CALL - THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-410-7778 or write to us at Mail Handlers Benefit Plan, P.O. Box 24503, Tucson, AZ 85734. You may also request replacement cards through our Web site: www.mhbp.com.

Where you get covered care

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

Covered providers

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

a licensed doctor of medicine (M.D.)

a licensed doctor of osteopathy (D.O.)

a licensed doctor of podiatry (D.P.M.)

a licensed dentist

a chiropractor (D.C.)

a licensed registered physical therapist (R.P.T.)

a licensed occupational therapist

a licensed speech therapist

a clinical psychologist

a clinical social worker

an optometrist

an audiologist

an acupuncturist

a physician�s assistant

a nurse midwife

a nurse practitioner/clinical specialist

a nursing school-administered clinic

a certified registered nurse anesthetist (C.R.N.A)

a Christian Science practitioner listed in the Christian Science Journal

a Christian Science nurse listed in the Christian Science Journal.

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

Covered facilities

Covered facilities include:

Freestanding ambulatory facility. A facility which meets the following criteria: has permanent facilities and equipment for the primary purpose of performing surgical and/or renal dialysis procedures on an outpatient basis; provides treatment by or under the supervision of doctors and nursing services whenever the patient is in the facility; does not provide inpatient accommodations; and is not, other than incidentally, a facility used as an office or clinic for the private practice of a doctor or other professional. The Plan will apply its outpatient surgical facility benefits only to facilities that have been accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) or the Accreditation Association for Ambulatory HealthCare (AAAHC), or that have Medicare certification as an ASC facility.

Managed In-Network providers. The Plan may approve coverage of providers who are not currently shown as Covered providers, to provide mental health/substance abuse treatment under the managed In-Network benefit. Coverage of these providers is limited to circumstances where the Plan has approved the treatment plan.

Hospital. An institution that is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or any other institution that is operated pursuant to law, under the supervision of a staff of doctors (M.D. or D.O.) and with 24-hour-a-day nursing services, and that is primarily engaged in providing:

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

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

(c) a licensed birthing center.

In no event shall the term �hospital� include any part of a hospital that provides long-term care or sub-acute care, rather than acute care, or a convalescent nursing home, or any institution or part thereof that:

(a) is used principally as a convalescent facility, rest facility, nursing facility, or facility for the aged; or

(b) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or

(c) is operated as a school; or

(d) is operated as a residential treatment facility regardless of its State licensure or accreditation status.

Christian Science nursing facility. A facility which is approved by the Commission for the Accreditation of Christian Science Nursing Organizations/Facilities, Inc.

Hospice. A facility that:

(a) provides primarily inpatient care to terminally ill patients;

(b) is licensed/certified by the jurisdiction in which it operates;

(c) is supervised by a staff of doctors (M.D. or D.O.) with at least one such doctor on call 24 hours a day;

(d) provides 24-hour-a-day nursing services under the direction of a registered nurse (R.N.) and has a full-time administrator; and

(e) provides an ongoing quality assurance program.

What you must do to get covered care

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

Transitional care

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

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

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

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

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

Hospital care

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-410-7778.

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

How to get approval for�

Your hospital stay

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

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

Warning:

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

Any stay greater than 23 hours must be precertified.

How to precertify an admission

You, your representative, your doctor, or your hospital must call us at 1-800-410-7778 at least two working days before admission. The toll-free number is 1-800-410-7778.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the doctor, or the hospital must telephone 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 of hospital or facility; and

Name and phone number of admitting doctor; and

Number of planned days of confinement.

We will then tell the doctor and/or hospital the number of approved days of confinement for the care of the patient�s condition. Written confirmation of the Plan�s certification decision will be sent to you, your doctor, and the hospital. If the length of stay needs to be extended, follow the procedures below.

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 you, your representative, 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.

If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will pay 70% for covered medical supplies and services that are otherwise payable on an outpatient basis.

If we denied the precertification request, we will not pay room and board inpatient hospital benefits. We will pay 70% for covered medical supplies and services that are otherwise payable on an outpatient basis.

If you remain in the hospital beyond the number of days we approved and you do not get the additional days precertified, then:

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

we will pay 70% of the covered medical services and supplies otherwise payable on an outpatient basis and will not pay room and board benefits for the part of the admission that was not medically necessary.

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.

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

Your stay is less than 23 hours.

Other services

Some services require precertification or preauthorization.

We require preauthorization of mental health/substance abuse services under the managed In-Network benefit for High Option and Standard Option.
See Section 5(e).

We require preauthorization of certain classes of drugs.
See Sections 5(f) and 6(d).

We require preauthorization of transplant services under the National Transplant Program. You or your physician must call 1-800-410-7778 to speak with a transplant case manager prior to your pre-transplant evaluation as a potential candidate for a transplant procedure. See Section 5(b) and 6(c).

We require precertification when Medicare Part B is the primary payer and an outpatient hospitalization exceeds 23-hours or results in hospital admission.

You should call us at 1-800-410-7778 before scheduling any outpatient procedures; we can help you locate a PPO facility.

Copayments

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

Example: When you have High or Standard Option and see your PPO physician you pay a copayment of $20 per visit for adult members or $10 per visit for dependent children under age 22.

Deductible

A deductible 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 do not count toward any deductible.

High Option and Standard Option

The High Option calendar year deductible for covered medical services and supplies is $250 per person ($750 per family) for services received from PPO providers, and $300 per person ($900 per family) for services received from non-PPO providers. The Standard Option calendar year deductible for covered medical services and supplies is $300 per person ($600 per family) for services received from PPO providers, and $350 per person ($900 per family) for services received from non-PPO providers. Whether or not you use PPO providers, your deductible will not exceed the applicable non-PPO amounts. Under a family enrollment, the medical services and supplies deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for all family members reach the respective per family limit.

If you were continuously enrolled in the Plan for the entire prior year and did not meet the calendar year deductible for medical services and supplies for that year (based on claims received by the Plan by December 31 of that year), we will waive $125 per person (up to $375 per family) of that deductible for the current year if you are enrolled in the High Option, or $150 per person (up to $450 per family) of that deductible if you are enrolled in the Standard Option. Example 1: If family member A incurs only $249 of the $250 High Option deductible for 2004, we will waive $125 of the deductible for 2005. Example 2: If three family members each incur only $299 of the $300 Standard Option deductible for 2004, we will waive $150 of the deductible for 2005 for each of these family members. This waiver does not apply to any other deductible under this Plan. This deductible waiver will apply even if you change options of the Plan in the current year. If you change options in this Plan during Open Season, the waiver amount will be based on your new option. This waiver is available only for High Option and Standard Option.

The calendar year deductible for covered mental health/substance abuse services under High Option is $250 per person, limited to $750 per family, for services received from managed in-network providers and $300 per person, limited to $900 per family, for services received from non-network providers. The calendar year deductible for covered mental health/substance abuse services under Standard Option is $300 per person, limited to $600 per family, for services received from managed in-network providers and $350 per person, limited to $900 per family, for services received from non-network providers. Whether or not you use PPO providers, your deductible will not exceed the applicable non-PPO amounts. This deductible is in addition to the medical services deductible. Under a family enrollment, the mental health/substance abuse services deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible reach the respective per family limit.

The calendar year deductible for prescription drugs is $200 per person under High Option and $350 per person under Standard Option. Under a family enrollment, this deductible is met when the family has incurred $400 under High Option and $700 under Standard Option. The prescription drug deductible does not apply to generic drugs. The prescription drug deductible is waived for members who have Medicare Parts A and B as their primary coverage.

Deductible (continued)

Note: If you change plans or plan options during Open Season, you do not have to start a new deductible under your old plan or plan option between January 1 and the effective date of your new plan or plan option. And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

If you change plans during the year, you must begin a new deductible under your new plan.

In 2005, we are introducing a new Consumer Option. Under the Consumer Option, you will have a Health Savings Account (HSA) if you are eligible or a Health Reimbursement Arrangement (HRA). An HSA is an account which you own. An HRA is a credit account which is used to pay for qualified out-of-pocket expenses. Due to Federal income tax rules, different cost sharing requirements apply to these options as explained below. For more information on the Consumer Option see Section 6.

Consumer Option (HSA):

The calendar year deductible for covered medical services and supplies, mental health/ substance abuse services, and prescription drugs, is $2,250 for a Self Only enrollment and $4,500 for a Self and Family enrollment.

Consumer Option (HRA):

The calendar year deductible for covered medical services and supplies, mental health/substance abuse services, and prescription drugs, is $2,250 for a Self Only enrollment and $4,500 for a Self and Family enrollment. This includes your HRA credit amount and your Member Responsibility.

Coinsurance

High Option And Standard Option

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn�t begin until you meet your deductible.

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

Consumer Option (HSA or HRA)

Coinsurance is the percentage of our allowance that you must pay under Traditional Health Coverage. Coinsurance does not begin until you meet your deductible (HSA) or your Member Responsibility (HRA).

Example: You pay 40% of our allowance for non-PPO office visits.

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

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

To help keep your coinsurance out-of-pocket costs to a minimum, we encourage you to call us at1-800-410-7778 or visit our Web site at www.mhbp.com for assistance locating PPO providers whenever possible.

Member Responsibility

Consumer Option (HRA Only):

Your Member Responsibility is your bridge between your Health Reimbursement Arrangement (HRA) and your Traditional Health Coverage. After you have exhausted your HRA credit, you must pay your Member Responsibility before your Traditional Health Coverage begins. Your Member Responsibility is $1,250 for a Self Only enrollment or $2,500 for a Self and Family enrollment.

Differences between our allowance and the bill

High Option and Standard Option: Our �Plan allowance� is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in different ways, so their allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 12.

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

PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an example: You see a PPO physician for an office visit who charges $150, but our allowance is $100. You are only responsible for your coinsurance. That is, you pay just $20 of our $100 allowance for an adult office visit. Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and his bill.

Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. When you use a non-PPO provider, you will pay your deductible and coinsurance � plus any difference between our allowance and charges on the bill. Here is an example: You see a non-PPO physician who charges $150 and our allowance is again $100. Because you�ve met your deductible, you are responsible for your coinsurance, so you pay 30% of our $100 allowance ($30). Plus, because there is no agreement between the non-PPO physician and us, he can bill you for the $50 difference between our allowance and his bill. For details on how we determine the Plan allowance, please see Section 12.

MultiPlan providers agree to limit what they can collect from you. You will still have to pay your deductible and coinsurance. These providers agree to write off the difference between billed charges and the discount amount.

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

Physician�s charge

$150

$150

Our allowance

We set it at: $100

We set it at: $100

We pay

$80

70% of our allowance: $70

You owe: Copayment

$20

30% of our allowance: $30

+Difference up to charge?

No: $0

Yes: $50

TOTAL YOU PAY

$20

$80

Differences between our allowance and the bill (continued)

Consumer Option:

PPO providers agree to accept our Plan allowance so if you use a PPO Provider, you never have to worry about paying the difference between the Plan�s allowance and the billed amount for covered services.

Non-PPO Providers: If you use a non-PPO provider, you will have to pay the difference between the Plan allowance and the billed amount. After you have exhausted your HSA or HRA, you will be responsible for paying your remaining deductible and also copayments and coinsurance under the Traditional Health Coverage

Note: We encourage you to use PPO providers because it will make the amounts in your HSA or HRA last longer.

Your catastrophic protection out-of-pocket maximum for coinsurance

High Option and Standard Option:

For those services with coinsurance (excluding mental health and substance abuse care), we pay 100% of the Plan allowance for the remainder of the calendar year after your coinsurance expenses total these amounts:

$4,500 for services of PPO providers/facilities under the High and Standard Options

$9,000 for services of PPO and non-PPO providers/facilities, combined, under the High and Standard Options.

For mental health and substance abuse benefits, we pay 100% of the Plan allowance for the remainder of the calendar year after your coinsurance expenses total:

$4,500 for services of In-network providers/facilities under the High and Standard Options.

Note: Your out-of-pocket maximum does not apply to these benefits and you must continue to pay applicable copayments and coinsurance for these expenses:

Skilled nursing care

Prescriptions drugs

Any out-of-network mental health and substance abuse care

Hospice

Dental services

Rehabilitative and alternative therapies

Note: The following cannot be counted toward out-of-pocket expenses:

Deductibles

Copayments

Expenses incurred under Prescription Drug Benefits

Expenses in excess of the Plan allowance or maximum benefit limitations

Any out-of-network expenses for mental health and substance abuse care

Amounts you pay for non-compliance with this Plan�s cost containment requirements

Coinsurance for skilled nursing care

Non-covered services and supplies

Coinsurance for alternative and rehabilitative therapy

Your catastrophic protection out-of-pocket maximum for coinsurance (continued)

Consumer Option:

PPO benefit: Your catastrophic out-of-pocket maximum is $5,000 per person ($10,000 per family) when you use PPO providers/facilities and pharmacies. Only eligible expenses for network providers count toward this limit.

Out of pocket expenses for purposes of this benefit are:

Your annual deductible and the in-network copayments that you pay under the Traditional Health Coverage

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

Expenses in excess of the Plan�s allowance, or maximum benefit limitations or expenses not covered under the Traditional Health Coverage

Any amounts you pay because benefits have been reduced for non-compliance with this Plan�s cost containment requirements (see pages 14-16)

Non-PPO benefit: Your catastrophic out-of-pocket maximum is $7,500 per person ($15,000 per family) when you use non-PPO providers/facilities. Eligible expenses for network providers also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers

Out of pocket expenses for purposes of this benefit are:

The copayments you pay for in-network inpatient and outpatient hospital charges, surgical, medical, maternity and emergency services under the Traditional Health Coverage

Your annual deductible and the 40% you pay for out-of-network inpatient and outpatient hospital charges, surgical, medical, maternity and emergency services under the Traditional Health Coverage

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

Expenses in excess of the Plan�s allowance, or maximum benefit limitations or expenses not covered under the Traditional Health Coverage

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

Amounts you pay for non-compliance with this Plan�s cost containment requirements

Coinsurance for skilled nursing care

Coinsurance for alternative and rehabilitative therapy

Carryover

If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan�s catastrophic protection benefit during the prior year will be covered by your old plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your old plan�s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your old plan will first apply your covered out-of-pocket expenses until the prior year�s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your old plan will pay these covered expenses according to this year�s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

When Government facilities bill us

Facilities of the Department of Veteran 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.

When you are age 65 or over and do not have Medicare

Under the FEHB law, we must limit our payments for inpatient hospital care and physician care to those benefits you would be entitled to if you had Medicare. And, your physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare. You and the FEHB benefit from these payment limits. Outpatient hospital and non-physician based care is not covered by this law; regular Plan benefits apply. The following chart has more information about the limits.

If you�

are age 65 or over, and

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

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

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

Then, for your inpatient hospital care,

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

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

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

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

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

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

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

If your physician�

Then you are responsible for�

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

your deductibles, coinsurance, and copayments;

Participates with Medicare and is not in our PPO network,

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

Does not participate with Medicare,

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

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

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than allowed, ask for a refund. If you need further assistance, call us at 1-800-410-7778.

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

High Option And Standard Option

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

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

When Medicare is primary, all or part of your Plan deductibles, copayments and coinsurance will be waived as indicated below:

When Medicare Part A is primary, the Plan will waive applicable per-admission copayments and coinsurance for inpatient hospital benefits, inpatient mental health/substance abuse benefits and nursing benefits.

When Medicare Part B is primary, the Plan will waive applicable deductibles, copayments and coinsurance for surgical and medical services billed by physicians, durable medical equipment, orthopedic and prosthetic appliances, ambulance services and outpatient mental health/substance abuse services.

When Medicare Parts A and B are primary, the plan will waive the calendar year deductible for prescription drugs purchased at a retail pharmacy and through the mail order prescription drug program for both High Option and Standard Option.

Note: The plan will not waive the copayment and coinsurance for retail or mail order prescription drugs.

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) that Medicare will send you will have more information about the limiting charge. If your physician tries to collect more than allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to your Medicare carrier who sent you the MSN form. Call us if you need further assistance.

Please see Section 11, Coordinating benefits with other coverage, for more information about how we coordinate benefits with Medicare.

Consumer Option (HRA):

If your physician accepts Medicare assignment, then you pay nothing if you have unused credit available under your HRA to pay the difference between the Medicare approved amount and Medicare�s payment. After your HRA is exhausted and your Member Responsibility has been met, you pay either the difference between the Medicare approved amount and Medicare�s payment or your copayment amount, whichever is less.

Note: The Plan will not waive any deductibles, copayments or coinsurance when you have Medicare Part A and/or B as your primary payer.

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

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

The calendar year deductible is: $300 per person ($600 per family) for Standard Option PPO services and $350 per person ($900 per family) for Standard Option non-PPO services; and $250 per person ($750 per family) for High Option PPO services and $300 per person ($900 per family) for High Option non-PPO services. 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. See Section 4 for more information about deductibles (including the deductible waiver) and other cost-sharing features such as coinsurance and copayments.

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

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 11 about coordinating benefits with other coverage, including with Medicare.

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

Professional services of physicians

In physician�s office (this includes evaluation and management services related to chemotherapy, hemodialysis and radiation therapy)

At home

In an urgent care center

Office medical consultations

Second surgical opinions provided in a physician�s office

PPO: $20 copayment per office visit for adults (No deductible); $10 copayment per office visit for dependent children under age 22 (No deductible)

Non-PPO: 30% of the Plan�s allowance and any difference between our allowance and the billed amount (No deductible)

PPO: $20 copayment per office visit for adults (No deductible); $10 copayment per office visit for dependent children under age 22 (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Christian Science Practitioners

Same as above

Same as above

Same-day services performed and billed in conjunction with the office visit (except allergy shots, rabies shots or routine immunizations)

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

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

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

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

Professional services of physicians during a hospital stay

Note: Outpatient cancer treatment (chemotherapy, X-rays, or radiation therapy) and dialysis services are paid under Treatment therapies, page 36.

PPO: 10% of the Plan�s allowance

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

PPO: 10% of the Plan�s allowance

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

Not covered:

Routine physical checkups and related tests, except those covered under preventive care

Thermography and related visits

Chelation therapy and related services provided in an outpatient setting

Orthoptic visits and related services

Telephone consultations

All charges

All charges

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

PPO: 10% of the Plan�s allowance

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

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

PPO: 10% of the Plan�s allowance

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

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

First Health Lab Program

You can use this voluntary program for covered lab tests. You show your Mail Handlers Benefit Plan identification card and ask your doctor to send your lab order to Quest Diagnostics. As long as Quest Diagnostics does the testing and bills us directly, you will not have to file any claims. To find a location near you, call 1-800-377-7220, or visit our Web site at www.mhbp.com.

Nothing (No deductible)

Note: This benefit applies to expenses for lab tests only. Related expenses for services provided by a physician are subject to applicable copayments and coinsurance.

Nothing (No deductible)

Note: This benefit applies to expenses for lab tests only. Related expenses for services provided by a physician are subject to applicable copayments and coinsurance.

Not covered:

Handling and administrative charges

Routine lab services except as covered under Preventive care

Professional fees for automated tests

All charges

All charges

Routine screenings, limited to:

Mammogram for women age 35 and older:

From age 35 to 39 � one during this five year period

From age 40 to 64 � one every calendar year

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

Pap smear � one per calendar year for women age 18 and older

Note: The office visit is covered if pap test is received on the same day.

Prostate Specific Antigen (PSA) test � one per calendar year for men age 40 and older

Colorectal Cancer Screening, including

Fecal occult blood (stool) test � one per calendar year for members age 40 and older

Screening sigmoidoscopy � one every two consecutive calendar years for members age 50 and older

Colonoscopy � one every 10 years for members age 50 and older

Blood Cholesterol � one per calendar year for all members

Urinalysis � one per calendar year for all members

Chlamydial infection screening

Osteoporosis screening (bone density study) one every two consecutive calendar years for members age 65 and older

PPO: Nothing (No deductible)

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

PPO: 10 % of the Plan�s allowance

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

Routine immunizations provided during an office visit

PPO: $20 copayment per office visit for adults (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

PPO: $20 copayment per office visit for adults (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Not covered:

Routine physical checkups and related tests except those listed above.

All charges.

All charges.

Routine childhood immunizations recommended by the American Academy of Pediatrics for members under age 22

PPO: Nothing (No deductible)

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

PPO: Nothing (No deductible)

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

Well-child office visits to a doctor for covered dependents up to age 18

Note: This benefit covers the office visit only, not any related services.

PPO: $10 copayment per office visit (No deductible). All charges after the Plan has paid $100 per child per calendar year

Non-PPO: All charges after the plan has paid $75 per child per calendar year (No deductible)

PPO: $10 copayment per office visit (No deductible). All charges after the Plan has paid $100 per child per calendar year

Non-PPO: All charges after the plan has paid $75 per child per calendar year (No deductible)

Routine Screenings, limited to:

Blood cholesterol � one per calendar year for all members

Urinalysis � one per calendar year for all members

PPO: 10% of the Plan�s allowance

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

PPO: 10% of the Plan�s allowance

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

Not covered:

Routine testing not specifically listed as covered

All charges

All charges

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Anesthesia

Postnatal care

Note: Here are some things to keep in mind:

You do not need to precertify your admission for a normal delivery; see page 15 for other circumstances, such as extended stays for you or your baby.

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

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

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

Newborn exams are payable under Section 5(a).

Newborn charges incurred as a result of illness, are considered expenses of the child, not the mother, and are subject to a separate precertification and separate coinsurance and/or copayments.

Maternity benefits will be paid at the termination of pregnancy.

PPO: 10% of the Plan allowance

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

PPO: 10% of the Plan allowance

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

Not covered:

Standby doctors

Home uterine monitoring devices

Services provided to the newborn if the infant is not covered under a self and family enrollment

All charges.

All charges.

Voluntary family planning services, limited to:

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

Surgically implanted contraceptives

Intrauterine devices (IUDs)

PPO: 10% of the Plan allowance

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

PPO: 10% of the Plan allowance

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

Injectable contraceptive drugs (such as Depo provera)

Note: We cover the related office visit under Diagnostic and treatment services (see page 27).

Note: We cover oral contraceptive drugs under the prescription drug benefit, Section 5(f).

PPO: 10% of the Plan�s allowance

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

PPO: 10% of the Plan�s allowance

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

Not covered:

Reversal of voluntary surgical sterilization

All charges.

All charges.

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

Note: Certain prescription drugs for the treatment of infertility are covered under Prescription drug benefits. Call the Plan for a list of drugs that are covered for this service, or go to www.mhbp.com for a link to the list.

PPO: 10% of the Plan allowance

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

PPO: 10% of the Plan allowance

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

Not covered:

Infertility services after voluntary sterilization

Assisted reproductive technology (ART) procedures, such as:

artificial insemination

in vitro fertilization

embryo transfer and gamete intra-fallopian transfer (GIFT)

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

Services and supplies related to ART procedures

Cost of donor sperm or egg

Sperm bank storage fees

All charges.

All charges.

Testing, including materials

PPO: $20 copayment per office visit for adults (No deductible); $10 copayment per office visit for dependent children under age 22 (No deductible); and 10% of the Plan allowance for other services performed during the visit (calendar year deductible applies)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible); 30% of the Plan�s allowance and any difference between our allowance and the billed amount for other services performed during the visit (calendar year deductible applies)

PPO: $20 copayment per office visit for adults (No deductible); $10 copayment per office visit for dependent children under age 22 (No deductible); and 10% of the Plan allowance for other services performed during the visit (calendar year deductible applies)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible); 30% of the Plan�s allowance and any difference between our allowance and the billed amount for other services performed during the visit (calendar year deductible applies)

Allergy serum

PPO: $5 copayment (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

PPO: $5 copayment (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Allergy injections (not including the serum)

PPO: $5 copayment per visit (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

PPO: $5 copayment per visit (No deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Not covered:

Any services or supplies considered by the National Institute of Health and the National Institute of Allergy and Infectious Disease to be not effective to diagnose allergies and/or not effective in preventing an allergy reaction

All charges

All charges

Chemotherapy and radiation therapy for treatment of cancer.

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on page 52-53.

Hyperbaric oxygen therapy

Treatment room

Observation room

Note: These therapies (excluding the related office visits) are covered under this benefit when billed by the outpatient department of a hospital, clinic or a physician�s office. Pharmacy charges for chemotherapy drugs (including prescription drugs to treat the side effects of chemotherapy) are covered under the Prescription drug benefit, see section 5(f).

PPO: 10% of the Plan allowance

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

PPO: 10% of the Plan allowance

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

Dialysis � hemodialysis and peritoneal dialysis

Intravenous (IV)/infusion therapy

Respiratory therapy

Inhalation therapy

Note: Call us at 1-800-410-7778 for details about coverage and information about IV/infusion therapy, respiratory therapy and inhalation therapy PPO providers.

Note: These therapies (excluding the related office visits) are covered under this benefit when performed on an outpatient basis. Pharmacy charges for growth hormones are covered under the Prescription drug benefit, see Section 5(f).

PPO: 10% of the Plan�s allowance

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

PPO: 10% of the Plan�s allowance

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

Rabies shots and related services

Nothing

Nothing

Not covered:

Chelation therapy and related services, except if the covered services and supplies are provided during a precertified inpatient admission

Chemotherapy supported by a bone marrow transplant or with stem cell support for any diagnosis not listed as covered under Section 5(b)

All charges

All charges

Outpatient physical therapy, speech therapy, and occupational therapy

Note: The annual $2,000 combined rehabilitative, chiropractic and alternative therapies maximum includes all covered services and supplies billed for these therapies.

Note: For the purposes of this benefit, services and supplies provided by a doctor of osteopathy (D.O.) are included in the $2,000 benefit maximum.

Note: Medically necessary outpatient physical or occupational therapy provided in a skilled nursing facility (SNF) is covered under this benefit if you are not confined in the SNF.

PPO: 10% of the Plan�s allowance and all charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount. All charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum.

PPO: 10% of the Plan�s allowance and all charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount. All charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum.

Not covered:

Charges billed after the Plan has paid the annual $2,000 rehabilitative, chiropractic and alternative treatment therapies maximum

Exercise programs

Outpatient pulmonary rehabilitation

Outpatient cardiac rehabilitation programs

All charges

All charges

One hearing aid per ear and related services are coved only when the hearing loss was caused by accidental injury. The hearing aid must be purchased within 120 days of the accident and the patient must be covered by the Plan at the time of purchase.

Note: The calendar year deductible applies.

All charges over $200 for one hearing aid per ear

All charges over $200 for one hearing aid per ear

Testing (non-routine)

Note: The calendar year deductible applies.

PPO: 10% of the Plan�s allowance

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

PPO: 10% of the Plan�s allowance

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

Not covered:

Routine hearing testing, hearing aids, and related services when the hearing loss is not directly related to an accidental injury

All charges

All charges

One pair of eyeglasses or contact lenses to correct an impairment directly caused by an accidental ocular injury or intraocular surgery (such as for cataracts). The eyeglasses or contact lenses must be purchased within one year of the injury or surgery and the patient must be covered by the Plan at the time of purchase.

Note: The calendar year deductible applies.

All charges over $50 for one set of eyeglasses or $100 for contact lenses (including examination)

All charges over $50 for one set of eyeglasses or $100 for contact lenses (including examination)

Not covered:

Routine eye exams

Eyeglasses, contact lenses and examinations not directly related to an ocular injury or intraocular surgery

Eye exercises, refractions and related office visits

Radial keratotomy including laser keratotomy and other refractive surgery

All charges

All charges

We pay the professional services for routine foot care for established diabetics. We also pay for medically necessary surgeries under the surgery benefit. See Section 5(b).

PPO: $20 copayment per office visit for adults (No deductible), $10 copayment per office visit for dependent children under age 22 (No deductible), and 10% of the Plan allowance for other services performed during the visit (calendar year deductible applies)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible); 30% of the Plan�s allowance and any difference between our allowance and the billed amount for other services performed during the visit (calendar year deductible applies)

PPO: $20 copayment per office visit for adults (No deductible), $10 copayment per office visit for dependent children under age 22 (No deductible), and 10% of the Plan allowance for other services performed during the visit (calendar year deductible applies)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible); 30% of the Plan�s allowance and any difference between our allowance and the billed amount for other services performed during the visit (calendar year deductible applies)

Not covered:

Cutting, trimming and removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except for the established diagnosis of diabetes

All charges

All charges

Orthopedic and prosthetic devices (see Definitions � Section 12) when recommended by an MD or DO, including:

Artificial limbs and eyes; stump hose

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

Internal prosthetic devices if billed by other than a hospital

Note: Call us at 1-800-410-7778 for details about coverage and information about orthopedic and prosthetic PPO providers.

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

PPO: 10% of the Plan allowance

Non-PPO: 10% of the Plan allowance and any difference between our allowance and the billed amount

PPO: 10% of the Plan allowance

Non-PPO: 10% of the Plan allowance and any difference between our allowance and the billed amount

Not Covered:

Orthopedic and corrective shoes unless attached to a brace

Arch supports, heel pads and heel cups

Foot orthotics and related office visits

Lumbosacral supports, corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic replacements provided less than 3 years after the last one we covered unless a replacement is needed for medical reasons

Penile prosthetics

Customization or personalization beyond what is necessary for proper fitting and adjustment of the items

All charges

All charges

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

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

2. Are medically necessary;

3. Are primarily and customarily used only for a medical purpose;

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

5. Are designed for prolonged use; and

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

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

We will limit our benefit for the rental of durable medical equipment to an amount no greater than what we would have paid if the equipment had been purchased. For coordination of benefits purposes, when we are the secondary payer, we will limit our allowance for rental charges to the amount we would have paid for the purchase of the equipment.

Under this benefit, we also cover:

Wheelchairs;

Hospital beds;

Oxygen equipment;

Ostomy supplies (including supplies purchased at a pharmacy).

Note: Call us at 1-800-410-7778 for details about coverage and information about durable medical equipment PPO providers. Any equipment billed by rehabilitative therapists or alternative medicine providers is covered under that benefit and subject to the combined annual maximum.

Note: For those members who have Medicare Part B as their primary payer, diabetic supplies will be covered under this benefit.

Note: See Treatment therapy for coverage of hyperbaric oxygen therapy.

Note: We will only cover the cost of standard equipment. Coverage for specialty items such as all terrain wheelchairs is limited to the cost of the standard equipment.

PPO: 10% of the Plan�s allowance

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

PPO: 10% of the Plan�s allowance

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

Not covered:

Equipment replacements provided less than 3 years after the last one we covered

Charges for service contracts for purchased or rented equipment

Safety, hygiene, convenience and exercise equipment

Household or vehicle modifications including seat, chair or van lifts; computer switchboard

Communication equipment including computer �story boards,� �light talkers,� and enhanced vision systems

Air conditioners, air purifiers, humidifiers, ultraviolet lighting (except for the treatment of psoriasis)

Wigs or hair pieces

Motorized scooters, lifts, ramps, prone standers and other items that do not meet the DME definition

Dental appliances used to treat sleep apnea and/or temporomandibular joint dysfunction

Charges for educational/instructional advice on how to use the durable medical equipment

All rental charges above the purchase price or charges in excess of the secondary payer amount when we are the secondary payer

Customization or personalization of equipment

Blood pressure monitors

All charges

All charges

A registered nurse (R.N.) or licensed practical nurse (L.P.N.) is covered for outpatient services when:

Prescribed by your attending physician (i.e., the physician who is treating your illness or injury) for outpatient services;

The physician indicates the length of time the services are needed; and

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

Note: Services of a Christian Science Nurse are covered under this benefit.

PPO: 10% of the Plan�s allowance and all charges after the Plan has paid $700 annual maximum

Non-PPO: 30% of the Plan�s allowance and any difference between our allowance and the billed amount. All charges after the Plan has paid $700 annual maximum

PPO: 10% of the Plan�s allowance and all charges after the Plan has paid $700 annual maximum

Non-PPO: 30% of the Plan�s allowance and any difference between our allowance and the billed amount. All charges after the Plan has paid $700 annual maximum

Not covered:

Inpatient private duty nursing

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

Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication

All charges after the Plan has paid $700 for covered nursing services

All charges

All charges

Chiropractic care

Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Note: The annual $2,000 combined rehabilitative, chiropractic and alternative treatment therapies maximum includes all covered services and supplies billed for these therapies.

PPO: $5 copayment per visit and all charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum (No deductible)

Non-PPO: 30% of the Plan�s allowance and any difference between our allowance and the billed amount. All charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum (No deductible).

PPO: 10% of the Plan�s allowance and all charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum (No deductible)

Non-PPO: 30% of the Plan�s allowance and any difference between our allowance and the billed amount. All charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum (No deductible).

Acupuncture

Note: The annual $2,000 combined rehabilitative, chiropractic and alternative treatment therapies maximum includes all covered services and supplies billed for these therapies.

PPO: 10% of the Plan�s allowance and all charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum

Non-PPO: 30% of the Plan�s allowance and any difference between our allowance and the billed amount. All charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum.

PPO: 10% of the Plan�s allowance and all charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum

Non-PPO: 30% of the Plan�s allowance and any difference between our allowance and the billed amount. All charges after the Plan has paid the $2,000 combined rehabilitative, chiropractic and alternative treatment therapy maximum.

Not covered:

Naturopathic and homeopathic services

Chelation therapy and related services, except if the covered services and supplies are provided during a precertified inpatient hospitalization

Thermography, biofeedback and related visits

Charges after the$2,000 combined rehabilitative, chiropractic therapies and alternative treatments annual maximum has been paid by the Plan

Note: Services of certain alternative treatment providers may be covered in medically underserved areas � see page 12.

All charges

All charges

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

Note: All benefits are paid directly to you.

Smoking deterrents are covered under the Prescription drug benefit. See Section 5(f).

All charges over $100.

All charges over $100

Not covered:

Self help or self management programs such as diabetic self management

Charges for educational/instructional advice on how to use durable medical equipment

All charges

All charges

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

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

The calendar year deductible is: $300 per person ($600 per family) for Standard Option PPO services and $350 per person ($900 per family) for Standard Option non-PPO services; and $250 per person ($750 per family) for High Option PPO services and $300 per person ($900 per family) for High Option non-PPO services. 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. See Section 4 for more information about deductibles (including the deductible waiver) and other cost-sharing features such as coinsurance and copayments.

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

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 11 about coordinating benefits with other coverage, including with Medicare.

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

PLEASE REMEMBER THAT ANY SURGICAL SERVICES THAT REQUIRE AN INPATIENT ADMISSION MUST BE PRECERTIFIED. Please refer to the precertification information shown in Section 3.

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

A comprehensive range of services, such as:

Operative procedures (performed by the primary surgeon);

Treatment of fractures, including casting;

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

Endoscopy procedures (diagnostic and surgical);

Biopsy procedures;

PPO: 10% of the Plan allowance

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

PPO: 10% of the Plan allowance

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

Surgical procedures (continued)

You pay � Standard Option

You pay � High Option

Electroconvulsive therapy;

Removal of tumors and cysts;

Correction of congenital anomalies (see Reconstructive surgery);

Surgical treatment of morbid obesity -- a diagnosed condition in which the body mass index is 40 or greater, or 35 or greater with co-morbidities such as diabetes, coronary artery disease, hypertension, hyperlipidemia, obstructive sleep apnea, pulmonary hypertension, weight-related degenerative joint disease, or lower extremity venous or lymphatic obstruction; eligible members must be age 18 or over;

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

Voluntary sterilization;

Surgically implanted contraceptives and intrauterine devices (IUDs);

Treatment of burns;

Correction of amblyopia & strabismus.

PPO: 10% of the Plan�s allowance

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

PPO: 10% of the Plan�s allowance

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

When multiple or bilateral surgical procedures are performed during the same operative session by the same surgeon, the Plan�s benefit is determined as follows:

For the primary procedure:

PPO: the Plan�s full allowance or

Non-PPO: the Plan�s full allowance

For the secondary procedure:

PPO: one-half of the Plan�s allowance or

Non-PPO: one-half of the Plan�s allowance

For the tertiary procedure and any other subsequent procedures:

PPO: one-quarter of the Plan�s allowance or

Non-PPO: one-quarter of the Plan�s allowance

PPO: 10% of the Plan�s allowance for the individual procedure

Non-PPO: 30% of the Plan�s allowance for the individual procedure and any difference between our allowance and the billed amount

PPO: 10% of the Plan�s allowance for the individual procedure

Non-PPO: 30% of the Plan�s allowance for the individual procedure and any difference between our allowance and the billed amount

Co-surgeons

When the surgery requires two surgeons with different skills to perform the surgery, the Plan�s allowance for each surgeon is 50% of what it would pay a single surgeon for the same procedure(s).

PPO: 10% of the Plan�s allowance

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

PPO: 10% of the Plan�s allowance

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

Assistant surgeons

Assistant surgical services provided by a qualified surgeon (M.D.) when medically necessary to assist the primary surgeon. When a surgery requires an assistant surgeon, the Plan will reduce its benefits for the assistant surgeon to 20% of the allowance for the surgery.

PPO: Nothing

Non-PPO: The difference between our allowance and the billed amount

PPO: Nothing

Non-PPO: The difference between our allowance and the billed amount

Not covered:

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

Reversal of voluntary sterilization

Services of a standby surgeon

Routine treatment of conditions of the foot except for services rendered to established diabetics

Cosmetic surgery (See definition, page 49)

Radial keratotomy, laser and other refractive surgery

Assistant surgeon services from a non-physician provider, such as a Physician Assistant (P.A.), Certified Registered Nurse First Assistant (C.R.N.F.A.) and a Certified Surgical Technologist (C.S.T.)

All charges

All charges

Surgery to correct a functional defect

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

The condition produces a major effect on the member�s appearance, and

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

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

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

Surgery to produce a symmetrical appearance of breasts;

Treatment of any physical complications, such as lymphedemas;

(See Prosthetic devices for coverage of breast prostheses and surgical bras and replacements.)

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

PPO: 10% of the Plan�s allowance

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

PPO: 10% of the Plan�s allowance

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

Not covered:

Cosmetic surgery � any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury or caused by illness

Surgery related to sex transformations or sexual dysfunction

All charges

All charges

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of impacted teeth that are not completely erupted (bony, partial bony, and soft tissue impactions);

Removal of stones from salivary ducts;

Excision of leukoplakia, tori or malignancies;

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

Temporomandibular joint dysfunction surgery;

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

Note: the related hospitalization (inpatient and outpatient) is covered if medically necessary. See Section 5(c).

PPO: 10% of the Plan�s allowance

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

PPO: 10% of the Plan�s allowance

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

Not covered:

Oral/dental implants and transplants;

Procedures that involve the teeth or their supporting structures, such as the periodontal membrane, gingiva, and alveolar bone (these procedures may be considered as covered dental procedures under the High Option Dental benefit);

Conservative treatment of temporomandibular joint dysfunction (TMJ);

Dental/oral surgical splints and stents.

All charges

All charges

You pay � High Option

National Transplant Program � The Plan participates in the First Health� National Transplant Program. Because transplantation is a highly specialized area, not all PPO hospitals are part of the National Transplant Program. To qualify for this program, you or your physician must call us at 1-800-410-7778 as soon as the possibility of a transplant is discussed. When you call, you will be given information about the program, including a list of participating facilities. To receive the highest level of benefits, you must choose one facility within the special network of transplant facilities. Transplant-related services must be received at the facility you choose in order to be covered under the National Transplant Program benefit. All transplant admissions must be precertified.

Travel Benefit - the Plan may approve reasonable travel, lodging and meal expenses (if the recipient lives more than 100 miles from the facility) up to $10,000 per transplant for the recipient and one companion (two companions if the recipient is a minor) and your organ donor, if applicable. For more information, contact us at 1-800-410-7778 before scheduling your pre-transplant evaluation.

Donor Coverage - we cover related medical and hospital expenses of the donor for the initial transplant confinement when we cover the recipient if these expenses are not covered under any other health plan.

Benefit Limitation: The maximum benefit for any organ/tissue transplant(s) is $1,000,000 per occurrence for the National Transplant Program, $200,000 per occurrence for PPO services or $100,000 per occurrence for non-PPO services, which includes the following transplant-related expenses: pre-transplant evaluation, inpatient and outpatient hospital care, professional fees and donor expenses. To use the National Transplant Program, this must be your primary plan for payment of benefits. Expenses related to complications arising during the transplant admission are considered part of the same occurrence. Outpatient prescription drugs and approved travel expenses related to the transplant are not subject to the transplant maximums. See Section 5(c) for coverage of transplant-related services provided by a hospital.

Limited to:

Cornea

Heart

Heart/lung

Kidney

Liver

Pancreas*

Kidney/Pancreas

Single lung

Double lung.

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

Allogenic (donor) bone marrow transplants for chronic myelogenous leukemia, acute leukemia, aplastic anemia, severe combined immuno-deficiency disease, Wiscott-Aldrich syndrome, advanced Hodgkin�s lymphoma, advanced non-Hodgkin�s lymphomas, and myelodysplastic syndrome (in advanced form).

Autologous (self) bone marrow transplants (autologous stem cell and peripheral stem cell support) for chronic or acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin�s lymphoma; advanced non-Hodgkin�s lymphomas; resistant or recurrent neuroblastoma; testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors; breast cancer; multiple myeloma; and epithelial ovarian cancer.

Autologous tandem bone marrow transplants for testicular and other germ cell tumors and for multiple myeloma.

(Covered transplants continued on next page)

National Transplant Program: 10% of the Plan�s allowance and all charges over $1,000,000.

PPO: 15% of the Plan�s allowance and all charges over $200,000.

Non-PPO: 30% of the Plan�s allowance and any difference between our allowance and the billed amount. All charges over $100,000.

National Transplant Program: 10% of the Plan�s allowance and all charges over $1,000,000.

PPO: 15% of the Plan�s allowance and all charges over $200,000.

Non-PPO: 30% of the Plan�s allowance and any difference between our allowance and the billed amount. All charges over $100,000.

Covered transplants (continued)

*Note: Pancreas (only) transplants are covered for insulin dependent (or Type 1) diabetes mellitus when exogenous treatment with insulin is deemed ineffective by the Plan.

Note: Benefits will be paid at the PPO or Non-PPO level of benefits if no National Transplant Program provider is available

Note: Corneal transplants are not part of the National Transplant Program. Benefits will paid as described on page 46.

Note: We cover related medical and hospital expenses of the donor for the initial transplant confinement when we cover the recipient if these expenses are not covered under any other health plan.

Note: Chemotherapy, when supported by a bone marrow transplant or autologous stem cell support, is covered only for the specific diagnoses listed.

Not covered:

Expenses for services or supplies specifically excluded by the Plan, unless part of a treatment plan approved through the National Transplant Program

Donor screening tests and donor search expenses except those performed on the actual donor or those approved through the National Transplant Program

Travel, lodging and meal expenses not approved by the Plan�

Services and supplies for or related to transplants not listed as covered. Related services or supplies include administration of chemotherapy when supported by transplant procedures

All charges

All charges

Professional services for the administration of anesthesia in hospital and out of hospital

PPO: 10% of the Plan�s allowance

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

Note: If your PPO provider uses a non-PPO anesthesiologist, we will pay non-PPO benefits for any anesthesia charges.

PPO: 10% of the Plan�s allowance

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

Note: If your PPO provider uses a non-PPO anesthesiologist, we will pay non-PPO benefits for any anesthesia charges.

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

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

In this Section, unlike Sections 5(a) and 5(b), the calendar year deductible applies to only a few benefits. In that case, we added �(calendar year deductible applies)�. If applicable, the calendar year deductible is $300 per person ($600 per family) for Standard Option PPO services and $350 per person ($900 per family) for Standard Option non-PPO services; and $250 per person ($750 per family) for High Option PPO services and $300 per person ($900 per family) for High Option non-PPO services

The non-PPO benefits the regular benefits of this Plan. PPO benefits apply only when you use a provider participating in the First Health� Network. When no PPO provider is available, non-PPO benefits apply. To help keep your out-of-pocket costs for coinsurance to a minimum, we encourage you to contact us for direction to PPO providers whenever possible.

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 11 about coordinating benefits with other coverage, including with Medicare.

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

Note: When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists may not all be preferred providers.

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

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

Room and board, such as

Ward, semiprivate, or intensive care accommodations, including birthing centers;

general nursing care; and

meals and special diets.

Note: We only cover a private room when you must be isolated to prevent contagion. Otherwise, our benefit will be based on the hospital�s average charge for semiprivate accommodations.

Note: Hospitals billing an all-inclusive rate will be prorated between room and board and ancillary charges.

PPO: Nothing.

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

PPO: Nothing.

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

Other hospital services and supplies (ancillary services), such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Pathology tests

Diagnostic laboratory tests and X-rays

Blood or blood plasma

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Autologous blood donations

Internal prosthesis

Note: We base payment on whether the facility or a health care professional bills for the services or supplies. For example, when the hospital bills for its anesthetists� services, we pay Hospital benefits and when the anesthetist bills, we pay under Section 5(b).

Note: The maximum benefit for any organ/tissue transplant(s) as described on pages 51-53 is $1,000,000 per occurrence for the National Transplant Program, $200,000 per occurrence for PPO services or $100,000 per occurrence for non-PPO services, which includes the following transplant-related expenses: pre-transplant evaluation, hospital care, professional fees and donor expenses. Expenses related to complications arising during the transplant admission are considered part of the same occurrence. Outpatient prescription drugs and approved travel expenses related to the transplant are not subject to the transplant maximums. See section 5(b) for transplant-related professional services.

Note: To use the National Transplant Program, this must be your primary plan for payment of benefits.

Note: Chemotherapy, when supported by a bone marrow transplant or autologous stem cell support is covered only for the specific diagnoses listed on pages 51-53.

PPO: $200 copayment per admission and 15% of the Plan�s allowance

Non-PPO: $400 copayment per admission plus 30% of the Plan�s allowance and any difference between our allowance and the billed amount

PPO: $200 copayment per admission and 15% of the Plan�s allowance

Non-PPO: $300 copayment per admission plus 30% of the Plan�s allowance and any difference between our allowance and the billed amount

Note: The Plan pays Inpatient Hospital Benefits as shown above in connection with dental procedures only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient.

Note: Benefits for admission to Christian Science nursing facilities are limited to $30,000 per person per calendar year.

Not covered:

A hospital admission, or portion thereof, that is not medically necessary (see definition), including an admission for medical services that did not require the acute hospital inpatient (overnight) setting, but could have been provided in a doctor�s office, outpatient department of a hospital, or some other setting without adversely affecting the patient�s condition or the quality of medical care rendered.

Hospital admissions for medical rehabilitation unless the admission is to an approved acute inpatient rehabilitation facility and the patient can actively participate in a minimum of 3 hours of acute inpatient rehabilitation to include any combination of the following therapies: physical, occupational, speech, respiratory therapy per day.

Custodial care; see Section 12: Definitions.

Non-covered facilities, such as nursing homes, subacute care facilities, extended care facilities, schools, domiciliaries and rest homes.

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

Private inpatient nursing care

Institutions that do not meet the definition of covered hospitals

All charges after the Plan has paid $30,000 for services provided by a Christian Science nursing facility.

All charges

All charges

Services and supplies, such as:

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services

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

Dressings, casts, and sterile tray services

Medical supplies, including anesthesia and oxygen

Anesthetics and anesthesia services

Note: � We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment.

Note: If the stay is greater than 23 hours, you need to precertify the admission.

Note: For services billed by a surgeon or anesthetist, see Section 5(b).

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

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

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

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

Not covered:

Surgical facility charges billed by entities that are not accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) or the Accreditation Association for Ambulatory HealthCare (AAAHC), or which do not have Medicare certification as an ASC facility.

All charges

All charges

No benefit

All charges

All charges

Hospice is a coordinated program of maintenance and supportive care for the terminally ill provided by a medically supervised team under the direction of a Plan-approved independent hospice administration.

We pay $5000 per lifetime for any combination of inpatient and outpatient services. If you use a PPO provider, your out-of-pocket expenses will be reduced.

PPO: All charges after the plan has paid $5,000

Non-PPO: All charges after the plan has paid $5,000

PPO: All charges after the plan has paid $5,000

Non-PPO: All charges after the plan has paid $5,000

Not covered:

Independent nursing, and homemaker services

Charges above $5,000.

All charges

All charges

Local professional ambulance service when medically appropriate to the nearest hospital where treated and from that hospital to or from the next nearest hospital or medical facility if necessary treatment is not available at the first hospital. Services must be related to a covered inpatient hospitalization, a medical emergency, or associated with covered hospice care.

Air ambulance to the nearest hospital where treatment is available and only if there is no emergency ground transportation available or suitable and the patient�s condition requires immediate evacuation.

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

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

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

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

Not covered:

Transportation to other than a hospital, hospice or urgent care medical facility

All charges

All charges

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

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

The calendar year deductible is: $300 per person ($600 per family) for Standard Option PPO services and $350 per person ($900 per family) for Standard Option non-PPO services; and $250 per person ($750 per family) for High Option PPO services and $300 per person ($900 per family) for High Option non-PPO services. 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. See Section 4 for more information about deductibles (including the deductible waiver) and other cost-sharing features such as coinsurance and copayments.

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

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 11 about coordinating benefits with other coverage, including with Medicare.

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What is an accidental injury? An accidental injury is a bodily injury sustained through external, and accidental means, such as broken bones, animal bites, poisonings, and injuries to sound natural teeth. Masticating (chewing) incidents are not considered to be accidental injuries.

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

If you receive outpatient care for your accidental injury in a hospital emergency room or urgent care center, we cover:

Non-surgical physician services and supplies

Related outpatient hospital services

Observation room

Surgery

Note: We pay Hospital benefits if you are admitted.

(Accidental injury/Medical Emergency benefits continued on next page)

PPO: $150 copayment per occurrence (if admitted to the hospital, copayment is waived)

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

PPO: 10% of the Plan�s allowance

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

Note: Repair of sound natural teeth due to an accidental injury is covered under this benefit. The services and supplies must be provided within one year of the accident and the patient must be a member of the Plan at the time services were rendered. Masticating (chewing) incidents are not considered to be accidental injuries.

Non-surgical physician services provided in a doctor�s office for your accidental injury.

PPO: $20 copayment per office visit for adults (No deductible), $10 copayment per office visit for dependent children under age 22 (No deductible); and 10% of the Plan�s allowance for other services performed during the visit (calendar year deductible applies)

Non-PPO: 30% of the Plan�s allowance and any difference between our allowance and the billed amount per office visit (No deductible); 30% of the Plan�s allowance and any difference between our allowance and the billed amount for other services (calendar year deductible applies)

PPO: $20 copayment per office visit for adults (No deductible), $10 copayment per office visit for dependent children under age 22 (No deductible); and 10% of the Plan�s allowance for other services performed during the visit (calendar year deductible applies)

Non-PPO: 30% of the Plan�s allowance and any difference between our allowance and the billed amount per office visit (No deductible); 30% of the Plan�s allowance and any difference between our allowance and the billed amount for other services (calendar year deductible applies)

Local professional ambulance service when medically appropriate to the nearest hospital where treated and from that hospital to or from the next nearest hospital or medical facility if necessary treatment is not available at the first hospital. Services must be related to a covered inpatient hospitalization, a medical emergency, or associated with covered hospice care.

Air ambulance to the nearest hospital where treatment is available and only if there is no emergency ground transportation available or suitable and the patient�s condition warrants immediate evacuation.

PPO: 10% of the Plan�s allowance

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

PPO: 10% of the Plan�s allowance

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

Not covered:

Transportation to other than a hospital, hospice or urgent care medical facility

All charges

All charges

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You may choose to get care Out-of-Network or In-Network. When you receive In-Network care, you must get our approval for services and follow a treatment plan we approve. If you do, cost-sharing and limitations for In-Network mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions. If In-Network care is not authorized, Out-of-Network benefits will be paid.

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

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

The Mental health and substance abuse benefits calendar year deductible is $300 per person ($600 per family) for Standard Option PPO services and $350 per person ($900 per family) for Standard Option non-PPO services; and $250 per person ($750 per family) for High Option PPO services and $300 per person ($900 per family) for High Option non-PPO services. 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. This calendar year deductible is in addition to the calendar year deductible for medical services and the calendar year deductible for prescription drugs.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 11 about coordinating benefits with other coverage, including with Medicare.

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

In-Network mental health and substance abuse benefits are below, then Out-of-Network benefits begin on page 64.

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

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

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

Outpatient professional services, including individual or group therapy by providers approved by the Managed In-Network vendor. This may include services provided by a Licensed Professional Counselor or Licensed Marital Family Therapist

Medication management.

$20 copayment per office visit for adults (No deductible); $10 copayment per office visit for dependent children under age 22 (No deductible)

$20 copayment per office visit for adults (No deductible); $10 copayment per office visit for dependent children under age 22 (No deductible)

Inpatient professional services

10% of the plan�s allowance

10% of the plan�s allowance

Electroshock therapy and laboratory procedures

Diagnostic tests including psychological testing

10% of the plan�s allowance

10% of the plan�s allowance

Services provided by a hospital or other inpatient facility

Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, facility based intensive outpatient treatment

$200 copayment per admission, nothing for room and board and 15% of the Plan�s allowance for hospital ancillary services (No deductible)

$100 copayment per admission, nothing for room and board and 15% of the Plan�s allowance for hospital ancillary services (No deductible)

Not covered: Services we have not approved.

All charges

All charges

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

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

Call the Plan at 1-800-410-7778 to be referred to the Managed Network vendor. If you do not call, the charges will be processed as Out-of-Network benefits.

Network Limitation � If you do not obtain an approved treatment plan we will provide only Out-of-Network benefits

Outpatient professional services to treat mental health/substance abuse.

Note: One day in partial hospitalization/day treatment program is considered as one outpatient visit.

30% of the Plan�s allowance for up to 20 visits and any difference between our allowance and the billed amount (No deductible). All charges after 20 visits.

30% of the Plan�s allowance for up to 20 visits and any difference between our allowance and the billed amount (No deductible). All charges after 20 visits.

Inpatient professional services to treat mental health/substance abuse.

30% of the Plan�s allowance after the mental health/substance abuse calendar year deductible, and any difference between our allowance and the billed amount

30% of the Plan�s allowance after the mental health/substance abuse calendar year deductible, and any difference between our allowance and the billed amount

Electroshock therapy, diagnostic tests and laboratory procedures.

30% of the Plan�s allowance after the mental health/substance abuse calendar year deductible, and any difference between our allowance and the billed amount

30% of the Plan�s allowance after the mental health/substance abuse calendar year deductible, and any difference between our allowance and the billed amount

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

$400 copayment per admission and 30% of charges for up to 45 days per calendar year. And any charges after the covered 45 days.

$300 copayment per admission and 30% of charges for up to 45 days per calendar year. And any charges after the covered 45 days.

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

$400 copayment per admission and 30% of charges for up to 45 days per calendar year. And any charges after the covered 45 days.

$300 copayment per admission and 30% of charges for up to 45 days per calendar year. And any charges after the covered 45 days.

Not covered Out-of-Network:

Services, that in the Plan�s judgment, are not medically necessary

Services by pastoral, marital, drug/alcohol and other counselors

Treatment for learning disabilities and mental retardation

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

All charges

All charges

Precertification The medical necessity of your admission to a hospital or other covered facility must be precertified for you to receive these Out-of-Network benefits. Emergency admissions must be reported within two business days following the day of admission even if you have been discharged. Otherwise, the benefits payable will be reduced by $500. See Section 3 for details.

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

Section 4, Your costs for covered services, for information about out-of-pocket maximum for In-Network benefits.

Section 9, Filing a claim for covered services, for information about submitting out-of-network claims.

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

We cover prescribed drugs and medications, as described in the chart beginning on page 69.

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

The deductible for prescription drugs is separate from the annual deductible for medical benefits and separate from the annual deductible for mental health and substance abuse. We added �(No deductible)� to show when the calendar year prescription drug deductible does not apply.

The calendar year deductible is: $350 per person ($700 per family) for Standard Option. The Plan will waive all of the prescription deductible as described on page 69 for members who have Medicare Parts A and B as their primary coverage. Generic drugs are not subject to the prescription drug deductible.

The Calendar Year prescription drug deductible is $200 per person ($400 per family) for High Option. The Plan will waive all of the prescription deductible as described on page 69 for members who have Medicare Parts A and B as their primary coverage. Generic drugs are not subject to the prescription drug 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 11 about coordinating benefits with other coverage, including with Medicare.

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

Who can write your prescription? A physician or other covered provider acting within the scope of their license.

Where you can obtain them. You may fill the prescription at a First Health Rx participating pharmacy, a non-network pharmacy, or by mail for certain drugs. We pay a higher level of benefits when you use a network pharmacy.

Network pharmacy � Present your Plan identification card at a network pharmacy to purchase prescription drugs. You must have the pharmacy file the claim electronically for you in order to receive the network pharmacy level benefit. Call 1-800-410-7778 or check the electronic directory via www.mhbp.com to locate the nearest network pharmacy.

Non-Network pharmacy � You may purchase prescriptions at pharmacies that are not part of our network. You pay full cost and must file a claim for reimbursement. See: When you have to file a claim.

Mail order � To obtain more information about the mail order drug program, order refills, check order status and request additional mail services envelopes and claim forms, or to ask questions about eligibility, copayments or other issues, call the Plan at 1-800-410-7778 or visit our Web site at www.mhbp.com.

Prescription drugs (continued)

We administer an open formulary. We administer a Formulary Management Program designed to control costs for you and the Plan. The formulary is updated periodically and includes all FDA-approved drugs that have been placed in tiers based on their clinical effectiveness, safety and cost. The tiers or categories include:

Generic Drug Category includes primarily generic drugs;

Preferred Drug Category includes preferred brand name drugs;

Non-Preferred Drug Category includes non-preferred brand name drugs.

Occasionally, drugs may change from one category to another category during the year; this can affect your copayment amount. We will attempt to notify you when this occurs.

Please note: Information about the program and a copy of the formulary was included with your identification card. When you need a prescription, share the formulary with your provider and request a Generic or Preferred category drug if possible. By choosing Generic or Preferred category drugs, you may decrease your out-of-pocket expenses. While all currently FDA-approved drugs are included on the formulary list, we may have restrictions on certain drugs, including but not limited to, quantity limits, age limits, dosage limits and preauthorization . To request a copy of our current formulary, call us at 1-800-410-7778 or visit our Web sit, www.mhbp.com.

Why use generic drugs? A generic drug is the chemical equivalent to a brand name drug, yet it costs much less. Choosing generic drugs rather than brand name drugs can reduce your out-of-pocket expenses. The U.S Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand name drugs. They must contain the same active ingredients, be equivalent in strength and dosage, and meet the same standards for safety, purity and effectiveness as the original brand name product.

There are dispensing limitations. All prescriptions will be limited to a 30-day supply for retail and a 90-day supply for mail order. Also, in most cases, refills cannot be obtained until 75% of the drug has been used. Occasionally, as part of regular review, we may recommend that the use of a drug is appropriate only with limits on its quantity, total dose, duration of therapy, age, gender or specific diagnoses. Since the prescription does not usually explain the reason your provider prescribed a medication, we may implement any of these limits and/or require preauthorization to confirm the intent of the prescriber.

Specialty drugs, including biotech drugs, require special handling and close monitoring, are used to treat chronic complex conditions including, but not limited to: hemophilia, immune deficiency, growth hormone deficiencies, multiple sclerosis, Crohn's disease, hepatitis C, HIV, hormonal disorders, rheumatoid arthritis and pulmonary disorders. These drugs require preauthorization to determine medical necessity and appropriate utilization. In addition to specialty drugs, we require preauthorization for certain classes of drugs, including, but not limited to: growth hormones; replacement enzymes; physical adjuncts; immunomodulators; drugs used to treat Attention Deficit Disorder and narcolepsy; oncologic agents; endothelin receptor antagonists; neuromuscular blocking agents; and monoclonal antibodies to IGE. Call us at 1-800-410-7778 if you have any questions regarding preauthorization, quantity limits, or other issues.

We can accommodate your drug refill requests when you are called to active military duty or in the case of a declared emergency. You can call us while you are in the pharmacy or in advance at 1-800-410-7778 to request the accommodation.

Prescription drugs (continued)

The Plan conducts Drug Utilization Review (DUR). When you fill your prescription at a network pharmacy or through the mail-order program, we and/or the pharmacist may electronically access information about prior prescriptions, checking for harmful drug interactions, drug duplication, excessive use and the frequency of refills. DUR helps protect against potentially dangerous drug interactions or inappropriate use. When appropriate, your pharmacist(s) and/or First Health Rx may contact your physician(s) to discuss an alternative drug or treatment option, prescription drug compliance, and the best and most cost-effective use of services. In addition, we may perform a periodic review of prescriptions to help ensure your safety and to provide health education and support. Upon review, we may contact you or your provider(s) to discuss your current medical situation and may offer assistance in coordinating care and treatment. For more information about this program, call us at 1-800-410-7778.

When you do have to file a claim. If you purchase prescriptions at a non-network pharmacy, mail your prescription receipts to: The Mail Handlers Benefit Plan, Prescription Drug Claims, Box 23824, Tucson, AZ 85734. Receipts must include the prescription number, name of drug, date, prescribing doctor�s name, charge, name and address of drugstore and NDC number (included on the bill).

Benefits for all prescription drugs will be determined based on the fill date for the prescription.

Note: All drugs may not be available through the mail order program. Some of the drug classes that may not be available are: narcotics, hospital solutions and certain drugs such as antipsychotic agents and AIDS therapies and other drugs for which state or federal laws or medical judgment limit the dispensing amount to less than 90 days. In addition, some injectables may not be available through mail-order services. However, these excluded drugs are covered under the retail prescription drug program. For questions about the mail-order prescription drug program or to inquire about specific drugs or medications, please call 1-800-410-7778.

This Plan has two levels of reimbursement for retail prescription drug claims. One is for prescriptions filled at a network pharmacy for claims filed electronically or for prescriptions filled at a foreign pharmacy while you are living outside the United States. The second is for prescriptions filled at a non-network pharmacy or other vendor, or when you reside in the United States and choose to submit a paper claim. It is in your best interest to have your prescription filled at a network pharmacy that files your claims electronically. If you do not file electronically and do not live overseas, your reimbursement will be reduced to 50% of the allowable charges. Remember to show your Mail Handlers Benefit Plan ID card with the First Health Rx logo to receive increased benefits and the convenience of having your claims filed electronically for you.

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

You may purchase the following medications and supplies prescribed by a physician from either a pharmacy or by mail (for certain prescription drugs):

Drugs and medicines that by Federal law of the United States require a doctor�s written prescription, including chemotherapy and drugs used to treat the side effects of chemotherapy.

Disposable needles and syringes, and alcohol swabs (if purchased at a pharmacy).

Insulin and related testing material.

Oral contraceptive. (Implants and implant insertions are covered under Surgical Benefits.

Diaphragms.

Smoking deterrents.

For questions about the prescription drug program, or to obtain a copy of our current formulary, please call 1-800-410-7778 or visit our Web site at www.mhbp.com.

Network pharmacies or prescriptions filled by foreign pharmacies: $10 per Generic drug (No deductible)/$30 per Preferred brand name drug/$45 per Non-Preferred brand name drug

Non-network pharmacies/Paper claims for prescriptions filled at a network pharmacy: 50% of the Plan�s allowance for the prescription and any difference between our allowance and the billed amount

Network pharmacies with Medicare: $10 per Generic drug /$30 per Preferred brand name drug/$45 per Non-Preferred brand name drug (No deductible)

Mail Order: $10 per Generic drug (No deductible)/$40 per Preferred brand name drug/$55 per Non-Preferred brand name drug

Mail Order Medicare: $10 per Generic drug/$40 per Preferred brand name drug/$55 per Non-Preferred brand name drug (No deductible)

Network pharmacies or prescriptions filled by foreign pharmacies: $10 per Generic drug (No deductible)/$25 per Preferred brand name drug /$40 per Non-Preferred brand name drug

Non-network pharmacies/Paper claims for prescriptions filled at a network pharmacy: 50% of the Plan allowance for the prescription and any difference between our allowance and the billed amount

Network pharmacies with Medicare: $10 per Generic drug /$25 per Preferred brand name drug/$40 per Non-Preferred brand name drug (No deductible)

Mail Order: $10 per Generic drug (No deductible)/$30 per Preferred brand name drug/$45 per Non-Preferred brand name drug

Mail Order Medicare: $10 per Generic drug/$30 per Preferred brand name drug/$45 per Non-Preferred brand name drug (No deductible)

Not covered:

Drugs and supplies for cosmetic purposes.

Prescriptions written by a non-covered provider.

Vitamins, nutrients and food supplements that do not require a physician�s prescription, even if a physician prescribes or administers them.

Total parenteral nutrition (TPN) products and related services.

Nonprescription drugs or medicines.

Anorexiants or weight loss medications.

Erectile dysfunction drugs.

Drugs and supplies when another insurance plan or payer provides benefits, regardless of actual payment, for these services/supplies except Medicare Part B covered diabetic supplies.

Any amount in excess of the cost of the generic drug when a generic is available and the physician has not specified that the pharmacist dispense the brand name drug.

All charges

All charges

Flexible benefits option

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

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

Alternative benefits are subject to our ongoing review.

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

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

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

First Health OnCall

First Health OnCall provides integrated health benefit services including a national PPO network, clinical management services, a national transplant program, a care support program with Internet visits, round-the-clock benefits support, pharmacy network and plan administration. A brief description of the specialized maternity program, care support and Internet visits is included below. If you have questions about any of the programs, your benefits or would like general health information, call us at 1-800-410-7778, 24 hours a day, 7 days a week.

Specialized Maternity Program

The specialized maternity program is a voluntary service designed to assist you during your pregnancy by identifying high-risk pregnancies to promote positive outcomes for the mother and baby and to assist in coordinating cost-effective care. To access the program, call us at 1-800-410-7778 during your first trimester. A nurse case manager will ask questions about your general health and medical history. If appropriate, a case manager will follow your case, inform you about specialists and/or facilities when applicable, and coordinate communication among you and the health care providers involved in your care.

First Health Care Support Program

A voluntary program providing a variety of disease management services designed to help you manage a chronic condition successfully with outpatient treatment and avoid unnecessary emergency care or inpatient admissions. Examples of conditions that can be managed through this program are: diabetes, asthma and heart failure. We use medical and/or pharmacy claims data as well as interactions with you and your physician(s) to determine if you may benefit from this program. If you have a chronic condition and would like more information, or if you have questions about your current treatment, call us at 1-800-410-7778, 24 hours a day, 7 days a week.

Internet visit

If you have a chronic illness and are receiving care support services, you and your PPO network physician may be able to help manage your condition using Internet visits. This service allows you to communicate with your physician, privately and securely, via the Internet. You are the only one allowed to initiate an Internet visit. You will be able to log on to a password-protected Web site and send a non-urgent message with pertinent information or questions regarding your condition to your physician. In turn, your physician will respond to your message, which may verify that your current treatment plan is working well, state what changes need to be made to your treatment plan, give answers to your questions, or recommend that you schedule an office visit. Using Internet visits does not affect your ability to seek a face-to-face consultation with your physician, and the Plan will always respect the physician-patient relationship. We limit the number of Internet visits to 24 per year. Please note: To use this service, this must be your primary plan for payment of benefits, you must have an established relationship with the treating physician for your illness and your physician must be participating in the network at the time of the Internet visit. If you have any questions or would like to register for this service, call us at 1-800-410-7778, at any time, day or night. Note: Services provided under this benefit are not subject to the FEHB disputed claims process.

Dental benefits

00120

Periodic oral examination (limit one per year)

$ 7.50

All charges above Plan benefit.

00210

X-rays, intraoral, complete series including bitewings (limit one per year)

22.00

All charges above Plan benefit.

00220

X-rays, intraoral, periapical � first film

3.25

All charges above Plan benefit.

00230

X-rays, intraoral, periapical � each additional film

$ 2.25

All charges above Plan benefit.

00240

X-rays, intraoral, occlusal film

7.50

All charges above Plan benefit.

00270

X-rays, bitewing, single film

2.75

All charges above Plan benefit.

0290

X-rays, posterior-anterior or lateral skull and facial bone survey

13.00

All charges above Plan benefit.

0330

X-rays, panoramic film

22.00

All charges above Plan benefit.

01110

Prophylaxis, adult (age 13 and over)

$ 14.25

All charges above Plan benefit.

01120

Prophylaxis, child (through age 12)

12.00

All charges above Plan benefit.

01203

Fluoride application, topical, adult

7.50

All charges above Plan benefit.

01204

Fluoride application, topical, child

7.50

All charges above Plan benefit.

01351

Sealant, per tooth

7.50

All charges above Plan benefit.

01510

Space maintainer, fixed, unilateral (limited to age 18 and under)

34.00

All charges above Plan benefit.

02140

One surface, permanent

$ 13.00

All charges above Plan benefit.

02150

Two surfaces, permanent

20.75

All charges above Plan benefit.

02160

Three surfaces, permanent

27.50

All charges above Plan benefit.

02951

Reinforcement pins, each pin

8.25

All charges above Plan benefit.

03110

Pulp cap, direct

$ 16.50

All charges above Plan benefit.

03310

Root canal therapy, one canal

96.75

All charges above Plan benefit.

03320

Root canal therapy, two canals

136.25

All charges above Plan benefit.

03330

Root canal therapy, three canals

178.00

All charges above Plan benefit.

03410

Apicoectomy

55.00

All charges above Plan benefit.

04320

Provisional splinting

$ 81.25

All charges above Plan benefit.

04341

Periodontal scaling and root planning (per quadrant)

13.00

All charges above Plan benefit.

04910

Periodontal maintenance procedures

13.00

All charges above Plan benefit.

02510

Inlay, metallic, one surface

$ 68.00

All charges above Plan benefit.

02710

Crown, resin (laboratory)

108.75

All charges above Plan benefit.

02720

Crown, resin with high noble metal

178.00

All charges above Plan benefit.

02740

Crown, porcelain with ceramic substrate

136.25

All charges above Plan benefit.

02750

Crown, porcelain fused to high noble metal

178.00

All charges above Plan benefit.

02752

Crown, porcelain fused to noble metal

178.00

All charges above Plan benefit.

02790

Crown, full cast, high noble metal

149.50

All charges above Plan benefit.

02950

Core Buildup, including any pins

27.50

All charges above Plan benefit.

02920

Recement crown

27.50

All charges above Plan benefit.

02952

Cast post and core, in addition to crown

68.00

All charges above Plan benefit.

02954

Prefabricated post and core, in addition to crown

34.00

All charges above Plan benefit.

02980

Crown repair

13.00

All charges above Plan benefit.

Pontics (includes local anesthesia)

06210

Cast high noble metal

$ 82.50

All charges above Plan benefit.

06240

Porcelain fused to high noble metal

136.25

All charges above Plan benefit.

05110

Complete denture, maxillary (including necessary adjustments within 6 months)

$ 239.75

All charges above Plan benefit.

05120

Complete denture, mandibular (including necessary adjustments within 6 months)

239.75

All charges above Plan benefit.

05130

Immediate denture, maxillary

272.50

All charges above Plan benefit.

05140

Immediate denture, mandibular

272.50

All charges above Plan benefit.

05211

Partial denture, maxillary, resin base

217.75

All charges above Plan benefit.

05510

Repair, complete denture, base

20.75

All charges above Plan benefit.

05520

Repair, complete denture, repair or replace teeth (each tooth)

9.75

All charges above Plan benefit.

05630

Repair, partial denture, repair or replace clasp

40.50

All charges above Plan benefit.

05640

Repair, partial denture, repair or replace teeth (each tooth)

13.00

All charges above Plan benefit.

05650

Add tooth, partial denture

34.00

All charges above Plan benefit.

05660

Add clasp, partial denture

40.50

All charges above Plan benefit.

05710

Rebase, complete denture, maxillary

68.00

All charges above Plan benefit.

04210

Gingivectomy or gingivoplasty (per quadrant)

$ 102.50

All charges above Plan benefit.

04260

Osseous surgery, including flap entry and closure (per quadrant)

137.50

All charges above Plan benefit.

07140

Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

15.00

All charges above Plan benefit.

07210

Surgical extraction of erupted tooth

23.00

All charges above Plan benefit.

07285

Biopsy of oral hard tissue

34.00

All charges above Plan benefit.

07310

Alveoloplasty in conjunction with extraction (per quadrant)

44.00

All charges above Plan benefit.

07450

Removal of odontogenic cyst or tumor/lesion, up to 1.25 cm

66.00

All charges above Plan benefit.

07510

Incision and drainage of abscess, intraoral soft tissue

13.00

All charges above Plan benefit.

07960

Frenulectomy (frenectomy or frenotomy), separate procedure

61.50

All charges above Plan benefit.

09110

Palliative treatment of dental pain, minor procedure

$ 7.50

All charges above Plan benefit.

09220

General anesthesia � first 30 minutes

8.75

All charges above Plan benefit.

09221

General anesthesia � each additional 15 minutes

4.38

All charges above Plan benefit.

09310

Consultation by other than attending dentist

20.75

All charges above Plan benefit.

I

M

P

O

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T

A

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T

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

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

For all other covered expenses, please see Sections 6(c-h) � Traditional health coverage.

The Consumer Option calendar year deductible does not apply to PPO preventive care 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.

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 11 about coordinating benefits with other coverage, including with Medicare.

I

M

P

O

R

T

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N

T

One annual routine office visit and examination for members age 18 and older

Nothing

Routine screenings, limited to:

Mammogram for women age 35 and older:

From age 35 to 39 � one during this five year period

From age 40 to 64 � one every calendar year

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

Pap smear � one per calendar year for women age 18 and older

Note: the office visit is covered if pap test is received on the same day.

Prostate Specific Antigen (PSA) test � one per calendar year for men age 40 and older

Colorectal cancer screenings:

Fecal occult blood (stool) test - one per calendar year for members age 40 and older

Screening sigmoidoscopy � one every two consecutive calendar years for members age 50 and older

Colonoscopy � one every 10 years for members age 50 and older

Nothing

Routine screenings (continued)

Blood Cholesterol � one per calendar year for all members

Urinalysis � one per calendar year for all members

Chlamydial infection screening

Osteoporosis screening (bone density study) one every two consecutive calendar years for members age 65 and older

Smoking cessation treatment -- up to $100 for one smoking cessation program per member per lifetime.

Note: All benefits are paid directly to you. Smoking deterrents are covered under the Prescription drug benefit. See Section 6(h).

Routine immunizations provided during an office visit

Nothing

Not covered:

Routine physical checkups and related tests except those listed above

All charges

Preventive care, children

Routine childhood immunizations recommended by the American Academy of Pediatrics for members under age 22

Nothing

Well-child office visits to a doctor for covered dependents up to age 18

Nothing

Routine screenings, limited to:

Blood cholesterol � one per calendar year for all members

Urinalysis � one per calendar year for all members

Nothing

Not covered:

Routine testing not specifically listed as covered

All charges

Administrator

The Plan will establish an HSA for you with JPMorgan Chase Bank, this HDHP�s fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS).

JPMorgan Chase Bank

270 Park Avenue

New York, NY 10017-2070

212-270-6000

MHBP is the administrator for your HRA:

Mail Handlers Benefit Plan

PO Box 24503

Tucson, AZ 85734

1-800-694 9901

Fees

Set-up fee is paid by the MHBP

None

Eligibility

To have an HSA:

You must be enrolled in the MHBP Consumer Option;

You must not have other health insurance coverage (except for certain �permitted� insurance plans, such as dental or vision care plans or another high-deductible health plan);

You must not be enrolled in Medicare Part A and/or Part B;

You may not be claimed as a dependent on someone else�s federal tax return;

You must complete and return all banking paperwork associated with the establishment of your account.

To have an HRA:

You must be enrolled in the MHBP Consumer Option;

When you enroll in the MHBP Consumer Option and do not qualify for an HSA, an HRA will be established for you

Tax advantages

Tax-free health plan deposits;

Tax-deductible enrollee deposits;

Tax-free distributions for qualified medical expense;

Tax-free interest earned on the account.

Tax-free health plan deposits;

Tax-free distributions for qualified medical expense.

Funding

A portion of your monthly health plan premium is deposited to your HSA each month. Contributions are based on the effective date of your enrollment in the HDHP.

For 2005, monthly contributions are:

$83.33 for a Self Only enrollment

$166.66 for a Self and Family enrollment

Eligibility for contributions will be determined on the first day of the month and will be prorated for length of enrollment.

The entire amount of your HRA will be available to you upon your enrollment.

For 2005, your HRA credit is:

$1,000 for a Self Only enrollment

$2,000 for a Self and Family enrollment

Eligibility for the annual credit will be determined on the first day of the month and will be prorated for length of enrollment.

Contributions/credits

The maximum that can be contributed to your HSA is an annual combination of HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the amount of the deductible.

For 2005, the maximum annual contributions are:

$2,250 for a Self Only enrollment

$4,500 for a Self and Family enrollment

The full HRA credit will be available on the effective date of your enrollment, subject to proration based on your length of enrollment.

The HRA does not earn interest.

Enrollee contributions to an HRA are not permitted.

Self-only

For each month you are eligible for HSA contributions, MHBP will make a premium pass through contribution of $83.33.

You may make a contribution of $104.17 for each month of eligibility, up to $1,250 for a full year. You can make your contributions at any time before April 15 after the plan year ends.

Enrollee contributions to an HRA are not permitted.

Self and Family

For each month you are eligible for HSA contributions, MHBP will make a premium pass through contribution of $166.66.

You may make a contribution of $208.33 for each month of eligibility, up to $2,500 for a full year. You can make your contributions at any time before April 15 after the plan year ends.

Enrollee contributions to an HRA are not permitted.

If you choose to contribute to your HSA

You must deduct 1/12 of total annual maximum contribution for every month you are not eligible for the HDHP the whole month. For instance, if your enrollment in this Plan was not effective on January 1, 2005, you cannot receive a credit for January and you would need to deduct 1/12 of the annual maximum contribution.

You may roll over funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

HSAs earn tax-free interest (does not affect your annual maximum contribution).

Enrollee contributions to an HRA are not permitted.

Accessing your funds

Debit card issued by JPMorgan Chase Bank

Manual HSA distribution form

For qualified medical expenses under your HDHP, you or your provider will be automatically reimbursed when claims are submitted to the MHBP Consumer Option. For expenses not covered by the HDHP, such as orthodontia, you can request a reimbursement form by phone or obtain one on-line at www.mhbp.com.

Distributions/withdrawals

Medical Expenses

You can use the available funds in your HSA to pay the out-of-pocket medical expenses for yourself, your spouse or your dependents even if they are not covered by the HDHP.

Medical expenses are not allowable if they occur before the first full month your enrollment is effective, and they are not reimbursable from your HSA until the first of the month following the effective date of your enrollment in this HDHP and the date your HSA account is established.

For most Federal enrollees (those not paid on a monthly basis), the earliest date medical expenses will be allowable is February 1, 2005.

See IRS Publication 502 for a complete list of eligible expenses. (http://www.irs.gov/pub/irs-pdf/p502.pdf).

The available credit in your HRA will be used to pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.

See Availability of funds below for information on when funds are available in the HRA.

See IRS Publication 502 for a complete list of eligible expenses. (http://www.irs.gov/pub/irs-pdf/p502.pdf).

Non-medical expenses

Under age 65

If you are under age 65, withdrawal of funds for non-medical expenses will create a 10% income tax penalty in addition to any other income taxes you may owe on the accumulated funds.

Distributions will not be made for anything other than non-reimbursed qualified medical expenses

Age 65 or over

When you turn age 65, distributions can be used for any reason without being subject to the 10% penalty.

Distributions will not be made for anything other than non-reimbursed qualified medical expenses, except that Medicare premiums are reimbursable.

Availability of funds

Funds are not available until:

Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change).

MHBP receives record of your enrollment and initially establishes your HSA account with JPMorgan Chase Bank by providing information it must furnish and by contributing the minimum amount required to establish an HSA.

JPMorgan Chase Bank sends out HSA paperwork for the enrollee to complete, and receives the completed paperwork.

After JPMorgan Chase Bank receives the completed paperwork from the enrollee, the enrollee can withdraw funds for expenses incurred on or after the date the HSA was initially established.

The entire amount of your HRA will be available to you upon your enrollment in this Plan.

Portability

You own your HSA and can take it with you when you leave Federal employment or change health plans.

If you retire and remain in the MHBP Consumer Option, you may continue to use and accumulate credits in your HRA.

If you terminate Federal employment or change health plans, only eligible expenses incurred while covered under the MHBP Consumer Option will be eligible for reimbursement subject to timely filing requirements. Unused funds are forfeited.

Annual rollover

Yes, accumulates without a cap.

Yes, accumulates without a cap.

Is the �premium pass through� to my HSA considered taxable income?

�Premium pass-through� contributions by the MHBP are not considered taxable income.

Can I contribute to my HSA?

Yes. All contributions are aggregated and cannot exceed the annual maximum contribution. You may contribute your own money to your account through payroll deductions (if available), or you may make a lump sum contribution at any time, in any amount up to an annual maximum limit. Others can also make contributions to your HSA on your behalf. If you (or someone on your behalf) contribute a lump-sum, you can claim the total amount contributed for the year as a tax deduction when you file your income taxes. You receive tax advantages in any case. You have until April 15 of the following year to make HSA contributions for the current year.

IRS contribution rules reduce the total annual maximum contribution if you are not eligible for the HDHP during the whole month. For instance, if your enrollment in this Plan was not effective on January 1, 2005, you cannot receive a credit for January and you would need to deduct 1/12 of the annual maximum contribution.

Catch-up contributions

If you are age 55 or older, the IRS permits you to make additional catch-up contributions to your HSA. In 2005, you may contribute up to $600 in �catch-up� contributions. Catch-up contributions in later years increase up to a maximum of $1,000 in 2009 and beyond. Contributions must stop once an individual is enrolled for Medicare. Additional details are available on the IRS Web site at www.irs.gov.

Rate of interest earned

Depending on how you choose to invest your HSA savings, the interest rate and payment of interest will vary. Contact JPMorgan Chase Bank for more details on the investment options available to you.

What happens to my HSA if I leave my health plan or my job?

You own your account, so you keep your HSA even if you change health plans, leave Federal employment, enroll for Medicare, or any of the other events which may make you ineligible for further contributions to your HSA. Even when you are not eligible to make contributions to your HSA, you may request withdrawals.

What happens to my HSA if I die?

Your HSA would pass to your named beneficiary. If you do not have a named beneficiary, the money is disbursed to your estate and is taxable. Additional details are available on the IRS Web site at www.irs.gov.

To make the most of your Health Savings Account, you should:

Use generic prescriptions whenever possible.

Use the network providers whenever possible.

Use your debit card at network pharmacies. Do not use your debit card at the point of service when visiting a health care provider. Use your debit card only after network discounts are applied by MHBP and you receive an explanation of benefits (EOB) with your financial responsibility described.

What expenses can I pay for with my HSA?

You can pay for �qualified medical expenses,� as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, and health insurance premiums if you are receiving Federal unemployment compensation, over-the-counter drugs, LASIK surgery, and some nursing services.

When you become Medicare-enrolled, you can use the account to purchase any health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are Medicare-enrolled.

For the complete list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 1-800-829-3676, or visit the IRS Web site at www.irs.gov and click on �Forms and Publications.�

Non-qualified health care expenses

You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, an additional 10% penalty tax on the amount withdrawn.

Tracking your HSA balance

You will receive a periodic statement that shows contributions and withdrawals, and interest earned on your account. In addition, you will receive an Explanation of Payment statement when you withdraw money from your HSA.

Minimum reimbursements from your HSA

You can request reimbursement in any amount.

HRAs

How do I know if I qualify for an HRA?

If you don�t qualify for an HSA when you enroll, or later become ineligible for an HSA, the MHBP will establish an HRA for you.

HRA and HSA differences

Please review the chart at the beginning of this Section which details the differences. The major differences are:

You cannot make contributions to an HRA.

Funds are forfeited if you leave the HDHP.

An HRA does not earn interest, and

HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the HDHP.

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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

PPO preventive care listed in Section 6(a) is covered at 100% and does not count against your Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA).

The Consumer Option provides coverage for both PPO and non-PPO providers. The non-PPO benefits are the regular benefits under the Traditional Health Coverage. PPO benefits apply only when you use a provider participating in the First Health� Network. When a PPO provider is not available, non-PPO benefits apply.

When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists, may not all be PPO providers. If they are not, they will be paid by this Plan as non-PPO providers.

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 11 about coordinating benefits with other coverage, including with Medicare.

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

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