on page 85 of this Section and in Section 3. Prior approval is part of our Patient Safety and Quality Monitoring (PSQM) program. See page 85 of this Section for more information about this important program.

� 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 9 about coordinating benefits with other coverage, including Medicare.

� Under Standard Option, PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

� Under Basic Option, you must use Preferred providers in order to receive benefits. See page 12 for the exceptions to this requirement.

� Please note that retail pharmacies and internet pharmacies that are Preferred under Standard Option are not necessarily Preferred under Basic Option. Refer to page 82 for information about locating Preferred pharmacies.

� Under Standard Option, you may use the Mail Service Prescription Drug Program to fill your prescriptions.

� Under Basic Option, the Mail Service Prescription Drug Program is not available.

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We will send each new enrollee a combined prescription drug/Plan identification card. Standard Option members are eligible to use the Mail Service Prescription Drug Program and will also receive a mail service order form and a preaddressed reply envelope.

� Who can write your prescriptions. A physician or dentist licensed in the United States or Puerto Rico, or a nurse practitioner in states that permit it, must write your prescriptions [see Section 5(i) for drugs purchased overseas].

� Where you can obtain them.

Under Standard Option, you may fill prescriptions at a Preferred retail pharmacy, through a Preferred internet pharmacy, at a Non-preferred retail pharmacy, or through our Mail Service Prescription Drug Program. Under Standard Option, we pay a higher level of benefits when you use a Preferred retail pharmacy, a Preferred internet pharmacy, or our Mail Service Prescription Drug Program.

Under Basic Option, you must fill prescriptions only at a Preferred retail pharmacy or through a Preferred internet pharmacy in order to receive benefits.

� We use an open formulary. This is a list of preferred drugs selected to meet patient needs at a lower cost to us. If your physician believes a brand-name drug is necessary or there is no generic equivalent available, ask your physician to prescribe a brand-name drug from our formulary list.

Under Standard Option, we may ask your doctor to substitute a formulary drug in order to help control costs. We cover drugs that require a prescription (whether or not they are on our formulary list). Your cooperation with our cost-savings efforts helps keep your premium affordable.

Under Basic Option, we encourage you to ask your physician to prescribe a brand-name drug from our formulary list when your physician believes a brand-name drug is necessary or when there is no generic equivalent available. If you purchase a drug that is not on our formulary list, your cost will be higher. (We cover drugs that require a prescription whether or not they are on our formulary list.)

Note: Before filling your prescription, please check the formulary status of your medication. Other than changes resulting from new drugs or safety issues, the formulary list is updated twice a year. Prescription drugs are reviewed by the Plan for safety and clinical efficacy. Drugs determined to be of equal therapeutic value and similar safety and efficacy are then evaluated on the basis of cost. Using lower cost formulary drugs will provide you with a high quality, cost-effective prescription drug benefit.

You can view our formulary on our Web site at www.fepblue.org or request a copy by mail by calling 1-800-624-5060 (TDD: 1-800-624-5077). Any savings we receive on the cost of drugs purchased under this Plan from drug manufacturers are credited to the reserves held for this Plan.

� Generic equivalents.

Standard Option: By submitting your prescription (or those of family members covered by the Plan) to your retail pharmacy or the Mail Service Prescription Drug Program, you authorize them to substitute any available Federally approved generic equivalent, unless you or your physician specifically request a brand-name drug.

Basic Option: By filling your prescriptions (or those of family members covered by the Plan) at a Preferred retail pharmacy or through a Preferred internet pharmacy, you authorize the pharmacist to substitute any available Federally approved generic equivalent, unless you or your physician specifically request a brand-name drug.

� Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. In most cases, they must contain the same active ingredients and must be equivalent in strength and dosage to the original brand-name product. Generics cost less than the equivalent brand-name product. The U.S. Food and Drug Administration (FDA) sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name drugs.

You can save money by using generic drugs. However, you and your doctor have the option to request a brand-name drug even if a generic option is available. Using the most cost-effective medication saves money.

� Disclosure of information. As part of our administration of prescription drug benefits, we may disclose information about your prescription drug utilization, including the names of your prescribing physicians, to any treating physicians or dispensing pharmacies.

� These are the dispensing limitations.

Standard Option: You may purchase up to a 90-day supply of covered drugs and supplies through the Retail Pharmacy Program. You may purchase a supply of more than 21 days up to 90 days through the Mail Service Prescription Drug Program for a single copayment.

Basic Option: When you fill a prescription for the first time, you may purchase up to a 34-day supply for a single copayment. For additional copayments, you may purchase up to a 90-day supply for continuing prescriptions and for refills.

Note: Certain drugs such as narcotics may have additional FDA limits on the quantities that a pharmacy may dispense. In addition, pharmacy dispensing practices are regulated by the state where they are located and may also be determined by individual pharmacies. In most cases, refills cannot be obtained until 75% of the prescription has been used. Call us or visit our Web site if you have any questions about dispensing limits. Please note that in the event of a national or other emergency, or if you are a reservist or National Guard member who is called to active military duty, you should contact us regarding your prescription drug needs. See the contact information below.

� Important contact information.

Standard Option: Retail Pharmacy Program: 1-800-624-5060 (TDD: 1-800-624-5077); Mail Service Prescription Drug Program: 1-800-262-7890 (TDD: 1-866-409-8525); or www.fepblue.org.

Basic Option: Retail Pharmacy Program: 1-800-624-5060 (TDD: 1-800-624-5077) or www.fepblue.org.

� Drugs, vitamins and minerals, and nutritional supplements that by Federal law of the United States require a prescription for their purchase

Note: See Section 5(a), page 42, for our coverage of medical foods for children with inborn errors of amino acid metabolism and for medical foods and nutritional supplements when administrated by catheter or nasogastric tube.

� Insulin

� Needles and disposable syringes for the administration of covered medications

� Drugs to aid smoking cessation that require a prescription by Federal law

Note: Prior approval is required if drug treatment extends beyond the initial course of treatment. See Section 3 for more information.

� Contraceptive drugs and devices, limited to:

- Depo-Provera*

- Diaphragms and contraceptive rings*

- Intrauterine devices (IUDs)

- Implantable contraceptives*

- Oral and transdermal contraceptives

*available only through retail and internet pharmacies

Note: See Family planning in Section 5(a).

See following pages

See following pages

Here is how to obtain your prescription drugs and supplies:

Preferred Retail Pharmacies

� Make sure you have your Plan ID card when you're ready to purchase your prescription

� Go to any Preferred retail pharmacy,

or

� Visit our special Web site, www.fepblue.org, click on "Pharmacy Programs," and follow the FEP Retail Pharmacy Providers link to fill your prescription and receive home delivery

� For a listing of Preferred retail pharmacies, call the Retail Pharmacy Program at

1-800-624-5060 (TDD: 1-800-624-5077) or visit our Web site, www.fepblue.org

Note: Please be sure to request the Preferred retail or internet pharmacy listing for your specific option. Retail and internet pharmacies that are Preferred under Standard Option are not necessarily Preferred under Basic Option.

Note: Retail and internet pharmacies that are Preferred for prescription drugs are not necessarily Preferred for durable medical equipment (DME) and medical supplies. To receive Preferred benefits for DME and covered medical supplies, you must use a Preferred DME or medical supply provider. See Section 5(a) for the benefit levels that apply to DME and medical supplies.

Note: For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on this page for retail pharmacy-obtained prescription drugs, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy. For a list of the Preferred Network Long Term Care pharmacies, call

1-800-624-5060 (TDD: 1-800-624-5077) or visit our Web site at www.fepblue.org. For benefit information about prescription drugs supplied by Non-preferred pharmacies, please refer to the next page.

Note:For coordination of benefits purposes, if you need a statement of Preferred retail pharmacy benefits in order to file claims with your other coverage when this Plan is the primary payer, call the Retail Pharmacy Program at 1-800-624-5060 (TDD: 1-800-624-5077) or visit our Web site at www.fepblue.org.

25% of the Plan allowance

First-time purchase of a new prescription up to a 34-day supply:

Generic drug:

$10 copayment

Formulary brand-name

drug: $25 copayment

Non-formulary

brand-name drug:

50% of Plan allowance ($35 minimum)

Refills or continuing prescriptions up to a 90-day supply:

Generic drug:

$10 copayment for each purchase of up to a 34-day supply ($30 copayment for 90-day supply)

Formulary brand-name

drug: $25 copayment for each purchase of up to a 34-day supply ($75 copayment for 90-day supply)

Non-formulary

brand-name drug:

50% of Plan allowance ($35 minimum for each purchase of up to a 34-day supply, or $105 minimum for 90-day supply)

Note: If there is no generic equivalent available, you must still pay the brand-name copayment when you receive a brand-name drug.

Note: For generic and brand-name drug purchases, if the cost of your prescription is less than your cost-sharing amount noted above, you pay only the cost of your prescription.

Non-preferred Retail Pharmacies

45% of the Plan allowance (Average wholesale price � AWP), plus any difference between our allowance and the billed amount

Note: If you use a Non-preferred retail pharmacy, you must pay the full cost of the drug or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for instructions on how to file prescription drug claims.

All charges

Mail Service Prescription Drug Program

Under Standard Option, if your doctor orders more than a 21-day supply of covered drugs or supplies, up to a 90-day supply, you can use this service for your prescriptions and refills.

Please refer to Section 7 for instructions on how to use the Mail Service Prescription Drug Program.

Note: Not all drugs are available through the Mail Service Prescription Drug Program.

Mail Service Program:

$10 generic

$35 brand-name

Note: If there is no generic equivalent available, you must still pay the brand-name copayment when you receive a brand-name drug.

Note: If the cost of your prescription is less than your copayment, you pay only the cost of your prescription. The Mail Service Prescription Drug Program will charge you the lesser of the prescription cost or the copayment when you place your order. If you have already sent in your copayment, they will credit your account with any difference.

No benefit

Note: You may request home delivery of your internet prescription drug purchases. See page 82 of this Section for our payment levels for drugs obtained through Preferred retail and internet pharmacies.

Drugs from other sources

� Covered prescription drugs and supplies not obtained at a retail pharmacy, through an internet pharmacy, or, for Standard Option only, through the Mail Service Prescription Drug Program

Note: Drugs purchased overseas must be the equivalent to drugs that by Federal law of the United States require a prescription.

Note:For covered prescription drugs and supplies purchased outside of the United States and Puerto Rico, please submit claims on an Overseas Claim Form. See Section 5(i) for information on how to file claims for overseas services.

� Please refer to the Sections indicated for additional benefit information when you purchase drugs from a:

- Physician's office � Section 5(a)

- Hospital (inpatient or outpatient) � Section 5(c)

- Hospice agency � Section 5(c)

� Please refer to page 82 for retail pharmacy-obtained prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility

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

Participating/Member: 25% of the Plan allowance (calendar year deductible applies)

Non-participating/Non-member: 25% of the Plan allowance (calendar year deductible applies); plus any difference between our allowance and the billed amount

Preferred: 30% of the Plan allowance

Participating/Member or Non-participating/Non-member: You pay all charges

Patient Safety and Quality Monitoring (PSQM)

We have a special program to promote patient safety and monitor health care quality. Our Patient Safety and Quality Monitoring (PSQM) program features a set of closely aligned programs that are designed to promote the safe and appropriate use of medications. Examples of these programs include:

� Prior approval � As described below, this program requires that approval be obtained for certain prescription drugs and supplies before we provide benefits for them.

� Safety checks � Before your prescription is filled, we perform quality and safety checks for usage precautions, drug interactions, drug duplication, excessive use, and frequency of refills.

� Quantity allowances � Specific allowances for several medications are based on FDA-approved recommendations, clinical studies, and manufacturer guidelines.

For more information about our PSQM program, including listings of drugs subject to prior approval or quantity allowances, visit our Web site at www.fepblue.org or call the Retail Pharmacy Program at 1-800-624-5060

(TDD: 1-800-624-5077).

Prior Approval

As part of our Patient Safety and Quality Monitoring (PSQM) program (see above), you must make sure that your physician obtains prior approval for certain prescription drugs and supplies in order to use your prescription drug coverage. Prior approval must be renewed periodically. To obtain a list of these drugs and supplies and to obtain prior approval request forms, call the Retail Pharmacy Program at

1-800-624-5060 (TDD: 1-800-624-5077). You can also obtain the list through our Web site at www.fepblue.org. Please read Section 3 for more information about prior approval.

Note: If your prescription requires prior approval and you have not yet obtained prior approval, you must pay the full cost of the drug or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for instructions on how to file prescription drug claims.

Not covered:

� Medical supplies such as dressings and antiseptics

� Drugs and supplies for cosmetic purposes

� Drugs and supplies for weight loss

� Drugs for orthodontic care, dental implants, and periodontal disease

� Medications and orally taken nutritional supplements that do not require a prescription under Federal law even if your doctor prescribes them or if a prescription is required under your State law

Note: See Section 5(a), page 42, for our coverage of medical foods for children with inborn errors of amino acid metabolism and for medical foods and nutritional supplements when administrated by catheter or nasogastric tube.

� Drugs for which prior approval has been denied or not obtained

� Infant formula other than described on page 42

� Drugs and supplies related to sex transformations, sexual dysfunction, or sexual inadequacy

� Drugs purchased through the mail or internet from pharmacies outside the United States by members located in the United States

All charges

All charges

Section 5(g) Special features

Special feature

Description

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/or direct the provision of Plan benefits to a less costly alternative benefit.

� Alternative benefits are subject to our ongoing review.

� By approving an alternative benefit, we cannot guarantee you will receive 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.

Note: Under the Blue Cross and Blue Shield Service Benefit Plan, the flexible benefits option is also referred to as "case management."

Online customer and claims service

By visiting our Web site, www.fepblue.org, you may check the status of your claims, change your address of record, request claim forms, request a duplicate or replacement Service Benefit Plan ID card, and access a range of other service and information options. It's easy! Give it a try and share any suggestions you may have for improved service by using the site's "Contact Us" feature.

24-hour nurse line

Help with health concerns is available 24 hours a day, 365 days a year, by calling a toll-free telephone number, 1-888-258-3432, or by accessing our Web site, www.fepblue.org. The service, called Blue Health Connection, offers health advice or health information and counseling by registered nurses. Also available is the AudioHealth Library with hundreds of tapes, ranging from first aid to infectious diseases to general health issues.

You can get information about health care resources to help you find local doctors, hospitals, or other health care services affiliated with the Blue Cross and Blue Shield Service Benefit Plan. Contact us at the number above or visit our Web site for more information. Please keep in mind that benefits for any health care services you may seek after using Blue Health Connection are subject to the terms of your coverage under this Plan.

Services for the deaf and hearing impaired

All Blue Cross and Blue Shield Plans provide TDD access for the hearing impaired to access information and receive answers to their questions.

Web accessibility for the visually impaired

Our Web site provides visually impaired individuals with access to important program information and services. Look for the "Web Accessibility" option at www.fepblue.org.

Travel benefit/services overseas

Please refer to Section 5(i) for benefit and claims information for care you receive outside the United States and Puerto Rico.

Health support programs

The Service Benefit Plan is developing and may offer patient education and support programs for certain diagnoses in select locations on a pilot basis. One program we have developed is the Patient Safety Risk Reduction Pilot Program. We will notify you if this pilot or other programs are available in your area.

Healthy Families Program

Healthy Families is a national health education prevention program that provides information to members and their families. The educational mailings assist members to understand and adopt healthy behaviors, reduce risk of injury and disease, and improve existing chronic conditions.

Section 5(h) Dental benefits

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� 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 Standard Option, the calendar year deductible applies only to the accidental injury benefit below. We added "(calendar year deductible applies)" when it applies.

� Under Basic Option, there is no calendar year deductible.

� Under Basic Option, you must use Preferred providers in order to receive benefits, except in cases of dental care resulting from an accidental injury as described below.

� 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 9 about coordinating benefits with other coverage, including Medicare.

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

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We provide benefits for services, supplies, or appliances for dental care necessary to promptly repair injury to sound natural teeth required as a result of, and directly related to, an accidental injury.

Note: An accidental injury is an injury caused by an external force or element such as a blow or fall and that requires immediate attention. Injuries to the teeth while eating are not considered accidental injuries.

Note: A sound natural tooth is a tooth that is whole or properly restored (restoration with amalgams only); is without impairment, periodontal, or other conditions; and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated by endodontics, is not considered a sound natural tooth.

Note: Treatment must be started promptly and completed within 12 months of the accident.

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

Participating: 25% of the Plan allowance (calendar year deductible applies)

Non-participating: 25% of the Plan allowance (calendar year deductible applies), plus any difference between our allowance and the billed amount

Note: Under Standard Option, we first provide benefits as shown in the Schedule of Dental Allowances on the following pages. We then pay benefits as shown here for any balances.

$20 copayment

Note: We provide benefits for accidental dental injury care in cases of medical emergency when performed by Preferred or Non-preferred providers. See Section 5(d) for the criteria we use to determine if emergency care is required. You are responsible for the applicable copayment as shown above. If you use a Non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.

Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.

What is Covered

Standard Option dental benefits are presented in the chart beginning below and continuing on the following pages.

Basic Option dental benefits appear on page 93.

Note: See Section 5(b) for our benefits for Oral and maxillofacial surgery, and Section 5(c) for our benefits for hospital services (inpatient/outpatient) in connection with dental services, available under both Standard Option and Basic Option.

Preferred Dental Network

All Local Plans contract with Preferred dentists who are available in most areas. Preferred dentists agree to accept a negotiated, discounted amount called the Maximum Allowable Charge (MAC) as payment in full for the following services. They will also file your dental claims for you. Under Standard Option, you are responsible, as an out-of-pocket expense, for the difference between the amount specified in this Schedule of Dental Allowances and the MAC. To find a Preferred dentist near you, refer to the Preferred provider directory, visit our Web site at www.fepblue.org, or call us at the customer service number on the back of your ID card. You can also call us to obtain a copy of the applicable MAC listing.

Note: Dentists who are in our Preferred Dental Network are not necessarily Preferred providers for other services covered by this Plan under other benefit provisions (such as oral and maxillofacial surgery).

Under Standard Option, we pay billed charges for the following services, up to the amounts shown per service as listed in the Schedule of Dental Allowances below and on the following pages. This is a complete list of dental services covered under this benefit for Standard Option. There are no deductibles, copayments, or coinsurance. When you use Non-preferred dentists, you pay all charges in excess of the listed fee schedule amounts. For Preferred dentists, you pay the difference between the fee schedule amount and the MAC (see above).

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

Limited oral evaluation

$14

$9

Detailed and extensive oral evaluation

Bitewings � four films

$19

$12

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

Tests and laboratory exams

Pulp vitality tests

$11

$7

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

Other restorative services

Pin retention � per tooth, in addition to restoration

$13

$8

Not covered: Any service not specifically listed above

Nothing

Nothing

All charges

Under Basic Option, we provide benefits for the services listed below. You pay a $20 copayment for each evaluation, and we pay any balances in full. This is a complete list of dental services covered under this benefit for Basic Option. You must use a Preferred dentist in order to receive benefits. For a list of Preferred dentists, please refer to the Preferred provider directory, visit our Web site at www.fepblue.org, or call us at the customer service number on the back of your ID card.

Clinical oral evaluations

Periodic oral evaluation*

Limited oral evaluation

Comprehensive oral evaluation*

*Benefits are limited to a combined total of 2 evaluations per person per calendar year

Preferred: All charges in excess of your $20 copayment

Participating/Non-participating:

Nothing

Preferred: $20 copayment per evaluation

Participating/Non-participating:

You pay all charges

Radiographs

Intraoral � complete series including bitewings (limited to 1 complete series every 3 years)

Bitewing � single film*

Bitewings � two films*

Bitewings � four films*

*Benefits are limited to a combined total of 4 films per person per calendar year

Preventive

Prophylaxis � adult (up to 2 per calendar year)

Prophylaxis � child (up to 2 per calendar year)*

Topical application of fluoride (including prophylaxis) � child (up to 2 per calendar year)*

Topical application of fluoride (prophylaxis not included) � child (up to 2 per calendar year)

Sealant � per tooth, first and second molars only (once per tooth for children up to age 16 only)

*Benefits are limited to a combined total of 2 visits per person per calendar year

Not covered: Any service not specifically listed above

Nothing

All charges

Section 5(i) Services, drugs, and supplies provided overseas

If you travel or live outside the United States and Puerto Rico, you are still entitled to the benefits described in this brochure. Unless otherwise noted in this section, the same definitions, limitations, and exclusions also apply.

Please note that the requirements to obtain precertification for inpatient care and prior approval for those services listed in Section 3 do not apply when you receive care outside the United States.

Overseas claims payment

For professional care you receive overseas, we provide benefits at Preferred benefit levels using an Overseas Fee Schedule as our Plan allowance. Under Standard Option, you must pay any difference between our payment and the amount billed, in addition to any applicable deductible, coinsurance, and/or copayment amounts. You must also pay any charges for noncovered services.

Under Basic Option, you pay any difference between our payment and the amount billed, as well as the applicable copayment or coinsurance. You must also pay any charges for noncovered services. The requirement to use Preferred providers in order to receive benefits under Basic Option does not apply when you receive care outside the United States and Puerto Rico.

For facility care you receive overseas, we provide benefits at the Preferred level under both Standard and Basic Options after you pay the applicable copayment or coinsurance. Standard Option members are also responsible for any amounts applied to the calendar year deductible for certain outpatient facility services � please see pages 61-63.

For dental care you receive overseas, we provide benefits as described in Section 5(h). Under Standard Option, you must pay any difference between the Schedule of Dental Allowances and the dentist's charge, in addition to any charges for noncovered services. Under Basic Option, you must pay the $20 copayment plus any difference between our payment and the dentist's charge, as well as any charges for noncovered services.

Worldwide Assistance Center

We have a network of participating hospitals overseas that will file your claims for inpatient facility care for you � without an advance payment for the covered services you receive. The Worldwide Assistance Center can help you locate a hospital in our network near where you are staying. You may also view a list of our network hospitals on our Web site, www.fepblue.org. Although we do not have a network of professionals overseas, the Worldwide Assistance Center can also help you locate a physician. You will have to file a claim to us for reimbursement for professional services.

If you are overseas and need assistance locating providers, contact the Worldwide Assistance Center (provided by World Access Service Corporation), by calling the center collect at

1-804-673-1678. Members in the United States, Puerto Rico, or the Virgin Islands should call

1-800-699-4337. World Access Service Corporation also offers emergency evacuation services to the nearest facility equipped to adequately treat your condition, translation services, and conversion of foreign medical bills to U.S. currency. You may contact one of their multilingual operators 24 hours a day, 365 days a year.

Filing overseas claims

� Hospital and physician care

Most overseas providers are under no obligation to file claims on behalf of our members. You may need to pay for the services at the time you receive them and then submit a claim to us for reimbursement. To file a claim for covered hospital and physician services received outside the United States and Puerto Rico, send a completed Overseas Claim Form and itemized bills to:

FEP Overseas Claims Section, CareFirst Blue Cross Blue Shield, P.O. Box 96242, Washington, DC 20090-6242. We will provide translation and currency conversion services for your overseas claims. Send any written inquiries concerning the processing of your overseas claims to this address or call us at 1-888-999-9862, using the appropriate AT&T country codes available on our Web site under Contact Us. You may also obtain Overseas Claim Forms from this address, from our Web site (www.fepblue.org), or from your Local Plan.

� Pharmacy benefits

Drugs purchased overseas must be the equivalent to drugs that by Federal law of the United States require a prescription. To file a claim for covered drugs and supplies you purchase from pharmacies outside the United States and Puerto Rico, send a completed FEP Retail Prescription Drug Overseas Claim Form, along with itemized pharmacy receipts or bills, to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057. We will provide translation and currency conversion services for your overseas claims. You may obtain claim forms for your drug purchases by writing to this address, by visiting our Web site, www.fepblue.org, or by calling 1-888-999-9862, using the appropriate AT&T country codes available on our Web site under Contact Us. Send any written inquiries concerning drugs you purchase to this address as well.

Please note that under both Standard and Basic Options, you may fill your prescriptions through a Preferred internet pharmacy only if the prescribing physician is licensed in the United States or Puerto Rico.

Under Standard Option, you may order your prescription drugs from the Mail Service Prescription Drug Program only if:

a) Your address includes a U.S. zip code (such as with APO and FPO addresses and in U.S. territories) and

b) The prescribing physician is licensed in the United States or Puerto Rico.

Please see page 83 for more information about using this program.

The Mail Service Prescription Drug Program is not available under Basic Option.

Section 6. General exclusions � things we don't cover

The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless we determine it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.

We do not cover the following:

� Services, drugs, or supplies you receive while you are not enrolled in this Plan;

� Services, drugs, or supplies that are not medically necessary;

� Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice in the United States;

� Experimental or investigational procedures, treatments, drugs, or devices;

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

� Services, drugs, or supplies related to sex transformations, sexual dysfunction, or sexual inadequacy;

� Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;

� Services, drugs, or supplies you would not be charged for if you had no health insurance coverage;

� Services, drugs, or supplies you receive without charge while in active military service;

� Amounts charged that neither you nor we are legally obligated to pay, such as amounts over the Medicare limiting charge or equivalent Medicare amount as described in Section 4 under Your costs for covered services,or State premium taxes, however applied;

� Services, drugs, or supplies you receive from immediate relatives or household members, such as spouse, parent, child, brother, or sister, by blood, marriage, or adoption;

� Services or supplies (except for medically necessary prescription drugs) that you receive from a noncovered facility, such as an extended care facility or nursing home, except as specifically described in Sections 5(a) and 5(c);

� Services, drugs, or supplies you receive from noncovered providers except in medically underserved areas as specifically described on page 11;

� Services, drugs, or supplies you receive for cosmetic purposes;

� Services, drugs, or supplies for the treatment of obesity, weight reduction, or dietary control, except for gastric bypass surgery or gastric stapling procedures and those nutritional counseling services specifically listed on pages 27, 44, and 59;

� Services you receive from a provider that are outside the scope of the provider's licensure or certification;

� Any dental or oral surgical procedures or drugs involving orthodontic care, the teeth, dental implants, periodontal disease, or preparing the mouth for the fitting or continued use of dentures, except as specifically described in Section 5(h), Dental benefits, and Section 5(b) under Oral and maxillofacial surgery;

� Orthodontic care for temporomandibular joint (TMJ) syndrome;

� Services of standby physicians;

� Self-care or self-help training;

� Custodial care;

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

� Routine services, such as periodic physical examinations; screening examinations; immunizations; and services or tests not related to a specific diagnosis, illness, injury, set of symptoms, or maternity care, except for those preventive services specifically covered under Preventive care, adult and child in Sections 5(a) and 5(c) and screenings specifically listed on pages 28 and 46;

� Recreational or educational therapy, and any related diagnostic testing, except as provided by a hospital during a covered inpatient stay; or

� Services not specifically listed as covered.

Section 7. Filing a claim for covered services

How to claim benefits

To obtain claim forms or other claims filing advice, or answers to your questions about our benefits, contact us at the customer service number on the back of your Service Benefit Plan ID card, or at our Web site at www.fepblue.org.

In most cases, physicians and facilities file claims for you. Just present your Service Benefit Plan ID card when you receive services. Your physician must file on the HCFA-1500, Health Insurance Claim Form. Your facility will file on the UB-92 form.

When you must file a claim � such as when another group health plan is primary � submit it on the HCFA-1500 or a claim form that includes the information shown below. Use a separate claim form for each family member. For long or continuing hospital stays, or other long-term care, you should submit claims at least every 30 days. Bills and receipts should be itemized and show:

� Name of patient and relationship to enrollee;

� Plan identification number of the enrollee;

� Name and address 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, balance due statements, or bills you prepare yourself are not acceptable substitutes for itemized bills.

In addition:

� You must send a copy of the explanation of benefits (EOB) form 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 or licensed practical nurse.

� Claims for rental or purchase of durable medical equipment, home nursing care, 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 received from the Retail Pharmacy Program, through a Preferred internet pharmacy, or through the Mail Service Prescription Drug Program must include receipts that show the prescription number, name of drug or supply, prescribing physician's name, date, and charge. (See below for information on how to obtain benefits from the Retail Pharmacy Program, a Preferred internet pharmacy, and the Mail Service Prescription Drug Program.)

Prescription drug claims

Preferred Retail/Internet Pharmacies � When you use Preferred retail pharmacies, show your Service Benefit Plan ID card. Preferred retail pharmacies will file your claims for you. To use Preferred internet pharmacies, go to our special Web site, www.fepblue.org, click on "Pharmacy Programs," and follow the FEP Retail Pharmacy Providers link to fill your prescriptions and receive home delivery. Be sure to have your Service Benefit Plan ID card ready to complete your purchase. We reimburse the Preferred retail or internet pharmacy for your covered drugs and supplies. You pay the applicable coinsurance or copayment.

Note: Even if you use Preferred pharmacies, you will have to file a paper claim form to obtain reimbursement if:

� You do not have a valid Service Benefit Plan ID card;

� You do not use your valid Service Benefit Plan ID card at the time of purchase; or

� You did not obtain prior approval when required (see page 15).

See the following paragraph for claim filing instructions.

Non-Preferred Retail/Internet Pharmacies

Standard Option: You must file a paper claim for any covered drugs or supplies you purchase at Non-preferred retail or internet pharmacies. Contact your Local Plan or call 1-800-624-5060 to request a retail prescription drug claim form to claim benefits. Hearing-impaired members with TDD equipment may call 1-800-624-5077. Follow the instructions on the prescription drug claim form and submit the completed form to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057.

Basic Option: There are no benefits for drugs or supplies purchased at Non-preferred retail or internet pharmacies.

Mail Service Prescription Drug Program

Standard Option: We will send you information on our Mail Service Prescription Drug Program, including an initial mail order form. To use this program:

1) Complete the initial mail order form;

2) Enclose your prescription and copayment;