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.

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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 212/501-4GHI (4444). You may also request replacement cards through the GHI website, www.ghi.com

Where you get covered care

You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/or coinsurance, and you will not have to file claims. If you have the High Option Plan with our point-of-service program, you can also get care from non-Plan providers, but it will cost you more.

� Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

� Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website.

What you must do to get covered care

Within the Plan's network, you are encouraged to select a personal doctor who will provide or arrange your care, in which case you will pay minimal amounts for comprehensive benefits under the High Option Plan. When you choose a non-Plan doctor or other non-Plan provider, you will pay a substantial portion of the charges, and the benefits available may be less comprehensive.

� Primary care

You may seek care from a doctor, dentist, podiatrist, qualified clinical psychologist, optometrists, chiropractor, nurse, certified midwife, nurse practitioner/clinical specialist, or qualified clinical social worker and any other duly-licensed, registered or certified practitioner or privately-operated facility permitted to perform or render care or service described in this brochure.

� Specialty care

You may see the specialist whenever you and your family feel you need care. Here are other things you should know about specialty care:

� If you have a chronic or disabling condition and lose access to your specialist because we:

- ­Terminate our contract with your specialist for other than cause; or

- ­ Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

- ­ Reduce our service area and you enroll in another FEHB Plan.

You may be able to continue seeing your specialist 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 until the end of your postpartum care, even if it is beyond the 90 days

� Hospital care

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our Customer Service Department immediately at 212/501-4GHI (4444). If you are new to the FEHB Program, we will arrange for you to receive care.

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

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

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

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

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program 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.

Circumstances beyond our control

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to assist you with the necessary care.

Services Requiring our
prior approval

For certain services, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, is medically necessary, and follows generally-accepted medical practice.

Your physician must obtain prior approval for the following services:

� High-tech radiology

� High-tech nursing

� Infusion therapy

� Mental Health and Substance Abuse

� Infertility Services

If no one contacted us, we will not pay for those services.

For certain services, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, is medically necessary, and follows generally accepted medical practice.

Your physician must obtain precertification for the following services:

� All inpatient hospital admission for maternity care and skilled nursing facilities

� Non-emergency hospital admissions

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 for the covered inpatient hospital benefits less the $125 per day penalty, up to a maximum of $250 per admission

� If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits.

You do not need precertification in these cases

� 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 exhauset 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.

Copayments

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

Example: When you see a participating provider you pay a copayment of $15 per office visit under the High Option and a $25 per office visit under the Standard Option and when you go in the hospital, you pay nothing.

Deductible

A deductible is a fixed expense you must pay for certain covered services and supplies before we start paying benefits for them. Copayments do not count towards any deductible.

The calendar year deductible for certain services is:

� For nursing service, you pay an annual deductible of $150 per individual or family.

� For appliances, oxygen or equipment, you pay an annual deductible of $100 per individual or family.

� For referred ambulatory, laboratory tests and diagnostic x-rays, which is only available under the High Option Plan, you pay a $25 deductible per referral.

� The Standard Option coverage has a $50 prescription drug deductible that you must meet each calendar year and a $250 per day maximum $750 per admission hospital deductible. The hospital deductible is waived for maternity care.

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

And, if you change 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.

Coinsurance

Any amount in excess of 50% of the High Option Plan's fee schedule for POS services provided by non-participating providers.

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

Under the High Option Plan, after your out-of-pocket expenses total $10,000 per person in any calendar year for covered services provided by a non-participating provider, GHI will then pay catastrophic benefits at 100% of reasonable and customary charges as determined by the Plan. Out-of-pocket expenses are calculated based upon the reasonable and customary charge for covered catastrophic services.

Covered catastrophic services include: 1) surgery, 2) administration of anesthesia, 3) chemotherapy and radiation therapy, 4) covered in-hospital service and diagnostic services, and 5) maternity. However, expenses for the following services do not count toward your catastrophic protection out-of-pocket maximum:

� Home and office visits and related diagnostic services

� Nursing, Appliances, Oxygen and Equipment

� Dental services

� Vision services

� Prescription drugs

� Diagnostic and treatment services

� Lab, X-ray, and other diagnostic tests

� Preventive care, adult

� Preventive care, children

� Maternity care

� Family planning

� Infertility services

� Allergy care

� Treatment therapies

� Physical and occupational therapies

� Speech therapy

� Hearing services (testing, treatment, and supplies)

� Vision services (testing, treatment, and supplies)

� Foot care

� Orthopedic and prosthetic devices

� Durable medical equipment (DME)

� Home health services

� Chiropractic

� Alternative treatments

� Educational classes and programs

� Surgical procedures

� Reconstructive surgery

� Oral and maxillofacial surgery

� Organ/tissue transplants

� Anesthesia

� Inpatient hospital

� Outpatient hospital or ambulatory surgical center

� Extended care benefits/skilled nursing care facility benefits

� Hospice care

� Ambulance

� Flexible benefit options

� Large Case Management

� Customer Service AnswerLine

� Services for deaf and hearing impaired

� High risk pregnancies

� Centers of excellence for transplants/heart surgery/etc.

� Travel benefit/services overseas

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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.

� Plan providers under the High Option benefit package non-Plan providers can provide or arrange your care. Limit out-of-pocket costs by using participating providers.

� The calendar year deductible for certain services is:

� For nursing services, you pay an annual deductible of $150 per individual or family.

� For appliances, oxygen or equipment, you pay an annual deductible of $100 per     individual or family.

� For referred ambulatory laboratory test and diagnostic x-rays, which are available only under the High Option Plan, you pay a $25 deductible per referral.

We added asterisks - * - to show when the calendar year deductible does not apply.

� Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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Professional services of physicians

� In physician's office

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers. Waived for Pediatric visits

All charges for non-participating providers.

Professional services of physicians

� In an urgent care center

� Office medical consultations

� Second surgical opinion

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

Waived for pediatric visits

All charges for non-participating providers.

� During a hospital stay

� In a skilled nursing facility

� Initial examination of a newborn child covered under a family enrollment

Nothing for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

Nothing for participating providers.

All charges for non-participating providers.

At home

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

All charges for non-participating providers.

Tests, such as:

� Blood tests

� Urinalysis

� Non-routine Pap tests

� Pathology

� X-rays

� Non-routine Mammograms

� CAT Scans/MRI

� Ultrasound

� Electrocardiogram and EEG

$15 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service.

POS: For non-participating providers, you pay any difference between our fee schedule and the billed amount.

$25 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service.

All charges for non-participating providers.

Routine screenings, such as:

� Total Blood Cholesterol - once every three years

� Colorectal Cancer Screening, including

- Fecal occult blood test

� Osteoporosis screening

$15 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service

POS: For non-participating providers, you pay any difference between our fee schedule and the billed amount

$25 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service

All charges for non-participating providers.

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

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

All charges for non-participating providers.

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

$15 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service

POS: For non-participating providers, you pay any difference between our fee schedule and the billed amount

$25 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service

All charges for non-participating providers.

Routine Pap test

$15 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service

POS: For non-participating providers, you pay any difference between our fee schedule and the billed amount.

$25 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service

All charges for non-participating providers.

Routine mammogram -covered for women age 35 and older, as follows:

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

� From age 40 through 64, one every calendar year

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

$15 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service

POS: For non-participating providers, you pay any difference between our fee schedule and the billed amount.

$25 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service

All charges for non-participating providers.

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.

All charges

All charges

Routine immunizations, limited to:

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

� Influenza vaccine annually

� Pneumococcal vaccine, age 65 and over

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

All charges for non-participating providers.

� Childhood immunizations recommended by the American Academy of Pediatrics

Nothing for participating providers.

POS: 50% of the Plan's fee schedule for non participating providers, and any difference between our fee schedule and the billed amount

Nothing for participating providers.

All charges for non-participating providers.

� Well-child care charges for routine examinations, immunizations and care (up to age 22)

Nothing for participating providers.

50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

Nothing for participating providers.

All charges for non-participating providers.

� Examinations, such as:

- Eye exams to determine the need for vision correction

- Ear exams to determine the need for hearing correction

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

All charges for non-participating providers.

� Examinations done on the day of immunizations (up to age 22)

Nothing for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

Nothing for participating providers.

All charges for non-participating providers.

Complete maternity (obstetrical) care, such as:

� Prenatal care

� Delivery

� Postnatal care

Note: Here are some things to keep in mind:

� You must precertify your normal delivery. Maternity admissions should be precertified no later than the second trimester.

� You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.

� 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 only if we cover the infant under a Self and Family enrollment. Surgical Benefits, not maternity benefits, apply to circumcision if this is the case.

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

A single $15 copay for all pre- and post-natal care from a participating provider.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

A single $25 copay for all pre- and post-natal care from a participating provider.

All charges for non-participating providers.

Not covered: Routine sonograms to determine fetal age, size or sex.

All charges

All charges

A range of voluntary family planning services, limited to:

Voluntary sterilization (See Surgical procedures Section 5b)

� Surgically implanted contraceptives (such as Norplant)

� Injectable contraceptive drugs (such as Depo provera)

� Intrauterine devices (IUDs)

� Diaphragms

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

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

All charges for non-participating providers.

Not covered: reversal of voluntary surgical sterilization, genetic counseling.

All charges

All charges

Diagnosis and treatment of infertility, such as:

� In vitro fertilization (limited to three transfers per lifetime)

� Embryo transfer

� Artificial insemination

- Intravaginal insemination (IVI)

- Intracervical insemination (ICI)

- Intrauterinal insemination (IUI)

� Fertility drugs

Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

All charges for non-participating providers.

Not covered: Cost of donor sperm

All charges

All charges

Testing and treatment

Allergy injections

Treatment materials (such as allergy serum)

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

All charges for non-participating providers.

Not covered: Provocative food testing and sublingual allergy desensitization

All charges

All charges

� Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 35.

� Respiratory and inhalation therapy

� Dialysis - hemodialysis and peritoneal dialysis

In a doctor's office, nothing for a participating provider.

POS: In a doctors office, 50% of the Plan's fee schedule, for non-participating providers, and any difference between our fee schedule and the billed amount.

In a doctor's office, nothing for a participating provider.

All charges for non-participating providers.

� High-tech nursing and infusion therapy

- IV infusion therapy

- Parenteral and enteral therapy

- Other home IV therapies

Note: Contact us at (212) 615-4662 prior to receiving services to ensure coverage.

� Intermittent home nursing service

- Provided by a Registered Nurse or Licensed Practitioner

- Authorized and supervised by a doctor

- Intermittent visits less than 2 hours per day

Nothing for a participating provider.

POS: All charges for non-participating providers.

Nothing for a participating provider.

All charges for non-participating providers.

� Growth hormone therapy (GHT). This benefit is provided under our Prescription Drug Benefits. You must fill the prescription at a pharmacy that participates under the program Express Scripts PERxCare Retail Pharmacy Program.

Generic drug: $10 copay per prescription or refill

Name brand drug, listed on formulary: $20 copay per prescription or refill

Name brand drug not on formulary:
$50 copay per prescription or refill

After a $50 annual deductible per person

Generic drug: $10 copay per prescription or refill

Name brand drug, listed on formulary: $25 copay per prescription or refill

Name brand drug not on formulary:
$50 copay per prescription or refill

Not covered:

� Treatment for experimental or investigational procedures.

� Therapy necessary for transsexual surgery.

All charges

All charges

� 60 visits per condition for the services of each of the following:

- qualified physical therapist;

- occupational therapist.

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury. Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other daily living activities.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction.

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

All charges for non-participating providers.

Not covered:

� long-term rehabilitative therapy

� exercise programs

All charges

All charges

� 60 visits per condition

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

All charges for non-participating providers.

� Hearing testing

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

All charges for non-participating providers.

Not covered: hearing aids, testing and examinations for them

All charges

All charges

� Medical and surgical benefits for diagnosis and treatment of diseases of the eye.

$15 per visit for participating provider.

For non-participating providers, you pay 50% of the Plan's fee schedule and any difference between our fee schedule and the billed amount.

$25 per visit for participating provider.

All charges for non-participating providers.

� Examination of the eyes to determine if glasses are required: once each calendar year.

�One set of single vision or bifocal lenses (toric kryptok or flat top 22mm): once each calendar year.

�One pair of basic frames from available styles: one every two years.

�Contact lenses for certain unusual medical conditions (such as post cataract surgery or keratoconus treatment).

� Replacement of broken lenses with lenses of the same prescription and material originally supplied.

Nothing for services provided by participating opticians, optometrists and vision centers.

POS: For non-participating providers, you pay any difference between our fee schedule and the billed amount.

Nothing for services provided by participating opticians, optometrists and vision centers.

All charges for non-participating providers.

Not covered:

� Frames at any time unless lenses are also provided.

� Replacement or repair of frames.

� Certain bifocals and trifocals, tinted, plastic and oversized lenses and sunglasses and frames other than basic frames; contact lenses for cosmetic purposes.

� Charges in excess of the maximum GHI allowance.

All charges

All charges

Podiatric services, including the routine treatment of corns, calluses, and bunions, and the partial removal of toenails, are limited to 4 visits per calendar year.

$15 per visit for participating provider.

For non-participating providers, you pay 50% of the Plan's fee schedule and any difference between our fee schedule and the billed amount.

$25 per visit for participating provider.

All charges for non-participating providers.

Not covered:

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

� Orthotics devices for the feet.

All charges

All charges

� Artificial limbs and eyes; stump hose.

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

� Orthopedic devices, such as braces.

� Ostomy supplies.

� Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy.

20% of the Plan's fee schedule for a participating provider.

POS: 50% of the Plan's fee schedule and any difference between our allowance and the billed amount for a non-participating provider.

Note: $100 deductible applies per individual or family. There is a combined maximum of $25,000 per year per person with these benefits and private duty nursing.

20% of the Plan's fee schedule for a participating provider.

All charges for non-participating providers.

Note: $100 deductible applies per individual or family. There is a combined maximum of $25,000 per year per person with these benefits and private duty nursing.

Not covered:

� orthopedic and corrective shoes

� arch supports

� foot orthotics

� heel pads and heel cups

� lumbosacral supports

� corsets, trusses, elastic stockings, support hose, and other supportive devices

� corrective appliances for treatment of tempormandibular joint (TMJ) pain dysfunction syndrome.

All charges

All charges

Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover:

� hospital beds;

� wheelchairs;

� crutches;

� walkers;

� blood glucose monitors; and

� insulin pumps.

Note: Call us at (212) 615-4662 as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

20% of the Plan's fee scheduled for a participating provider.

POS: 50% of the Plan's fee schedule and any difference between our allowance and the billed amount for a non-participating provider.

Note: $100 deductible applies per individual or family. There is a combined maximum of $25,000 per year per person with these benefits and private duty nursing.

20% of the Plan's fee scheduled for a participating provider.

All charges for non-participating providers.

Note: $100 deductible applies per individual or family. There is a combined maximum of $25,000 per year per person with these benefits and private duty nursing.

Not covered

� Hearing aids and air purification devices

� Alarm and Alert Services

All charges

All charges

The following conditions must be met:

� Home health care must be provided and billed by a certified home health agency, which has an agreement with GHI to provide home health care services.

� You must remain under the care of a medical doctor.

� The services are provided according to a plan of treatment approved by the attending medical doctor.

� Medical evidence substantiates that you would have required further inpatient care had the home health care not been available.

� Part-time or intermittent nursing care by a registered professional nurse (R.N.) or a home health aide under the supervision of a registered professional nurse.

� Physical therapy.

� Respiration or inhalation therapy.

� Prescription drugs.

� Medical supplies which serve a specific therapeutic or diagnostic purpose.

� Other medically necessary services or supplies that would have been provided by a hospital if the subscriber were still hospitalized.

Nothing for a participating provider.

POS: All charges for a non-participating provider.

Nothing for a participating provider.

All charges for a non-participating provider.

� Private Duty Nursing services rendered at home or in the hospital by a registered nurse (R.N.) or when an R.N. is not available by a licensed practical nurse (L.P.N).

Nothing for a participating provider.

POS: 50% of the Plan's fee schedule and any difference between our allowance and the billed amount for a non-participating provider.

Note: $150 annual deductible applies per person or family. There is a combined maximum of $25,000 per calendar year per person with these benefits and Durable Medical Equipment.

Nothing for a participating provider.

All charges for non-participating providers.

Note: $150 annual deductible applies per person or family. There is a combined maximum of $25,000 per calendar year per person with these benefits and Durable Medical Equipment.

Not covered:

� Homemaking services, including housekeeping, preparing meals, or acting as a companion or sitter.

� Services and supplies related to normal maternity care.

� Services and supplies provided following a noncovered hospital admission or admission to a facility that is not a participating facility.

� Services and supplies provided when the subscriber would not have required continued inpatient care.

� Services and supplies provided by a non-participating facility for home health care.

� High-tech nursing and infusion therapy.

All charges

All charges

� Manipulation of the spine and extremities

� Adjustment procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application.

$15 per visit for participating providers.

POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.

$25 per visit for participating providers.

All charges for non-participating providers.

Not covered:

� naturopathic services

� hypnotherapy

� biofeedback

All charges

All charges

� Acupuncture - After 5 visits a treatment plan must be approved by

GHI in order for additional visits to be covered

All charges

$20 per visit for participating providers.

All charges for non-participating providers.

Coverage is limited to:

� Diabetes self-management

� Cholesterol Management

� Arthritis

� Asthma

� Hepatitis C

� Multiple Sclerosis

� Depression

� Osteoporosis

Nothing

For diabetes self management call Diabetes Health Solutions at (800) 881-4008

For arthritis and osteoporosis information call Arthritis Foundation NYC Chapter at (212) 984-8713

To enroll in our Asthma Cholesterol Management, Hepatitis C Multiple Sclerosis & Depression program call GHI Disease Management Line (212) 615-0363

Nothing

For diabetes self management call Diabetes Health Solutions at (800) 881-4008

For arthritis and osteoporosis information call Arthritis Foundation NYC Chapter at (212) 984-8713

To enroll in our Asthma program call (212) 615-0363

� Smoking Cessation

All charges in excess of $100

All charges in excess of $100

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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.

� Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 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 at Section 5 (c) for charges associated with facility (i.e., hospital, surgical center, etc.).

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

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A comprehensive range of services, such as:

� Operative procedures

� Treatment of fractures, including casting

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

� Correction of amblyopia and strabismus

� Endoscopy procedures

� Biopsy procedures

� Removal of tumors and cysts

� Correction of congenital anomalies (see reconstructive surgery)

� Surgical treatment of morbid obesity - a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over

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

$15 per office procedure for a participating provider.

Nothing for a participating provider in a hospital or a participating ambulatory surgery center.

POS: 50% of the Plan's fee schedule and any difference between our fee schedule and the billed amount for non-participating providers.

$25 per office procedure for a participating provider.

Nothing for a participating provider in a hospital or a participating ambulatory surgery center.

All charges for non-participating providers.

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

� Treatment of burns

$15 per office procedure for participating providers.

Nothing for a participating provider in the hospital or a participating ambulatory surgery center.

POS: 50% of the Plan's fee schedule and any difference between our fee schedule and the billed amount for non-participating providers.

$25 per office procedure for participating providers.

Nothing for a participating provider in the hospital or a participating ambulatory surgery center.

All charges for non-participating providers.

Not covered:

� Reversal of voluntary sterilization.

� Stand-by services.

All charges

All charges

� Surgery to correct a functional defect

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

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

- the condition can reasonably be expected to be corrected by such surgery.

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

$15 per office procedure for participating providers.

Nothing for a participating provider in the hospital or a participating ambulatory surgery center.

POS: 50% of the Plan's fee schedule and any difference between our fee schedule and the billed amount for non-participating providers.

$25 per office procedure for participating providers.

Nothing for a participating provider in the hospital or a participating ambulatory surgery center.

All charges for non-participating providers.

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

- surgery to produce a symmetrical appearance on the other breast

- treatment of any physical complications, such as lymphedemas

- breast prostheses and surgical bras and replacements (see Prosthetic devices).

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

$15 per office procedure for participating providers.

Nothing for a participating provider
in the hospital or a participating ambulatory surgery center.

POS: 50% of the Plan's fee schedule and any difference between our fee schedule and the billed amount for non-participating providers.

$25 per office procedure for participating providers.

Nothing for a participating provider
in the hospital or a participating ambulatory surgery center.

All charges for non-participating providers.

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

� Surgeries related to sex transformation

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 stones from salivary ducts

� Excision of leukoplakia or malignancies

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

� Removal of impacted teeth

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

$15 per office procedure for participating providers.

Nothing for a participating provider in the hospital or a participating ambulatory
surgery center.

POS: 50% of the Plan's fee schedule and any difference between our fee schedule and the billed amount for non-participating providers..

$25 per office procedure for participating providers.

Nothing for a participating provider in the hospital or a participating ambulatory
surgery center.

All charges for non-participating providers.

Not covered:

� Oral implants and transplants

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

� All other procedures involving the teeth or intra-oral areas surrounding the teeth are not covered, including any dental care involved in the treatment of teporomandibular joint (TMJ) pain dysfunction syndrome.

All charges

All charges

Limited to:

� Cornea

� Human Heart

� Heart/lung

� Kidney

� Kidney/Pancreas

� Liver

� Lung: Single -Double

� Pancreas

� Allogeneic (donor) bone marrow transplants

� Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

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

�National Transplant Program (NTP) - We will cover transplants approved as safe and effective for a specific disease by the Federal Drug Administration (FDA) or National Institute of Health, or which our Medical Director determines is medically necessary, appropriate and advisable on a case-by-case basis. We will cover the medical and hospital services, and related organ acquisition costs. Eligibility for transplants will be determined and approved in advance solely by our Medical Director upon recommendation of your PCP. Additionally, all transplants must be performed at hospitals specifically approved and designated by us to perform these procedures. Specialty physician experts from our designated centers of excellence will provide clinical review and support to the Medical Director's decision.

Limited Benefits - Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI- or NIH-approved clinical trial at a Plan-designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols.

$15 per office procedure for participating providers.

Nothing for a participating provider
in the hospital or a participating ambulatory surgery center.

POS: 50% of the Plan's fee schedule and any difference between our fee schedule and the billed amount for non-participating providers.

$25 per office procedure for participating providers.

Nothing for a participating provider
in the hospital or a participating ambulatory surgery center.

All charges for non-participating providers.

We cover:

�We cover related medical and hospital expenses of the donor when we cover the recipient up to a maximum of $10,000 per transplant.

�Travel expenses up to a maximum of $150 per person per day and $10,000 per lifetime of the recipient if the recipient patient lives more than 75 miles from the transplant center. This includes food and lodging for the recipient patient and one adult family member (two, if the recipient is a minor) to the city where the transplant takes place.

Note: The benefit period begins five (5) days prior to surgery and extends for a period of up to one year from the date of surgery. There is a separate lifetime maximum benefit up to $1,000,000 per recipient for each type of covered transplant.

See previous page.

See previous page.

Not covered:

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

� Implants of artificial organs

� Transplants not listed as covered

All charges

All charges

Professional services provided in -

� Hospital (inpatient)

Nothing for a participating provider in the hospital or a participating ambulatory surgery center.

POS: Any difference between our fee schedule and the billed amount for non-participating providers.

Nothing for a participating provider in the hospital or a participating ambulatory surgery center.

All charges for non-participating providers.

Professional services provided in -

� Hospital outpatient department

� Skilled nursing facility

� Hospital ambulatory surgical center

� Office

Nothing for a participating provider
in the hospital or a participating ambulatory surgery center.

POS: Any difference between our fee schedule and the billed amount for non-participating providers.

Nothing for a participating provider
in the hospital or a participating ambulatory surgery center.

All charges for non-participating providers.

Not covered:

� Services administered by the same practitioner performing surgery

All charges

All charges

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Here are some important things to remember 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.

� Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

� The amounts listed below are for the facility 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 addressed in Section 5(a) or (b).

� YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

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Room and board, such as

� ward, semiprivate, or intensive care accommodations

� general nursing care; and

� meals and special diets.

NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate. (Hospital deductible is waived for maternity care.)

$100 per impatient admission up to a maximum of $200 per year

$250 per day per impatient admission up to a maximum of $750 per inpatient admission.

Other hospital services and supplies, such as:

� Operating, recovery, maternity, and other treatment rooms

� Prescribed drugs and medicines

� Diagnostic laboratory tests and X-rays

� Administration of blood and blood products

� Blood or blood plasma, if not donated or replaced

� Dressings, splints, casts, and sterile tray services

� Medical supplies and equipment, including oxygen

� Anesthetics, including nurse anesthetist services

� Take-home items

� Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies.)

Nothing (included in the $100.00 per inpatient admission for a Plan facility

Nothing (included in $250 per day per impatient admission to a maximum of $750 per inpatient admission)

Not covered:

� Custodial care, rest cures, domiciliary or convalescent care

� Non-covered facilities, such as nursing homes and schools

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

� Private nursing care

� Long term rehabilitation

All charges

All charges

� Operating, recovery, and other treatment rooms

� Prescribed drugs and medicines

� Administration of blood, blood plasma, and other biologicals

� Pre-surgical testing

� Dressings, casts, and sterile tray services

� Medical supplies, including oxygen

� Anesthetics and anesthesia service

Nothing for a Plan facility.

Nothing for a Plan facility.

� Diagnostic laboratory tests, X-rays, and pathology services

$25 copayment

All Charges

� Chemotherapy and radiation

Nothing for chemotherapy and radiation provided in a participating facility.

POS: 50% of the Plan's fee schedule and any difference between our fee schedule and the billed amount for non-participating providers.

Nothing for chemotherapy and radiation provided in a participating facility.

All charges for non-participating providers.

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures. Conditions for which hospitalization would be covered include hemophilia, impacted teeth, and heart disease; the need for anesthesia, by itself, is not such a condition.

Not covered: blood and blood derivatives not replaced by the member

All charges

All charges

Skilled nursing facility (SNF):

Limited to 30 days:

� Bed, board and general nursing care

� Drugs, biologicals, supplied and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by your doctor as governed by Medicare guidelines.

Nothing for a participating provider.

POS: All charges for a non-participating provider.

Nothing for a participating provider.

All charges for a non-participating provider.

Not covered:

� custodial care

All charges

All charges

Supportive and palliative care for a terminally ill member in the home or hospice facility. Services include:

� inpatient/outpatient care; and

� family counseling under the direction of a doctor.

Note: Your provider must certify that you are in the terminal stages of illness, with a life expectancy of approximately six months or less. The hospice must have an agreement with us or recognized by Medicare as a hospice.

Nothing

Nothing

Not covered: Independent nursing, homemaker services

All charges

All charges

� Ambulance services for each trip to or from a hospital for medically necessary services. This includes the use of an ambulance for emergency outpatient care and maternity care, to the nearest facility.

All charges in excess of $100.

All charges in excess of $100.

Not covered:

� Air ambulance

� Ambullette services

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.

� Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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What is a medical emergency?

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

What to do in case of emergency:

If you are in an emergency situation, please call your doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 telephone system) or go to the nearest hospital emergency room. It is your responsibility to ensure that the Plan has been promptly notified.

Emergencies within the service area:Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

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

Note: If you were admitted to the hospital from the Emergency Room the applicable copay is waived.
A participating GHI provider must provide your follow-up care. We cover care provided by a non-participating provider at 100% of the Plan's fee schedule.

� Emergency medical/surgical care at a doctor's office

� Emergency medical/surgical care at an urgent care center

� Emergency care as an outpatient or inpatient at a hospital, including doctors' services

Note: Copay waived if admitted to the hospital. If private physicians who are not hospital employees provide the emergency care, you may receive a separate bill for these services, which we will process as a medical benefit.

$15 per office visit for a participating provider.

POS: Any difference between our fee schedule and the billed amount for a non-participat-ing provider.

$50 copay and any charges that exceed the emergency fee schedule.

$25 per office visit for a participating provider.

Any difference between our fee schedule and the billed amount for a non-participat-ing provider.

$75 copay and any charges that exceed the emergency fee schedule.

Not covered: Elective care or non-emergency care

All charges

All charges

� Emergency medical/surgical care at a doctors' office

� Emergency medical/surgical care at an urgent care center

$15 per visit for a participating provider.

POS: Any difference between our fee schedule and the billed amount for a non-participating provider.

$25 per visit for a participating provider.

Any difference between our fee schedule and the billed amount for a non-participating provider.

� Emergency care as an outpatient or inpatient at a hospital, including doctors' services

Note: Copay waived if admitted to the hospital. If private physicians who are not hospital employees provide the emergency care, you may receive a separate bill for these services, which we will process as a medical benefit.

POS: Any difference between our fee schedule and the billed amount for a non-participating provider.

Note: For emergency services billed for by a doctor, you pay any difference between our fee schedule and the billed amount.

Any difference between our fee schedule and the billed amount for a non-participating provider.

Note: For emergency services billed for by a doctor, you pay any difference between our fee schedule and the billed amount.

Not covered:

� Elective care or non-emergency care

All charges

All charges

Professional ambulance service to or from a hospital for medically necessary services. This includes the use of an ambulance for emergency outpatient care and maternity care, to the nearest facility.

See 5(c) for non-emergency service.

All charges in excess of $100.

All charges in excess of $100.

Not covered: air ambulance and ambullette services

All charges

All charges

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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions.

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

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

� Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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

� Participating providers must provide all care.

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

Note: Plan 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.

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

� Medication management

$15 per visit for outpatient mental health care.

$25 per visit for outpatient mental health care.

� Diagnostic tests

Nothing

Nothing

� Services provided by a Plan hospital or other Plan facility

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

Nothing

Nothing

Not covered:

� Services we have not approved.

� Facility charges of a non-participating general hospital or facility.

� Treatment by a non-participating provider.

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

All charges

All charges

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all of our network authorization processes on pages 10 and 38. Contact us at 1-(800) 692-7311

Limitation There are no benefits if you do not obtain a treatment plan.

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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 the next page.

� 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 9 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 licensed doctor must write the prescription.

� Where you can obtain them. You may fill the prescription at a pharmacy that participates under the program through Express Scripts PERxCare Retail Pharmacy Program. You must fill the prescription at a Plan pharmacy, or by mail for a maintenance medication.

� We use a formulary. The formulary is a list of preferred, clinically effective prescription drugs that are also cost-effective. Express Scripts acts on behalf of GHI to provide affordable access to clinically sound, high quality pharmacy benefits for you. The formulary is developed using an evaluation process. The process begins with an assessment of the drug's clinical effectiveness by an independent panel of physicians and pharmacists, also known as the Pharmacy and Therapeutics Committee. If the panel determines that the drug is clinically effective, the drug is further evaluated on an economic basis.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call 1-877- 534-3682.

� These are the dispensing limitations. Prescription drugs prescribed by a doctor and obtained at a pharmacy that participates under the program through Express Scripts PERxCare Retail Pharmacy Program. Drugs are prescribed by doctors and dispensed in accordance with the Plan's drug formulary. Under the High Option, you pay a $15 copay for a generic drug, a $25 copay per prescription unit or refill for a name brand drug listed on the preferred prescriptions drug formulary and a $50 copay per prescription unit or refill for a name brand drug not listed on the preferred prescription drug formulary. Under the Standard Option benefit package, you pay a $15 copay for a generic drug, a $25 copay per prescription unit or refill for a name brand drug listed on the preferred prescriptions drug formulary and a $50 copay per prescription unit or refill for a name brand drug not listed on the preferred prescription drug formulary. A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not specified "dispense as written" for the name brand drug, you have to pay the brand name copay.

- Mandatory Mail: Your prescription coverage also includes a mandatory mail program. All maintenance medications must be sent to Express Scripts Mail Service Pharmacy. Two refills per prescription will be allowed at any local "preferred" Express Scripts PERxCare Pharmacy. When a new maintenance medication is prescribed the patient should request 2 prescriptions. The initial for a 31-day supply to be filled at a retail pharmacy, and the second, for up to a 90-day supply, to be submitted to Express Scripts Mail Service Pharmacy. For all existing maintenance medications at a retail pharmacy, the patient is required to obtain a new prescription, for up to a 90-day supply, to be sent to Express Scripts Mail Service Pharmacy.

- Maintenance Drug Program: The maintenance drug program permits long-term prescriptions to be filled for up to a 90-day supply. Under the High Option, you pay a $35 copay for a generic drug, a $60 copay per prescription unit or refill for a name brand drug listed on the preferred prescriptions drug formulary and a $75 copay per prescription unit or refill for a name brand drug not listed on the preferred prescription drug formulary. Under the Standard Option benefit package, you pay a $35 copay for a generic drug, a $60 copay per prescription unit or refill for a name brand drug listed on the preferred prescriptions drug formulary and a $75 copay per prescription unit or refill for a name brand drug not listed on the preferred prescription drug formulary.

Prescription Drug Programs

� Step Therapy Prior Authorization Program

The Step Therapy Prior Authorization Prescription Program refers to a "step approach" in requiring you to use one or more "first-line" drugs before a more costly "second-line" is approved.

� Drug Quantity Management Program

The DQM Program refers to quantity limits implementedon pre-selected medications, based on FDArecommendations for dosing.

� Diabetic Supplies Close Category Program

The Diabetic Supplies Category Program refers only to prescriptions for test strips and meters. You will be granted authorization for test strips and meters when you present a prescription for a covered diabetic supply product (Roche and J&J products are covered)

� Non-Sedating Antihistamines Program

The NSAH Program allows for the coverage of generic prescription antihistamines.

Most NSAH medications now have, or will have in the very near future, an over-the-counter (OTC) equivalent product on the market. As a result of the OTC's available on the market, brand name NSAH's will not be covered under your prescription drug benefits.

� A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.

� Why use a generic drug?

--Generic drugs may have unfamiliar names, but they are safe and effective.

--Generic drugs contain the same active ingredients, in the same dosage form as their brand name counterparts, and are manufactured according to the same strict federal regulations.

--Generic drugs may differ in color, size, or shape, but they have the same strength, purity, and quality as the brand-name alternatives.

--Prescriptions filled with generic drugs often have lower co-payments. Therefore, you may be able to get the same health benefits at a lower cost. You should ask your physician or pharmacist whether a generic version of your medications is available. By using a generic drug, you may be able to receive the same high-quality medication but reduce your expenses.

� When you have to file a claim. In an emergency, a direct reimbursement claim form must be filed for prescriptions that you obtained through a non-participating retail pharmacy. Upon filling your prescriptions through non-participating pharmacies:

- You must pay the full cost of the prescription.

- You must complete a direct reimbursement claims form, and submit it to Express Scripts. This form can be obtained by calling Express Scripts at 1-877-534-3682.

- Express Scripts will reimburse you for the amount the medication would have cost your benefits plan at a participating pharmacy, minus the co-payment you would have paid.

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

We cover the following medications and supplies prescribed by a physician and obtained from either a Plan pharmacy or by mail. Note: Mandatory mail requirements apply for maintenance drugs:

� Drugs for which a prescription is required by law.

� FDA-approved prescription drugs and devices for birth control.

� Fertility drugs.

� Drugs to treat sexual dysfunction (Viagra is limited to six tablets per every thirty-one days).

� Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape.

� Disposable needles and syringes needed for injection of covered prescribed medication.

� Smoking cessation drugs and medication, including nicotine patches
(up to 90-day supply).

� Intravenous fluids and medications for home use through our Participating Provider network for home infusion therapy

Network Retail:

$15 generic

$25 brand name listed on the preferred prescription drug formulary

$50 brand name drug not listed on the preferred prescription drug formulary.

Network Mail Order:

$35 generic

$60 brand name listed on the preferred prescription drug formulary

$75 brand name drug not listed on the preferred prescription drug formulary.

Network Retail:

$15 generic

$25 brand name listed on the preferred prescription drug formulary

$50 brand name drug not listed on the preferred prescription drug formulary.

Network Mail Order:

$35 generic

$60 brand name listed on the preferred prescription drug formulary

$75 brand name drug not listed on the preferred prescription drug formulary.

� A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not specified "dispense as written" for the name brand drug, you have to pay the brand name copay.

� We administer an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call Express Scripts at 1-877-534-3682.

Not covered:

� Nonprescription medications

� Drugs obtained at a non-participating pharmacy, except for emergencies.

� Vitamins and nutritional substances that can be purchased without a prescription.

� Medical supplies such as dressings and antiseptics.

� Drugs for cosmetic purposes.

� Drugs to enhance athletic performance.

All Charges

All Charges

Section 5 (g). Special features

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.

Large Case Management

The Plan provides a large case management program that seeks to provide alternatives for improving the quality and cost effectiveness of care. The large case management program focuses on catastrophic illnesses � for example, major head injury, high-risk infancy, stroke and severe amputations. The large case management process begins when we are notified that you or covered family member has experienced a specific illness or injury with potential long-term effects or changes in lifestyle. Case Managers evaluate individual needs, and the full range of treatment and financial exposures, from the onset of a condition or illness to recovery or stabilization. They review the efforts of the health care team and family with the goal of helping the patient return to pre-illness/injury functioning or of lessening the burden of a chronic or terminal condition. Case Managers provide the family with support and advice ranging from referral to family counseling. If it is determined that involvement of a Case Manager would be both care- and cost-effective, we will obtain the necessary authorization from the patient to proceed. Throughout the process, we will maintain strict confidentiality.

Customer Service AnswerLine

For information and assistance 24 hours a day, 7 days a week, access our automated telephone AnswerLine at 212/501-4GHI (4444).

Services for deaf and hearing impaired

If you have a question concerning Plan benefits or how to arrange for care, contact (212) 721-4962 (Hearing impaired � TDD) or you may write to us at Post Office Box 1701, New York, NY 10023-9476 or contact our office nearest you. You may also contact the Plan at its website at http://www.ghi.com.

High risk pregnancies

The Plan provides an intensive large case management program as described above.

Centers of excellence

We have a special network of hospitals that perform a broad range of cardiac care and organ transplants. These centers are recognized leaders in their respective specialties and their services are available to you at no out-of-pocket expense. Call GHI Managed Care at least 10 days before the hospital admission to pre-certify coverage and for details on how to use this program.

Travel benefit/ services overseas

As a GHI subscriber under the High Option Plan benefit package, you are not restricted to just using members of our provider network. However, if you go outside the network, your out-of-pocket expenses will increase significantly. You will receive 50% of our fee schedule if you use a non-participating provider � you are responsible for the balance of the provider's charge. Also, unlike when you use a network provider, you are responsible for paying the non-participating provider up front and filing a claim form with us for reimbursement.

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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.

� We cover hospitalization for certain dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard
the health of the patient; see section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below. We will cover the hospitalization, but not the cost of the professional dental services. Conditions for which hospitalization would be covered include hemophilia, impacted teeth, and heart disease; the need for anesthesia, by itself, is not such a condition.

� Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I

M

P

O

R

T

A

N

T

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury caused by external means and services must be completed within one year.

Any difference between our fee schedule and the actual charges.

Any difference between our fee schedule and the actual charges.

Not covered:

� Therapeutic service.

� Other dental services not shown as covered.

� Charges which exceed the Plan's fee schedule.

All charges

All charges

This Plan provides the following program of dental coverage. The emphasis is on prevention, with preventive and diagnostic dental services covered with no copayments through Participating Plan Dentists. Services by non-participating dentists are covered in accordance with the fees listed below.

Examinations (maximum 2 per calendar year)

Nothing for a participating provider.

POS: All charges in excess of $10.00

Nothing for a participating provider.

All charges for non-participating providers.

Prophylaxes (under 12 years - maximum 2 per calendar year)

Nothing for a participating provider.

POS: All charges in excess of $7.00

Nothing for a participating provider.

All charges for non-participating providers.

Prophylaxes (over 12 years maximum 2 per calendar year)

Nothing for a participating provider.

POS: All charges in excess of $10.00

Nothing for a participating provider.

All charges for non-participating providers.

Emergency visits for relief of pain (1 per calendar year)

Nothing for a participating provider.

POS: All charges in excess of $10.00

Nothing for a participating provider.

All charges for non-participating providers.

X-rays (Full-mouth series, 1 every 3 years)

Nothing for a participating provider.

POS: All charges in excess of $20.00

Nothing for a participating provider.

All charges for non-participating providers.

Bitewings (4 per calendar year)

Nothing for a participating provider.

POS: All charges in excess of $2.50 per each bitewing

Nothing for a participating provider.

All charges for non-participating providers.

Space maintainers

Nothing for a participating provider.

POS: All charges in excess of $65.00

Nothing for a participating provider.

All charges for non-participating providers.

Fluoride Treatments - dependent children to age 22

Nothing for a participating provider.

POS: All charges in excess of $5.00

Nothing for a participating provider.

All charges for non-participating providers.

Resin (anterior) 1 surface

$60.00

$49.00

Benefits on this page are not part of the FEHB contract.

* Downstate includes New York, Bronx, Kings, Queens, Richmond, Nassau, Suffolk, Putnam, Orange, Rockland and Westchester Counties and New Jersey

** Upstate includes Eastern, Central, and Western New York Counties.

1

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

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

(b) Send your request to us at: GHI Customer Service Department, 441 Ninth Avenue, New York, NY 10001; and

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

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

2

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

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

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

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

3

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

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

We will write to you with our decision.

4

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

You must write to OPM within:

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

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

� 120 days after we asked for additional information.

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

The Disputed Claims process, continued

Send OPM the following information:

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

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

� Copies of all letters you sent to us about the claim

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

� Your daytime phone number and the best time to call.

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

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

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

5

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

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

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

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

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

�

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

�

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

�

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

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

�

You have FEHB coverage through your spouse who is an annuitant

�

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

�

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

�for Part B services

� for other services

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

�*

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

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

�

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

�

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

� This Plan was the primary payer before eligibility due to ESRD

�for 30-month coordination period

� Medicare was the primary payer before eligibility due to ESRD

�

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

�

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

�

�

�Medicare Advantage

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs) in some areas of the country. In most Medicare Advantage plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare Advantage plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare Advantage plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www.medicare.gov.

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

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

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

TRICARE and CHAMPVA

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

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the program

Workers' Compensation

We do not cover services that:

� You need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or

� OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or a similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.

Medicaid

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a one of these State programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the State program.

When other Government agencies are responsible for your care

We do not cover services and supplies when a local, State, or Federal Government agency directly or indirectly pays for them.

When others are responsible for injuries

When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

Calendar year

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Copayment

A copayment is a fixed amount of money you pay when you receive covered services. See page 12.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.

Covered services

Care we provide benefits for, as described in this brochure.

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 those services. See page 12.

Medically Necessary Services

Medically necessary services are services; supplies or equipment provided by a hospital or covered provider of the health care services that the carrier determines:

� are appropriate to diagnose or treat the patient's condition, illness, or injury;

� are consistent with standards of good medical practice in the United States;

� are not primarily for the personal comfort or convenience of the patient, the family, or the provider;

� are not part of or associated with scholastic education or vocational training of the patient; and

� in case of inpatient care, cannot be provided safely on an outpatient basis.

The fact that a covered provider has prescribed, recommended, or approved a service, supply or equipment does not, in itself, make it medically necessary.

Experimental or investigational services

Experimental treatment is a treatment that has not been tested in human beings; or that is being tested but has not yet been approved for general use; or that is subject to review or approval by an Institutional Review Board.

Investigational treatment includes, but is not limited to, services or supplies which are under study or in a clinical trial to evaluate their toxicity, safety and efficiency for a particular diagnosis or set of indications.

Clinical trials include, but are not limited to, controlled experiments having a clinical event as an outcome measurement involving persons having a specific disease or health condition; or involving the administration of different study treatments in a parallel treatment design done to evaluate the efficacy and safety of a test measurement. Clinical trials include Phase I, Phase II, and Phase III studies. Clinical trials also include randomized trials or studies.

Plan allowance

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in different ways. We determine our allowance as follows:

The Plan allowance is the fee schedule or negotiated rate that GHI uses as payment in full for covered services rendered by participating providers.

Us/We

Us and we refer to Group Health Incorporated

You

You refers to the enrollee and each covered family member.

No pre-existing condition limitation

We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information about enrolling in the FEHB Program

See www.opm.gov/insure. Also, your employing or retirement office can answer your questions, and give you A Guide to Federal Employees Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

� When you may change your enrollment.

� How you can cover your family members

.

� What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire.

� When your enrollment ends; and

� When the next open season for enrollment begins.

We don't determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.

Types of coverage available for you and your family

Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your unmarried dependent children under age 22, including any foster children or stepchildren your employing or retirement office authorizes coverage for. Under certain circumstances, you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your spouse until you marry.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we. Please tell us immediately when you add or remove family members from your coverage for any reason, including divorce, or when your child under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan.

Children's Equity Act

OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

� If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option,[M4]

� if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family in the same option of the same plan; or

� if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that doesn't serve the area in which your children live, unless you provide documentation that you have other coverage for the children. If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that doesn't serve the area in which your children live as long as the court/administrative order is in effect. Contact you employing office for further information.

When benefits and

premiums start

The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be paid according to the 2004 benefits of your old plan or option. However, if your old plan left the FEHB Program at the end of the year, you are covered under the plan's 2003 benefits until the effective date of your coverage under your new plan. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

When you retire

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

When FEHB coverage ends

You will receive an additional 31 days of coverage, for no additional premium, when:

� Your enrollment ends, unless you cancel your enrollment, or

� You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy.)

� Spouse equity coverage

If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. This is the case even when the court has ordered your former spouse to provide health coverage to you. But, you may be eligible for your own FEHB coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse's employing or retirement office to get RI 70-5, the Guide To Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download the guide from OPM's Web site, www.opm.gov/insure.

� Temporary Continuation of Coverage (TCC)

If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal job, if you are a covered dependent child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, from your employing or retirement office or from www.opm.gov/insure. It explains what you have to do to enroll.

� Converting to individual coverage

You may convert to a non-FEHB individual policy if:

� Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);

� You decided not to receive coverage under TCC or the spouse equity law; or

� You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a waiting period or limit your coverage due to pre-existing conditions.

� Getting a Certificate of Group Health Plan Coverage

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that offers limited Federal protections for health coverage availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB Web site at www.opm.gov/insure/archive/health; refer to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as the requirement that Federal employees must exhaust any TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and information about Federal and State agencies you can contact for more information.

Important information

OPM wants to make sure you are aware of two Federal programs that complement the FEHB Program. First, the Federal Flexible Spending Account (FSA) Program, also known as FSAFEDS, lets you set aside pre-tax money to pay for health and dependent care expenses. The result can be a discount of 20% to more than 40% on services you routinely pay for out-of-pocket. Second, the Federal Long Term Care Insurance Program (FLTCIP) helps cover long term care costs, which are not covered under the FEHB.

� What is an FSA?

It is a tax-favored benefit that allows you to set aside pre-tax money from your paychecks to pay for a variety of eligible expenses. By using an FSA, you can reduce your taxes while paying for services you would have to pay for anyway, producing a discount that can be over 40%!!

There are two types of FSAs offered by FSAFEDS:

Health Care Flexible Spending Account (HCFSA)

� Covers eligible health care expenses not reimbursed by this Plan, or any other medical, dental, or vision care plan you or your dependents may have.

� Eligible dependents for this account include anyone you claim on your Federal Income Tax return as a qualified dependent under the U.S. Internal Revenue Service (IRS) definition and/or with whom you jointly file your Federal Income Tax return, even if you don't have self and family health benefits coverage. Note: The IRS has a broader definition of a "family member" than is used under the FEHB Program to provide benefits by your FEHB Plan.

� The maximum annual amount that can be allotted for the HCFSA is $4,000. Note: The Federal workforce includes a number of employees married to each other. If each spouse/employee is eligible for FEHB coverage, both may enroll for a HCFSA up to the maximum of $4,000 each ($8,000 total). Both are covered under each other's HCFSA. The minimum annual amount is $250.

Dependent Care Flexible Spending Account (DCFSA)

� Covers eligible dependent care expenses incurred so and your spouse, if married, can work, look for work, or attend school full-time.

� Qualifying dependents for this account include your dependent children under age 13, or any person of any age whom you claim as a dependent on your Federal Income Tax return (and who is mentally or physically incapable of self care).

� The maximum annual amount that can be allotted for the DCFSA is $5,000. The minimum annual amount is $250. Note: The IRS limits contributions to a DCFSA. For single taxpayers and taxpayers filing a joint return, the maximum is $5,000 per year. For taxpayers who file their taxes separately with a spouse, the maximum is $2,500 per year. The limit includes any child care subsidy you may receive.

Enroll during Open Season

You must make an election to enroll in an FSA during the 2005 FEHB Open Season. Even if you enrolled during 2004, you must make a new election to continue participating in 2005. Enrollment is easy!

� Online: visit www.FSAFEDS.com and click on Enroll.

� Telephone: call an FSAFEDS Benefits Counselor toll-free at 1-877-FSAFEDS (372-3337), Monday through Friday, from 9 a.m. until 9 p.m., Eastern Time. TTY: 1-800-952-0450

What is SHPS?

SHPS is a third-party administrator hired by OPM to manage the FSAFEDS Program. SHPS is the largest FSA administrator in the nation and is responsible for enrollment, claims processing, customer service, and day-to-day operations of FSAFEDS.

Who is eligible to enroll?

If you are a Federal employee eligible for FEHB - even if you're not enrolled in FEHB - you can choose to participate in either, or both, of the FSAs. However, if you enroll in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA), you are not eligible to participate in an HCFSA.

Almost all Federal employees are eligible to enroll for a DCFSA. The only exception is intermittent (also called "when actually employed" [WAE]) employees expected to work fewer than 180 days during the year.

Note: FSAFEDS is the FSA Program established for all Executive Branch employees and Legislative Branch employees whose employers have signed on to participate. Under IRS law, FSAs are not available to annuitants. Also, the U.S. Postal Service and the Judicial Branch, among others, have their own plans with slightly different rules. However, the advantages of having an FSA are the same regardless of the agency for which you work .

� How much should I contribute to my FSA?

Plan carefully when deciding how much to contribute to an FSA. Because of the tax benefits an FSA provides, the IRS places strict guidelines on how the money can be used. Under current IRS tax rules, you are required to forfeit any money for which you did not incur an eligible expense under your FSA account(s) during the Plan Year. This is known as the "use-it-or-lose-it" rule. You will have until April 30, following the end of the Plan Year to submit claims for your eligible expenses incurred from January 1through December 31. For example if you enroll in FSAFEDS for the 2005 Plan Year, you will have until April 30, 2006 to submit claims for eligible expenses.

The FSAFEDS Calculator at www.FSAFEDS.com will help you plan your FSA allocations and provide an estimate of your tax savings based on your individual situation.

� What can my HCFSA pay for?

Every FEHB plan includes cost sharing features, such as deductibles you must meet before the Plan provides benefits, coinsurance or copayments that you pay when you and the Plan share costs, and medical services and supplies that are not covered by the Plan and for which you must pay. These out-of-pocket costs are summarized on page xx and detailed throughout this brochure. Your HCFSA will reimburse you when those costs are for qualified medical care that you, your spouse and/or your dependents receive that is NOT covered or reimbursed by this FEHB Plan or any other coverage that you have.

Under the High Option .of this Plan, typical out-of-pocket expenses which are subject to deductibles, coinsurance and or copayments include: office copayments, private duty nursing services and non-participating provider charges. Typical out-of-pocket expenses not covered under the High Option include: hearing aids, cosmetic surgery and air ambulance.

Under the Standard Option of this Plan, typical out-of-pocket expenses which are subject to deductibles, coinsurance and or copayment include: office copayments, hospital deductibles, and private duty nursing services. Typical out-of-pocket expenses not covered under the Standard Option include: all non-participating provider charges, hearing aids, and cosmetic surgery.

The IRS governs expenses reimbursable by a HCFSA. See Publication 502 for a comprehensive list of tax-deductible medical expenses. Note: While you will see insurance premiums listed in Publication 502, they are NOT a reimbursable expense for FSA purposes. Publication 502 can be found on the IRS Web site at http://www.irs.gov/pub/irs-pdf/p502.pdf. The FSAFEDS Web site also has a comprehensive list of eligible expenses at www.FSAFEDS.com/fsafeds/eligibleexpenses.asp. If you do not see your service or expense listed, call an FSAFEDS Benefits Counselor at 1-877-FSAFEDS (372-3337), who will be able to answer your specific questions

� Tax savings with an FSA

An FSA lets you allot money for eligible expenses before your agency deducts taxes from your paycheck. This means the amount of income that your taxes are based on will be lower, so your tax liability will be less. Without an FSA, you would still pay for these expenses, but you would do so using money remaining in your paycheck after Federal (and often state and local) taxes are deducted. The following chart illustrates a typical tax savings example:

$50,000

$50,000

$ 2,000

$0-

$48,000

$50,000

$13,807

$14,383

-$0-

$ 2,000

$34,193

$33,617

$576

$0-

� Tax credits and Deductions

You cannot claim expenses on your Federal Income Tax return if you receive reimbursement for them from your HCFSA or DCFSA. Below are some guidelines that may help you decide whether to participate in FSAFEDS

Health care expenses

The HCFSA is Federal Income Tax-free from the first dollar. In addition, you may be reimbursed from HCFSA at any time during the year for expenses up to the annual amount you've elected to contribute.

Only health care expenses exceeding 7.5% of your adjusted gross income are eligible to be deducted on your Federal Income Tax return. Using the example shown above, only health care expenses exceeding $3,750 (7.5% of $50,000) would be eligible to be deducted on your Federal Income Tax return. In addition, money set aside through an HCFSA is also exempt from FICA taxes. This exemption is not available on your Federal Income Tax return.

Dependent care expenses

The DCFSA generally allows many families to save more than they would with the Federal tax credit for dependent care expenses. Note that you may only be reimbursed from the DCFSA up to your current account balance. If you file a claim for more than your current balance, it will be held until additional payroll allotments have been added to your account.

Visit www.FSAFEDS.com and download the Dependent Care Tax Credit Worksheet from the Forms and Literature page to help you determine what is best for your situation. You may also wish to consult a tax professional for more details

� Does it cost me anything to participate in FSAFEDS?

No. Section 1127 of the National Defense Authorization Act (Public Law 108-136) requires agencies that offer FSAFEDS to employees to cover the administrative fee(s) on behalf of their employees. However, remember that participating in FSAFEDS can cost you money if you don't spend your entire account balance by the end of the Plan Year, resulting in the forfeiture of funds remaining in your account (the IRS "use-it-or-lose-it" rule).

� Contact us

To learn more or to enroll, please visit the FSAFEDS Web site at www.FSAFEDS.com, or contact SHPS directly via email or by phone. FSAFEDS Benefits Counselors are available Monday through Friday, from 9:00 a.m. until 9:00 p.m. Eastern Time.

� E-mail: FSAFEDS@shps.net

� Telephone: 1-877-FSAFEDS (1-877-372-3337)

� TTY: 1-800-952-0450

� It's important protection

Why should you consider applying for coverage under the Federal Long Term Care Insurance Program (FLTCIP)?

� FEHB plans do not cover the cost of long term care. Also called "custodial care," long term care is help you receive to perform activities of daily living - such as bathing or dressing yourself - or supervision you receive because of a severe cognitive impairment. The need for long term care can strike anyone at any age and the cost of care can be substantial.

� The Federal Long Term Care Insurance Program can help protect you from the potentially high cost of long term care. This coverage gives you options regarding the type of care you receive and where you receive it. With FLTCIP coverage, you won't have to worry about relying on your loved ones to provide or pay for your care.

� It's to your advantage to apply sooner rather than later. In order to qualify for coverage under the FLTCIP, you must apply and pass a medical screening (called underwriting). Certain medical conditions, or combinations of conditions, will prevent some people from being approved for coverage. By applying while you're in good health, you could avoid the risk of having a future change in your health disqualify you from obtaining coverage. Also, the younger you are when you apply, the lower your premiums.

� You don't have to wait for an open season to apply. The Federal Long Term Care Insurance Program accepts applications from eligible persons at any time. You will have to complete a full underwriting application, which asks a number of questions about your health. However, if you are a new or newly eligible employee, you (and your spouse, if applicable) have a limited opportunity to apply using the abbreviated underwriting application, which asks fewer questions. Newly married spouses of employees also have a limited opportunity to apply using abbreviated underwriting.

Qualified relatives are also eligible to apply. Qualified relatives include spouses and adult children of employees and annuitants, and parents, parents-in-law, and stepparents of employees.

� To find out more and to request an application

Call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557) or visit www.ltcfeds.com

Medical services provided by physicians:

� Diagnostic and treatment services provided in the office

$15 per visit for a Participating Provider.

POS: 50% of the Plan's fee schedule and any difference between our fee schedule and the billed amount for a non-participating provider.

$25 per visit for a Participating Provider.

All charges for non-participating providers.

Copayment for pediatric visits waived.

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Services provided by a hospital:

� Inpatient

� Outpatient

$100 per inpatient admission up to a maximum of $200.

Note: $25 deductible per referral for ambulatory laboratory test and diagnostic X-rays when referred and rendered.

$250 per day inpatient admission up to a maximum of $750 per admission. (Waived for maternity care)

All charges for non-participating providers.

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Emergency benefits:

� In-area

� Out-of-area

$50 per hospital emergency room visit or urgent care center visit and charges that exceed the Plan's emergency fee schedule.

$50 plus charges per hospital emergency room visit or urgent care center visit for non-participating facilities.

$75 per hospital emergency room visit or urgent care center visit and charges that exceed the Plan's emergency fee schedule.

$75 plus charges per hospital emergency room visit or urgent care center visit for non-participating facilities.

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Mental health and substance abuse treatment

Regular cost sharing.

Regular cost sharing.

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Prescription drugs prescribed by a doctor and obtained at a participating pharmacy

Mandatory Mail

$15 copay for generic drugs; $25 copay per prescription unit or refill for name brand drugs listed on the preferred prescription drug formulary, and $50 copay per prescription unit or refill for a name brand drug not listed on the preferred prescription drug formulary. For mail-order maintenance you pay a $35 copay for generics and a $60 copay for name brand name drug listed on the preferred prescription drug formulary and $75 copay for a name brand drug not listed on the preferred prescription drug formulary

All maintenance medications must be sent to Express Scripts Mail Service Pharmacy. Two refills per prescription will be allowed at any local "preferred" Express Scripts PERxCare.

$15 copay for generic drugs; $25 copay per prescription unit or refill for name brand drugs listed on the preferred prescription drug formulary, and $50 copay per prescription unit or refill for a name brand drug not listed on the preferred prescription drug formulary. For mail-order maintenance you pay a $35 copay for generics and a $60 copay for name brand name drug listed on the preferred prescription drug formulary and $75 copay for a name brand drug not listed on the preferred prescription drug formulary

All maintenance medications must be sent to Express Scripts Mail Service Pharmacy. Two refills per prescription will be allowed at any local "preferred" Express Scripts PERxCare.

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Dental Care

Nothing for preventive services provided by Participating Providers. For non-participating providers, you pay any difference between GHI's fee schedule and the billed amount.

Nothing for preventive services provided by Participating Providers. All charges for non-participating providers.

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Vision Care

One refraction annually. Lenses (annually) and frames (every two years). Nothing to Participating Vision Centers.

One refraction annually. Lenses (annually) and frames (every two years). Nothing to Participating Vision Centers.

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Special features: Large Case Management, High Risk Pregnancies, Centers of Excellence for Transplants/Heart/Surgery/etc.

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Point-of-Service benefits --

Yes

No

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Protection against catastrophic costs

(your catastrophic protection out-of-pocket maximum)

Nothing after $10,000 per person per year

Some costs do not count toward this protection

No benefits

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