CALL - THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 952-883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952-883-5127). You may also request replacement cards through our Web site at www.healthpartners.com.

Where you get covered care

You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/or coinsurance, and you will not have to file claims.

� 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 for the Plan you select, which we update periodically. For the most up-to-date information, visit www.consumerchoice.com/fehb, where information is updated weekly. There are separate provider directories for the HealthPartners Classic Plan and the HealthPartners Open Access Deductible Plan.

HealthPartners Classic Plan

The HealthPartners Classic Plan is a group practice prepayment plan that allows members to receive health services at more than 100 medical, mental health and dental facilities. HealthPartners Classic Plan medical providers include more than 700 primary care doctors and nearly 12,000 specialists to whom patients may be referred.

When you enroll in the HealthPartners Classic Plan, you select a primary care clinic. You�ll receive most of your care from that clinic. Each covered person in a family may select a different primary care clinic and may change clinic selections monthly.

HealthPartners Open Access Deductible Plan

The HealthPartners Open Access Deductible Plan lets you receive care from nearly 12,000 physicians in the HealthPartners Open Access Network across Minnesota and in western Wisconsin. Referrals are not required and you do not need to choose a primary care clinic. Any time you or a member in your family needs care, you may choose to see any provider in this network. With limited exceptions, if you seek care from a provider who is not listed in this directory, your care is considered out-of-network and may not be covered.

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 Web site: www.consumerchoice.com/fehb.

What you must do to get covered care

HealthPartners Classic Plan

It depends on the type of care you need. First, you and each family member should choose a primary care physician at the primary care clinic you enroll in. This decision is important since your primary care physician provides or arranges for most of your health care. For help selecting a primary care physician, call your clinic.

HealthPartners Open Access Deductible Plan

Any time you or a member in your family needs care, you may choose to see any provider in this network. With limited exceptions, if you seek care from a provider who is not listed in this directory, your care is considered out-of-network and may not be covered.

Primary care

HealthPartners Classic Plan

Your primary care physician* can be a family practitioner, internist, pediatrician, or general practitioner. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

* Although Obstetrics/Gynecology (Ob/Gyn) is not considered primary care, each care network allows members direct access � no referral required � to the Ob/Gyn providers associated with the care network.

HealthPartners Open Access Deductible Plan

Members in this Plan are not required to pick a primary clinic. However, we encourage people to work with a personal physician who will get to know them.

Your primary care physician can be a family practitioner, internist, Ob/Gyn, pediatrician, or general practitioner. Your primary care physician will provide most of your health care, or suggest that you see a specialist. You can see any specialist in the health plan network without a referral.

If you want to change your primary care physician or if your primary care physician leaves the Plan, simply choose another provider from the HealthPartners Open Access directory.

For the most up-to-date provider information, visit www.consumerchoice.com/fehb, where information is updated weekly.

Specialty care

HealthPartners Classic Plan

In most cases, your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral.

However, some clinics allow you to self-refer to certain specialists. These specialists are listed in the directory and on www.consumerchoice.com/fehb with the note �No Referral Required.�

No matter which primary care clinic you use, all members have direct access � no referral required � to the following specialized care:

Ob/Gyn providers associated with your care network

Mental Health/Chemical Health Network

Vision Care Network

Urgent Care Network

Here are other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

HealthPartners Open Access Deductible Plan

You have direct access to any specialist in the HealthPartners Open Access Network without a referral.

If you are seeing a specialist when you enroll in our Plan and your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call Member Services at 952-883-5000 or 1-800-883-2177 for assistance. You may receive services from your current specialist until we can make arrangements for you to see someone else.

Both Plans

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 120 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 HealthPartners Member Services immediately at 952-883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952-883-5127). 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 provide you with the necessary care.

Services requiring our prior approval

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process prior authorization. Your physician must obtain prior authorization for services such as:

reconstructive surgery

promising therapies/new technologies

transplants

medically necessary dental care, such as orthognathic surgery

durable medical equipment and prosthetics

home health care

skilled nursing care

hospice care

habilitative therapy

The complete list, along with the criteria we use to review authorization requests, is available on www.healthpartners.com. or by calling HealthPartners Member Services at 952-883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952-883-5127).

Your Plan physician is responsible for obtaining prior authorization.

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 your primary care physician you pay a copayment of $15 per office visit and when you go in the hospital, you pay $100 per admission.

Deductible

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

For the HealthPartners Open Access Deductible Plan, the calendar year deductible is $250 per person. Under a family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $500.

For the HealthPartners Classic Plan, there is a $50 annual deductible for emergency dental services for accidental injury when care is provided by a non-Plan dentist. Copayments or coinsurance for any other service do not count toward this deductible.

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

Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our Plan, you pay 20% of our allowance for infertility services and durable medical equipment.

Your catastrophic protection out-of-pocket maximum

After your copayments and/or coinsurance total $3,000 per person or $5,000 per familyin any calendar year, you do not have to pay any more for covered services. Be sure to keep accurate records of your copayments and or coinsurance since you are responsible for informing us when you reach the maximum.

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

The calendar year deductible is $250 per person and $500 per family. Some services in this section are subject to the deductible.

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

Plan physicians must provide or arrange your care.

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

In an office

In an urgent care center

Office medical consultations

Second surgical opinion

Testing and treatment of sexually transmitted diseases and testing for HIV and HIV-related conditions provided by a Plan or non-Plan provider

$15 per office visit

$15 per office visit

During a hospital stay

In a skilled nursing facility

Nothing

Nothing

Not covered: Genetic counseling and studies not required for diagnosis and treatment.

All charges.

All charges.

Lab, X-ray and other diagnostic tests

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

Ultrasound

Electrocardiogram and EEG

Nothing

Nothing

MRI/CT scans

20% of charges

20% of charges

Routine health exams, periodic health assessments, and cancer screenings, such as:

Total Blood Cholesterol � once every three years

Colorectal Cancer Screening, including

Fecal occult blood test

Sigmoidoscopy, screening � every five years starting at age 50

Double contrast barium enema � every five years starting at age 50

Colonoscopy screening � every ten years starting at age 50

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

Routine pap test

Routine hearing and eye exams

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

Adult immunizations

Note: The above frequency guidelines are minimum benefits offered under the Plan. These services may be provided more frequently if they are medically necessary.

Nothing

Nothing

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

All charges.

All charges.

Child health supervision services, including well-child care charges for routine examinations and care (up to age 22)

Childhood immunizations recommended by the American Academy of Pediatrics

Routine hearing and eye exams

Nothing

Nothing

Prenatal care

Postnatal care

Nothing

Nothing

Delivery

Note: Here are some things to keep in mind:

You do not need to prior authorize your normal delivery; see page 13 for other circumstances, such as extended stays for you or your baby.

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

We cover routine nursery care of the newborn child and other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury.

SeeHospital benefits (Section 5c) and Surgery benefits (Section 5b).

SeeHospital benefits (Section 5c) and Surgery benefits (Section 5b).

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

All charges.

All charges.

A range of voluntary family planning services, such as:

Family planning services provided by a Plan provider or non-Plan provider

Nothing

Nothing

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

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital � after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 � after deductible

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

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

20% of charges

20% of charges

Not covered:

Reversal of voluntary surgical sterilization

Genetic counseling.

All charges.

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

Fertility drugs

Note: We cover injectible fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit. We cover the diagnosis of infertility services provided by a Plan or non-Plan provider, in accordance with our Medical Policy.

20% of charges

20% of charges

Not covered:

Assisted reproductive technology (ART) procedures, such as:

in vitro fertilization

embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)

Services and supplies related to ART procedures

Cost of donor sperm or egg

Cost of storage of donor sperm, ova or embryo

Treatment of infertility after reversal of sterilization

Artificial insemination for surrogate pregnancy

All charges.

All charges.

Testing and treatment

$15 per office visit

$15 per office visit

Allergy injection and serum

Nothing

Nothing

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 is limited to those transplants listed under Organ/Tissue Transplants on page 32.

Respiratory and inhalation therapy

Dialysis � hemodialysis and peritoneal dialysis

Intravenous (IV)/Infusion Therapy

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital � after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 � after deductible

Blood and blood plasma (unless replaced) and blood derivatives for the treatment of blood disorders

Nothing

Nothing

Growth hormone therapy (GHT)

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

See Services requiring our prior approval in Section 3.

20% of charges

20% of charges

Not covered: Growth hormones which are not for growth hormone deficiency or chronic renal insufficiency.

All charges.

All charges.

Usually two months per condition per year for the services of each of the following:

qualified physical therapists;

occupational therapists

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. You must achieve significant functional improvement, within a predictable period of time (generally within a period of two months), toward your maximum potential ability to perform functional daily living activities.

Habilitative care rendered for congenital, developmental or medical conditions which have significantly limited the successful initiation of normal speech and motor development.

Note: To be considered habilitative, significant functional improvement and measurable progress must be made toward achieving functional goals and your maximum potential ability, within a predictable period of time. Our Plan Medical Director will determine whether measurable progress has been made based on objective documentation.

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital � after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 � after deductible

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for Phase I. Phase II is provided if we determine it is medically necessary. Phase III is not covered.

$15 per office visit

Nothing for inpatient or outpatient hospital

$15 per office visit

Nothing for inpatient or outpatient hospital

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

All charges.

Speech therapy for congenital, developmental or medical conditions which have significantly limited the successful initiation of normal speech development.

Usually 60 visits or two months per condition per year

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital � after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 � after deductible

Not covered:

Long term rehabilitative therapy

All charges.

All charges.

Hearing services (testing, treatment, and supplies)

First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 17

Note: See Preventive care, adult; Preventive care, children

Nothing

Nothing

Hearing aids for members age 18 or younger who have hearing loss due to functional congenital malformation of the ears that is not correctable by other covered procedures. Coverage is limited to one hearing aid for each ear every three years.

20% of the charges

20% of the charges

Not covered:

All other hearing testing

All other hearing aids, testing and examinations for them

All charges.

All charges.

Eye exam to determine the need for vision correction

Annual eye refractions

Note: See Preventive care, adult; Preventive care, children

Nothing

Nothing

Diagnosis and treatment of illness and injury to the eye

$15 per office visit

$15 per office visit

Initial evaluation, lenses and fitting for contact or eyeglass lenses if medically necessary for the post-surgical treatment of cataracts or for the treatment of aphakia or keratoconous

$15 per office visit

All charges for lens replacement beyond the initial pair

$15 per office visit

All charges for lens replacement beyond the initial pair

Not covered:

Eyeglasses or contact lenses except as described above

Eye exercises

Radial keratotomy and other refractive surgery

All charges.

All charges.

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

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

$15 per office visit

$15 per office visit

Not covered:

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

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

All charges.

All charges.

We cover the following:

Orthopedic devices, such as braces and foot orthotics

Prosthetic devices, such as artificial limbs and eyes

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

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

Note: We pay internal prosthetic devices as hospital benefits; see Section 5(c) for payment information. See Section 5(b) for coverage of the surgery to insert the device.

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Orthopedic and corrective shoes when approved by this Plan based on our criteria

20% of charges

20% of charges

Wigs required due to hair loss caused by alopetia areata

20% of charges, and all charges beyond the $350 calendar year limit

20% of charges, and all charges beyond the $350 calendar year limit

Not covered:

Over-the-counter foot orthotics

Replacement or repair of any covered items if they are damaged or destroyed by member misuse, abuse or carelessness; lost; or stolen

Duplicate or similar items

Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience or recreation

Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage

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;

Insulin pumps

Diabetic supplies, and

Disposable needles and syringes needed for the administration of covered medications.

Note: We reserve the right to determine if an item will be approved for rental vs. purchase.

20% of charges

20% of charges

Not covered:

Replacement or repair of any covered items if they are damaged or destroyed by member misuse, abuse or carelessness; lost; or stolen

Duplicate or similar items

Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience or recreation

Household equipment, such as exercise cycles, air purifiers, water purifiers, air conditioners, non-allergenic pillows, mattresses or water beds

Household fixtures, such as escalators or elevators, ramps, swimming pools or saunas

Modifications to the home, such as wiring, plumbing or charges to install equipment

Vehicle, car or van modifications, such as hand brakes, hydraulic lifts and car carriers

Rental of medically necessary durable medical equipment while your own equipment is being repaired, that is beyond one month rental

Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage

All charges.

All charges.

We cover home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), or home health aide, as shown below:

Physical therapy, occupational therapy, speech therapy, respiratory therapy and home health aide services

$15 per visit

$15 per visit

TPN/intravenous therapy, skilled nursing services, prenatal and postnatal services, child health services and phototherapy

Nothing

Nothing

Not covered:

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

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

All charges.

All charges.

Chiropractic services for rehabilitative care, provided to diagnose and treat acute neuromusculo-skeletal conditions, limited to:

Manipulation of the spine and extremities

Adjunctive procedures such as massage therapy, ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application, when they are performed in conjunction with other treatment by a chiropractor, are part of a prescribed treatment plan and are not billed separately

$15 per office visit

$15 per office visit

Not covered:

Naturopathic services

Hypnotherapy

All charges.

All charges.

We cover the following services:

Acupuncture � by a certified Plan acupuncturist for:

anesthesia

pain management

chemical dependency

headaches

nausea

Biofeedback for:

incontinence

headaches

musculo-skeletal spasms which do not respond to other treatments

mental/nervous disorders

neurological retraining

$15 per office visit

$15 per office visit

Not covered:

Naturopathic services

Hypnotherapy

All charges.

All charges.

We cover education for the management of chronic health problems (such as diabetes) and smoking cessation

$15 per office visit/session

$15 per office visit/session

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

The calendar year deductible is $250 per person and $500 per family. Some services in this section are subject to the deductible.

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

Plan physicians must provide or arrange your care.

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 services described in this section are for the charges billed by a physician or other health care professional for your surgical care. The amount that you pay for these services depends on where the services are provided and follow the benefits described in Section 5(a) and (c), unless otherwise specified below.

YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION FOR SOME SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure which services require prior authorization and identify which surgeries require prior authorization.

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A comprehensive range of services, such as:

Operative procedures, including normal pre- and post-operative care by the surgeon

Treatment of fractures, including casting

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

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

Voluntary sterilization

Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital � after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 � after deductible

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care

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; port wine stains; webbed fingers; and webbed toes.

Note: Port wine stains do not have to result in a functional defect to be covered.

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

surgery to produce a symmetrical appearance of breasts;

treatment of any physical complications, such as lymphedemas;

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

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 visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital � after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 � after deductible

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, unless determined medically necessary by the Plan Medical Director

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;

Removal of stones from salivary ducts;

Excision of leukoplakia or malignancies;

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

Other surgical procedures that do not involve the teeth or their supporting structures, including non-dental treatment of temporomandibular joint dysfunction (TMJ).

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital � after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 � after deductible

Orthognathic surgery for the treatment of a skeletal malocclusion when a functional occlusion cannot be achieved through non-surgical treatment alone and a demonstrable functional impairment exists.

25% of charges

25% of charges

Not covered:

Oral implants and transplants

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

Orthodontic services (pre or post operative) associated with orthognathic surgery

All charges.

All charges.

Transplant services are covered at our designated centers of excellence for transplants and are limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas for diabetes

Liver

Lung: Single � Double, for primary pulmonary hypertension, Eisenmenger�s syndrome, end stage pulmonary fibrosis, alpha 1 antitrypsin disease, cystic fibrosis and emphysema

Allogeneic (donor) bone marrow transplants or peripheral stem cell support associated with high dose chemotherapy for acute myelogenous leukemia; acute lymphotytic leukemia; chronic myelogenouis leukemia; severe combined immunodeficiency disease; Wiscott-Aldrich syndrome; and aplastic anemia

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; Hodgkin�s lymphoma; non-Hodgkin�s lymphoma; Burkitt�s lymphoma; 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

Limited Benefits � Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in a National Cancer Institute- or National Institutes of Health-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.

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

$100 per admission for inpatient hospital

$100 per admission for inpatient hospital � after deductible

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.

Professional services provided in �

Hospital (inpatient)

Skilled nursing facility

$100 per admission for inpatient hospital

$100 per admission for inpatient hospital � after deductible

Professional services provided in �

Hospital outpatient department

Ambulatory surgical center

Nothing

10% of outpatient charges, up to a calendar year maximum of $1,500 � after deductible

Professional services provided in �

An office

$15 per office visit

$15 per office visit

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

The calendar year deductible is $250 per person and $500 per family. Some services in this section are subject to the deductible.

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

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

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 the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care and any costs associated with the professional charge (i.e., physicians, etc.) which are described in Sections 5(a) or (b).

YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require prior authorization.

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Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets.

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 (unless replaced) and blood derivatives

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

MRI / CT scans

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$100 per admission for inpatient hospital

$100 per admission for inpatient hospital � after deductible

Not covered:

Custodial care

Non-covered facilities, such as nursing homes, extended care facilities, schools

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

Private nursing care

All charges.

All charges.

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals

Blood and blood plasma (unless replaced) and blood derivatives

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

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

$15 per visit

10% of outpatient charges, up to a calendar year maximum of $1,500 � after deductible

MRI / CT scans

20% of charges

20% of charges

We cover a comprehensive range of benefits for up to 120 days per period of confinement when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by your Plan doctor and prior authorized by this Plan. All necessary services are covered, including:

Bed, board and general nursing care

Drugs, biologicals, services and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by your Plan doctor.

Period of confinement means (1) continuous stay in a hospital or skilled nursing facility, or (2) a series of two or more stays in a hospital or skilled nursing facility for the same condition in which the end of each inpatient stay is separated from the beginning of the next one by less than 90 days. Same condition means illness or injury related to a former illness or injury that is (1) within the same ascertainable diagnosis, or (2) within the scope of complications, or related conditions.

$100 per admission

$100 per admission � after deductible

Not covered: Custodial care

All charges.

All charges.

We cover supportive and palliative care in your home or a hospice if you are terminally ill. We cover the following services:

Outpatient care, family counseling and continuous care

Inpatient care

Nothing

Nothing

Respite care

20% of charges

20% of charges

Note: Respite care is limited to 5 days per episode, and respite care and continuous care combined are limited to 30 days.

Not covered: Independent nursing, homemaker services

All charges.

All charges.

Ambulance and medical transportation for medical emergencies described in section 5(d).

Prior authorized transfers between network hospitals for treatment if initiated by a Plan physician.

20% of charges

20% of charges

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

The calendar year deductible is $250 per person and $500 per family. Some services in this section are subject to the deductible.

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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:

Emergencies within our service area:In life-threatening emergencies, contact the local emergency system (e.g., 911 telephone system) or go to the nearest hospital emergency room. In other situations, if you need emergency care, call your clinic, or, after clinic hours, call the CareLine^SM service at 612-339-3663 or 1-800-551-0859 (hearing impaired individuals should call 952-883-5474). A CareLine nurse or Plan doctor will recommend how, when and where to obtain the appropriate treatment.

Emergencies outside our service area:You must notify us within two days of admittance to an out-of-network hospital, or as soon as reasonably possible under the circumstances. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible. Follow-up care recommended by non-Plan providers must be approved by this Plan or provided by our providers.

Emergency and urgently needed care at a doctor�s office

Emergency and urgently needed care at an urgent care center

$15 per office visit

$15 per office visit

Emergency and urgently needed care as an outpatient at a hospital, including doctors� services

NOTE: Copay waived if admitted to the hospital for the same condition within 24 hours

$55 per visit

$55 per visit

Not covered: Elective care or non-emergency care

All charges.

All charges.

Emergency and urgently needed care at a doctor�s office

Emergency and urgently needed care at an urgent care center

Emergency and urgently needed care as an outpatient at a hospital, including doctors� services

Emergency and urgently needed care as an inpatient at a hospital, including doctors� services

20% of the first $2,500 of charges per calendar year

20% of the first $2,500 of charges per calendar year

Not covered:

Elective care or non-emergency care

Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges.

All charges.

Professional ambulance service when medically appropriate.

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

20% of charges

20% of 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:

The calendar year deductible is $250 per person and $500 per family. Some services in this section are subject to the deductible.

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

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 do not need a referral from your primary care physician to obtain mental health or substance abuse services. You must use a mental health or substance abuse provider that is in our Plan network. We list the mental health and substance abuse providers in our provider directory and on our Web site at www.consumerchoice.com/febh. If you have questions or need a provider directory, call HealthPartners at 952-883-5811 or 1-888-638-8787 (hearing impaired individuals should call 952-883-5127).

CERTAIN SERVICES MUST BE PRE-AUTHORIZED. Your Plan physician is responsible for obtaining prior authorization.

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

NOTE: 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 by providers such as psychiatrists, psychologists, or clinical social workers

Medication management

Overnight stay at a contracted organization if you are actively involved in an affiliated licensed chemical dependency day treatment program for treatment of alcohol or drug abuse

$15 per visit

$15 per visit

Group therapy

$7.50 per office visit

$7.50 per office visit

Diagnostic tests

Nothing

Nothing

Services provided by a hospital or other facility

Services in approved alternative care settings such as:

Residential treatment

Partial hospitalization or full-day hospitalization for mental health services

$100 per admission

$100 per admission � after deductible

Not covered: Services we have not approved.

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

All charges.

All charges.

Prior authorization You do not need a referral from your primary care physician to obtain mental or substance abuse services. You must use a mental health or substance abuse provider that is in our Plan network. We list the mental health and substance abuse providers in our provider directory and on our Web site at www.consumerchoice.com/febh. If you have questions or need a provider directory, call HealthPartners Member Services Department at 952-883-5811 or 1-888-638-8787 (hearing impaired individuals should call 952-883-5127).

Some therapies require the approval of a treatment plan, which your provider will submit for you.

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

The calendar year deductible is $250 per person and $500 per family. Some services in this section are subject to the deductible.

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. 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 Plan physician must write the prescription.

Where you can obtain them. You must fill the prescription at a Plan pharmacy or by mail. Specialty formulary drugs must be obtained at a designated vendor. The specialty formulary is available by calling Member Services or by visiting our Web site at www.consumerchoice.com/fehb.

We cover formulary and non-formulary drugs. Formulary drugs are a preferred list of drugs that we selected to meet patient needs at a lower cost.

These are the dispensing limitations. Unless otherwise specified in this section, you may receive up to a 30-day supply per prescription. No more than a 90-day supply will be covered and dispensed at a time. If a copayment is required, you must pay one copayment for each 30-day supply, or portion thereof, or for each manufacturer�s pre-packaged dispensing unit (but not less than your physicians� recommendation of a 30-day supply), except as follows:

For insulin, a copayment will apply per vial or box of insulin cartridges.

For contraceptive barrier devices, a copayment will apply per device.

For mail order drugs, see benefit described below.

A member who is called to active military duty can call HealthPartners Member Services Department at 952-883-5000 or 1-800-883-2177 to get information on how to get a medium-term supply of drugs.

In the event of a national or other emergency, you can call HealthPartners Member Services Department at 952-883-5000 or 1-800-883-2177 to get information on how to get a supply of drugs to meet your needs.

A generic equivalent will be dispensed if it is available, unless your physician specifies �Dispense as Written.�

Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer advertises and sells a drug. Under Federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic prescription costs you � and us � less than a name brand prescription.

If you request a refill too soon after the last one was filled, it may not be filled at that time. It may require up to 14 days to get mail order prescriptions filled, so this service is best for maintenance drugs, not for drugs you need immediately or for drugs you are taking on a short-term basis. Federal or state regulations may prevent us from filling certain prescriptions through our mail order service, such as laws which prohibit us from sending narcotic drugs across state lines.

When you have to file a claim. You do not need to file a claim for drugs obtained at a network pharmacy or through our mail order service. You would need to file a claim for prescription drugs covered as part of an out-of-area emergency, if you did not get them at a network pharmacy. See Section 7 for instructions on filing a claim.

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

Drugs and medicines that by Federal law of the United States require a physician�s prescription for their purchase

Insulin, with a copay applied per vial

Oral contraceptive drugs and contraceptive barrier devices, a single copay charge will apply for 1 cycle of oral contraceptive drugs or for each barrier device

Tobacco cessation products, as determined by this Plan, limited to a 180-day supply per calendar year. Benefits will be limited to one product at a time, and no more than a 30-day supply will be covered and dispensed at a time.

$12 copay for formulary drugs

$24 copay for non-formulary drugs

The copay applies per 30-day supply, or portion thereof, or for one manufacturer�s pre-packaged dispensing units, if applicable.

$10 copay for formulary drugs

$35 copay for non-formulary drugs

The copay applies per 30-day supply, or portion thereof, or for one manufacturer�s pre-packaged dispensing units, if applicable.

You may also get outpatient prescription drugs which can be self-administered through HealthPartners mail order service. For information on how to obtain drugs through HealthPartners� mail order service, please call 1-888-356-6656.

This benefit does not apply to drugs listed under Limited Benefits on the following page.

$24 copay for formulary drugs

$48 copay for non-formulary drugs

The copay applies per 90-day supply, or portion thereof, or for three manufacturer�s pre-packaged dispensing units, if applicable.

For your convenience, you may also order insulin, infertility drugs, and growth hormones through the mail order service without a discounted benefit.

$20 copay for formulary drugs

$70 copay for non-formulary drugs

The copay applies per 90-day supply, or portion thereof, or for three manufacturer�s pre-packaged dispensing units, if applicable.

For your convenience, you may also order insulin, infertility drugs, and growth hormones through the mail order service without a discounted benefit.

Injectable, implantable contraceptive drugs or devices (such as Depo Provera, Norplant, IUDs)

Growth hormones

Injectable drugs for the treatment of infertility

Special dietary treatment for phenylketonuria (PKU)

Drugs for treatment of sexual dysfunction are limited to six doses per month.

20% of charges

20% of charges

Not covered:

Drugs and supplies for cosmetic purposes

Vitamins, nutrients and food supplements even if a physician prescribes or administers them, except as specified

Nonprescription medicines

Fertility drugs {Plan specific}

Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Medical supplies such as dressings and antiseptics

Drugs to enhance athletic performance

All charges.

All charges.

CareLine^SM Service

When you call the CareLine service after regular clinic hours, you reach a skilled nurse who is specially trained to assess medical conditions of all kinds. Call 612-339-3663 or 1-800-551-0859 and talk with a registered nurse who will discuss treatment options and answer your health questions.

BabyLine^SM Service

If you�re an expecting or new parent and have questions after regular clinic hours, our BabyLine service is just for you. The BabyLine service is staffed by obstetric nurses who can help with questions relating to pregnancy, new baby care, nursing, and postpartum concerns. Call 612-333-BABY (333-2229) or 1-800-845-9297.

Services for deaf and hearing impaired

If you are deaf or hearing impaired, we have special phone lines which you may call for the following services:

Member Services: 952-883-5127

CareLine Service: 952-883-5474

BabyLine Service: 952-883-5474

Log on to your personalized member page

As a Plan member, you have instant access to detailed, secured information and helpful services tailored to you. Depending on your coverage, you may be able to:

Make appointments at HealthPartners Clinics

See your claims information

View your benefits

Refill a mail order prescription or a prescription at a HealthPartners Clinic

View your medical provider network

View your dental provider network

Change your clinic

Order new ID cards

To access your personalized member page, visit www.consumerchoice.com/fehb.

10,000 Steps^� Program

You may be eligible for the Plan�s 10,000 Steps^� Program. For more information or to register, call 952-883-7800 or 1-800-311-1052. Members with hearing impairments may call the TTY line at 952-883-7498.

Frequent Fitness Program 

You may be eligible for the Plan�s Frequent Fitness Program. For more information on the program visit www.consumerchoice.com/fehb.

We cover restorative services and supplies provided by Plan dentists necessary to promptly repair or replace sound, natural, unrestored teeth, including the cost and installation of necessary prescription dental prosthetic items or devices. The need for these services must directly result from an accidental injury, not including injury from biting or chewing. Coverage is limited to the initial treatment (or course of treatment) and/or restoration. Only services provided within 24 months from the date treatment or restoration was initiated are covered.

Nothing

Nothing

Emergency dental services for accidental injury, as described above, are covered when they are provided by non-Plan dentists if the services require immediate treatment.

$50 calendar year deductible, then 20% of the charges, up to a maximum benefit of $300 per calendar year, and any charges thereafter

25% of the charges, up to a maximum benefit of $300 per calendar year, and any charges thereafter

Not covered: Other dental services not shown as covered.

All charges.

All charges.

We cover the preventive and diagnostic dental services shown below for all members when provided by Plan dentists. Benefit limits are noted where they apply.

Routine dental examinations (per Plan dentist�s recommendation);

Teeth cleaning, prophylaxis or periodontal maintenance recall (limited to twice per year);

Topical application of fluoride (per Plan dentist�s recommendation);

Oral hygiene instruction (per Plan dentist�s recommendation);

Bitewing x-rays (limited to once per year); and

Full mouth (panoramic) x-rays (limited to once every three calendar years)

Nothing

Nothing

Not covered: Other dental services not shown as covered.

All charges.

All charges.

Medical, hospital and drug benefits

In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Your facility will file on the UB-92 form. For claims questions and assistance, call us at 952-883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952-883-5127).

When you must file a claim � such as for out-of-area care � submit it on the HCFA-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

Covered member�s name and ID number;

Name and address of the physician or facility that provided the service or supply;

Dates you received the services or supplies;

Diagnosis;

Type of each service or supply;

The charge for each service or supply;

A copy of the explanation of benefits, payments, or denial from any primary payer � such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.

Submit your claims to:

HealthPartners Claims

P.O. Box 1289

Minneapolis, MN55440-1289

Deadline for filing your claim

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

When we need more information

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

1

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

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

b) Send your request to us at: Member Services, P.O. Box 1309, Minneapolis, MN 55440-1309; and

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

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

2

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

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

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

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

3

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

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

We will write to you with our decision.

4

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

You must write to OPM within:

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

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

120 days after we asked for additional information.

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

When you have other health coverage

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

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

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

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to the reasonable charges. We will not pay more than our allowance.

What is Medicare?

Medicare is a Health Insurance Program for:

People 65 years of age or older.

Some people with disabilities under 65 years of age.

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

Medicare has two parts:

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

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

Should I enroll in Medicare?

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

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal employees and annuitants are entitled to Medicare Part A at age 65 without cost. When you don't have to pay premiums for Medicare Part A, it makes good sense to obtain the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which can help keep FEHB premiums down.

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

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

The Original Medicare Plan (Part A or Part B)

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. You must coordinate your care with your Plan primary care physician, who will authorize your referrals to Plan specialists and prior authorize services with the Plan, as specified under Section 3.

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

When we are the primary payer, we process the claim first.

When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something about filing your claims, call us at 952-883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952-883-5127).

We do not waive any costs if the Original Medicare Plan is your primary payer.

Please see the Primary Payer Chart on the following page.

Primary Payer Chart

A. When you - or your covered spouse - are age 65 or over and have Medicare and you�

The primary payer for the individual with Medicare is�

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

*

B. When you or a covered family member�

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

C. When either you or a covered family member are eligible for Medicare solely due to disability and you�

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

D. When you are covered under the FEHB Spouse Equity provision as a former spouse

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:

Applicable to the Classic Plan and our Medicare Advantage plan (not available if you are enrolled in the Open Access Deductible Plan): You may enroll in our Medicare Advantage plan and also remain enrolled in our FEHB plan.

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

Workers� Compensation

We do not cover services that:

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

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

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

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 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.

We will be entitled to immediately collect the present value of subrogation rights from any recovery payments you receive, whether or not you have been fully compensated for your losses and damages. Unless we agree, you may not deduct attorneys� fees and expenses, which you incur in the recovery of monies from a third party, from the subrogation/reimbursement amounts.

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.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 14.

Copayment

A copayment is a fixed amount of money you pay when you receive covered services. See page 14.

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 14.

Experimental or investigational services

This Plan determines if a treatment or procedure is experimental/investigative or unproven if it is:

Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use; or

If reliable evidence shows that the drug, device or medical treatment or procedure is the subject of ongoing Phase I, II, or III Clinical Trials; or

If reliable evidence shows that the drug, device or medical treatment or procedure is under study to determine its maximum tolerated dose, its toxicity, its safety, and its efficacy as compared with the standard means of treatment or diagnosis.

Medical necessity

This Plan defines medically necessary care as care that is appropriate for the condition, including those related to mental health. It includes the kind and level of service. It includes the number of treatments. It also includes where you get the service and how long it continues. Medically necessary care must:

be the service that other providers would usually order.

help you get better, or stay as well as you are.

help stop the condition from getting worse.

help prevent and find health problems.

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:

For covered services delivered by Plan providers, or Plan referral providers, our allowance is the provider�s discounted charge for a given medical/surgical service, procedure or item, which Plan providers have agreed to accept as payment in full.

For covered services delivered by non-Plan providers, our allowance is the provider�s charge for a given medical/surgical service, procedure or item, according to the fair and reasonable charge amount.

The Fair and Reasonable Charge is the maximum amount we allow when we calculate the payment for charges incurred for covered services provided by non-Plan providers. It is consistent with what other providers in the same community charge for a given service or item, as defined by the Health Insurance Association of America (HIAA) schedule.

Us/We

Us and we refer to HealthPartners Classic Plan or Open Access Deductible Plan.

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 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 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 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;

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 your employing office for further information.

When benefits and premiums start

The benefits in this brochure are effective 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 2005 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 that plan�s 2004 benefits until the effective date of your coverage with 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 you, 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 14 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 HealthPartners Classic Plan, typical out-of-pocket expenses include:

The office visit and outpatient hospital visit copay of $15.

The prescription drug copay of $12 for formulary drugs and $24 for non-formulary drugs.

The inpatient hospital copay of $100 per admission.

Under the HealthPartners Open Access Deductible Plan, typical out-of-pocket expenses include:

The $250 individual deductible and $500 family deductible that applies to inpatient and outpatient hospital services, ambulance services and durable medical equipment.

The office visit copay of $15.

The prescription drug copay of $10 for formulary drugs and $35 for non-formulary drugs.

The inpatient hospital copay of $100 per admission.

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, please 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:

If your taxable income is:

$50,000

$50,000

And you deposit this amount into an FSA:

$2,000

-$0-

Your taxable income is now:

$48,000

$50,000

Subtract Federal & Social Security taxes:

$13,807

$14,383

If you spend after-tax dollars for expenses:

-$0-

$2,000

Your real spendable income is:

$34,193

$33,617

Your tax savings:

$576

-$0-

Note: This example is intended to demonstrate a typical tax savings based on 27% Federal and 7.65% FICA taxes. Actual savings will vary based upon the retirement system in which you are enrolled (CSRS or FERS), your state of residence, and your individual tax situation. In this example, the individual received $2,000 in services for $1,424 � a discount of almost 36%! You may also wish to consult a tax professional for more information on the tax implications of an FSA.

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 your 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 find out more or to enroll, please visit the FSAFEDS Web site at www.FSAFEDS.com, or contact SHPS via email or by phone. FSAFEDS Benefit Counselors are available 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.

Classic Plan

Open Access Deductible Plan

Medical services provided by physicians:

Diagnostic and treatment services provided in the office...........................................

$15 per office visit

$15 per office visit

17

Inpatient

$100 per admission

$100 per admission*

34

Outpatient

$15 per outpatient hospital service

10% of the charges, up to a calendar maximum of $1,500*

35

In-area

$55 Emergency Room visit;

$15 Urgent Care Center visit

$55 Emergency Room visit;

$15 Urgent Care Center visit

38

Out-of-area...................................................................................................................

20% of the first $2,500; nothing thereafter

20% of the first $2,500; nothing thereafter

38

Regular cost sharing

Regular cost sharing

39

Retail pharmacy (generally a 30-day supply)

$12 copay for formulary drugs; $24 copay for non-formulary drugs

$10 copay for formulary drugs; $35 copay for non-formulary drugs

42

Mail order service (generally a 90-day supply)

$24 copay for formulary drugs; $48 copay for non-formulary drugs

$20 copay for formulary drugs; $70 copay for non-formulary drugs

42

Special features: CareLine^SM service; BabyLine^SM service; special phone lines for deaf and hearing impaired; personalized member page on Web site; health improvement programs

44

Classic Plan

Open Access Deductible Plan

Accidental injury

Nothing, if care is provided by Plan dentist

Nothing

45

Preventive dental

Nothing

Nothing

46

Vision care...................................................................................... .

Nothing for preventive care

Nothing for preventive care

24

Protection against catastrophic costs

(your catastrophic protection out-of-pocket maximum)...........

$3,000 /Self Only or $5,000 /Family per calendar year

$3,000 /Self Only or $5,000 /Family per calendar year

14

Non-Postal Premium

Postal Premium

Biweekly

Monthly

Biweekly

Type of

Enrollment

Code

Gov�t Share

Your Share

Gov�t Share

Your Share

USPS Share

Your Share

Classic High Option

Self Only

531

$ 131.08

$ 101.04

$ 284.01

$ 218.92

$ 154.74

$ 77.38

Classic High Option

Self and Family

532

$ 298.23

$ 258.84

$ 646.17

$ 560.82

$ 352.08

$ 204.99

Open Access

Standard Option

Self Only

534

$ 131.08

$ 49.28

$ 284.01

$ 106.77

$ 154.74

$ 25.62

Open Access Standard Option

Self and Family

535

$ 298.23

$ 134.62

$ 646.17

$ 291.67

$ 352.08

$ 80.77