CALL � THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-866-320-0697or write to us at Coventry Health Care of Kansas, Inc., 8301 East 21^st North, Suite 300, Wichita, KS 67206. You may also request replacement cards through our Web site at www.chckansas.com.

Where you get covered care

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

Plan providers

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

We list Plan providers in the provider directory, which we update periodically. The list is also on our website. Visit www.chckansas.com to utilize our doctor search option. Our doctor search on the web is updated monthly.

Plan facilities

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

What you must do to get covered care

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. The Plan�s provider directory lists primary care doctors (generally family practitioners, pediatricians, and internist), with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Customer Service Department at 1-866-320-0697. You can also find out if your doctor participates by calling these numbers

If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients.

Primary care

Your primary care physician will generally be a family practitioner, internist or pediatrician.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.

Specialty care

Your primary care physician will refer you to a specialist for needed care. You must receive a referral from your primary care doctor before seeing or obtaining special services, with the following exceptions:, (1) Female members may visit a participating gynecologist without a referral from their primary care doctor; (2) All members may visit the Plan's mental health providers for mental conditions and substance benefits without a referral from their primary care doctor (See "Mental Conditions /Substance Abuse Benefits").

Referral to a participating specialist is given at your primary care doctor's discretion; if specialists or consultants are required beyond those participating in the Plan, your primary care doctor will make arrangements for appropriate referrals.

When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation. All follow-up care must be provided or arranged by the primary care doctor. On referrals, the primary care doctor will give specific instructions to the consultant as to what services are authorized. If the consultant suggests additional services or visits, you must first check with your primary care doctor. Do not go to the specialist unless your primary care doctor has arranged for and the Plan has issued an authorization for the referral in advance.

Here are some 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 workwith the specialist to 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.

If you have a chronic and 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 program Plan; or

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

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

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

Hospital care

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

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-866-320-0697. 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 for example, prior authorization from the Plan for outpatient surgeries or inpatient hospitalization. You may call customer service at 1-866-320-0697to find out if a specific procedure treatment requires prior authorization.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services. You are responsible for paying copayments to providers at the time of service.

Example: When you see your primary care physician you pay a copayment of $15 per office visit. When you go in the hospital, you pay $100 copay per day up to a $300 maximum per admission.

Deductible

A deductible 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.

High and Standard Option Plan - we have no deductible.

High Deductible Health Plan - the individual deductible applies to members enrolled in Self Only. The family deductible applies collectively to all members enrolled in Self and Family.

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 allowance that you must pay for your care. If your Plan has a deductible, Coinsurance doesn�t begin until you meet your deductible.

Example: In our Plan, you pay 50% of our allowance for infertility services and 20% for covered durable medical equipment.

Your catastrophic protection out-of-pocket maximum

After your copayments and coinsurance total the amounts listed below, you do not have to pay any more for covered services. Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.

High and Standard Option Plans: After your copayments and coinsurance total the amounts listed below in the calendar year, you do not have to pay any more for covered services. However, copayments or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments or coinsurance for : Dental Care Services and Prescription Drugs.

High Option Plan - the out-of-pocket maximum for Self Only is $2,000 and $4,000 for Self and Family.

Standard Option Plan - the out-of-pocket maximum for Self Only is $2,500 and $5,000 for Self and Family.

High Deductible Health Plan:. After your copayments and coinsurance total the amounts listed below in the calendar year, you do not have to pay any more for covered services. However, copayments or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments or coinsurance for : Dental Care Services. The individual out-of-pocket maximum applies to members enrolled in Self Only. The family out-of-pocket maximum applies collectively to all members enrolled in Self and Family.

High Deductible Health Plan - the out-of-pocket maximum for Self Only is $5,000 and $10,000 for Self and Family.

When Government facilities bill us

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

If we overpay you

We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments.

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

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

Plan physicians must provide or arrange your care.

We have no calendar year deductible

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

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Professional services of physicians

In a physician�s office

$15 per visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

Professional services of physicians

In an urgent care center

Nothing

Nothing

During a hospital stay

Initial examination of a newborn child covered under a family enrollment

In a skilled nursing facility

Nothing

Nothing

Office medical consultations

Second surgical opinion

$15 per visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

At home

$25 per visit

$25 per visit

Laboratory tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

$15 per visit to your primary care physician; $30 per visit to your specialist. You only pay the office visit copayment when the test is performed during your office visit.

$20 per visit to your primary care physician; $35 per visit to your specialist. You only pay the office visit copayment when the test is performed during your office visit.

Radiology and other diagnostic tests, such as:

X-rays

Electrocardiogram and EEG

CAT Scans/MRI

Ultrasound

10% of our allowance

$100 per test

Non-routine Mammograms

Nothing

Nothing

Routine screenings, such as:

Total Blood Cholesterol

Colorectal Cancer Screening, including

- Fecal occult blood test

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

$15 per visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

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

$15 per visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

Preventive care, adult - continued on next page

Preventive care, adult (continued)

High Option

You pay

Standard Option

You pay

Routine pap test

Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.

$15 per visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

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

Nothing

Nothing

Routine immunizations, limited to:

Tetanus-diphtheria (Td) booster � once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually

Pneumococcal vaccine, age 65 and older

$15 per office visit to your primary care physician

$30 per visit to a specialist

Nothing if you receive these services during your office visit

$20 per office visit to your primary care physician

$35 per visit to a specialist

Nothing if you receive these services during your office visit

Childhood immunizations recommended by the American Academy of Pediatrics

Examinations done on the day of immunizations (under age 22)

$15 per office visit to your primary care physician

$30 per visit to a specialist

Nothing if you receive these services during your office visit

$20 per office visit to your primary care physician

$35 per visit to a specialist

Nothing if you receive these services during your office visit

Preventive care, children (continued)

High Option

You pay

Standard Option

You pay

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

Examinations, such as:

- Eye exams through age 17 to determine the need for vision correction

- Ear exams through age 17 to determine the need for hearing correction

$15 per visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see page 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 during the covered portion of the mother�s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

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

$15 for initial office visit to your primary care physician to confirm pregnancy.

$30 for initial office visit to a specialist to confirm pregnancy.

All other copayments for prenatal visits during the course of pregnancy are waived.

$20 for initial office visit to your primary care physician to confirm pregnancy.

$35 for initial office visit to a specialist to confirm pregnancy.

All other copayments for prenatal visits during the course of pregnancy are waived

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

All charges.

All charges.

A range of voluntary family planning services, limited to:

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

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo Provera)

Intrauterine devices (IUDs)

Diaphragms

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

$50 copayment

$15 per visit to your primary care physician or $30 per visit to a specialist..

$200 copayment

$20 per visit to your primary care physician or $35 per visit to a specialist applies to implanted or injectable contraceptive devices.

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)

50% of our allowance

50% of our allowance

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)

- zygote transfer

Services and supplies related to ART procedures

Cost of donor sperm

Cost of donor egg

All charges.

All charges.

Testing

Treatment/Allergy injections

50% of our allowance

$15 per visit to your primary care physician or $30 to a specialist

50% of our allowance

$20 per visit to your primary care physician or $35 to a specialist

Allergy 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 48.

$15 per visit to your primary care physician

$30 per visit to a specialist; or nothing for outpatient test

$20 per visit to your primary care physician

$35 for office visit; or $100 for outpatient test

Respiratory and inhalation therapy

$15 copayment

$20 copayment

Dialysis � hemodialysis and peritoneal dialysis

Nothing

Nothing

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

$15 per visit to your primary care physician

$30 per visit to a specialist; Nothing when provided in the home

$20 per visit to your primary care physician

$35 office visit or; Nothing when provided in the home

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the medical benefit.

Note: � We only cover GHT when we preauthorize the treatment. Call 1-866-320-0697 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

Nothing

Nothing

60 days per condition for the services of each of the following:

qualified physical therapists

occupational therapists

chiropractors (coverage limited to subluxation and manipulation)

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.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided for up to 60 sessions.

$15 per visit to a specialist

Nothing per visit during covered inpatient admission

$20 copay for each outpatient session;

Nothing per visit during covered inpatient admission

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

All charges.

60 days per condition

$15 per visit to a specialist

Nothing per visit during covered inpatient admission

$20 copay for each outpatient session;

Nothing per visit during covered inpatient admission

First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 17 (see Preventive care, children)

$15 per visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

All charges.

One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

Eye exam to determine the need for vision correction for children through age 17 (see Preventive care, children)

$15 per visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

Annual eye refractions

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

$10 per office visit

$20 per office visit

Not covered:

Eyeglasses or contact lenses and after age 17, examinations for them

Eye exercises and orthoptics

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 visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

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 limit coverage to $1,000 per member per calendar year.

Orthopedic devices such as braces

Artificial limbs and eyes; stump hose

Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy. External prosthetic devices, except those associated with reconstructive surgery after a mastectomy, are limited to one per member per lifetime.

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

20% of our allowance

20% of our allowance

Not covered:

Orthopedic and corrective shoes

Arch supports

Foot orthotics

Heel pads and heel cups

Lumbosacral supports

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

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

All charges.

All charges.

We limit coverage to $1,000 per member per calendar year.

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;

Insulin pumps; and

20% of our allowance

20% of our allowance

Blood glucose monitors for those members with diabetes.

Note: Call us at 866-795-3995 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Nothing.

Nothing.

Not covered:

Motorized wheelchairs

All charges.

All charges.

Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aid.

Services include oxygen therapy, intravenous therapy and medications.

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.

See Physical and occupational therapies

No benefit

All charges.

All charges.

Coverage is limited to:

Diabetes self- management educational classes, as referred by your Plan physician

$15 per office visit

$20 per office visit

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

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

Plan physicians must provide or arrange your care.

We have no calendar year deductible.

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

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

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

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A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

$15 per visit to your primary care physician

$30 per visit to a specialist

Nothing for physician hospital visits

$20 per visit to your primary care physician

$35 per visit to a specialist

Nothing for physician hospital visits

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

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

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 visit to your primary care physician

$30 per visit to a specialist

Nothing for physician hospital visits

$20 per visit to your primary care physician

$35 per visit to a specialist

Nothing for physician hospital visits

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

$50 copayment

$50 copayment

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; webbed fingers; and webbed toes.

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

- surgery to produce a symmetrical appearance on the other breast;

- treatment of any physical complications, such as lymphedemas;

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

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

$15 per visit to your primary care physician

$30 per visit to a specialist

Nothing for physician hospital visits

$20 per visit to your primary care physician

$35 per visit to a specialist

Nothing for physician hospital visits

Not covered:

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

Surgeries related to sex transformation

All charges.

All charges.

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

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

Removal of stones from salivary ducts;

Excision of leukoplakia or malignancies;

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

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

Treatment of TMJ.

$15 per visit to your primary care physician

$30 per visit to a specialist

Nothing for physician hospital visits

$20 per visit to your primary care physician

$35 per visit to a specialist

Nothing for physician hospital visits

Not covered:

Oral implants and transplants

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

TMJ related dental work

All charges.

All charges.

Limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

Lung: Single � Double

Pancreas

Allogeneic (donor) bone marrow transplants

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

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

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 .

Nothing

Nothing

Organ/tissue transplants � continued on next page

Not covered:

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

Implants of artificial organs

Transplants not listed as covered

All charges.

All charges.

Professional services provided in �

Hospital (inpatient)

Nothing

Nothing

Professional services provided in �

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Nothing

Nothing

Office

$15 per visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

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

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

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

We have no calendar year deductible

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. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).

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

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Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care;

Meals and special diets; and

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 day up to a $300 maximum per admission

$300 per day up to a $900 maximum per admission

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Administration of blood and blood products

Blood or blood plasma, if not donated or replaced

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Take home items

Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

Nothing

Not covered:

Custodial care

Non-covered facilities, such as nursing homes, 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, if not donated or replaced

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

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

$50 per surgery

$200 per surgery

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

All charges.

All charges.

A comprehensive range of benefits with no dollar or day limit when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are covered, including:

Bed, board, and general nursing care

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

$100 copay per day up to a $300 maximum per admission if separate admission

$300 copay per day up to a $900 maximum per admission if separate admission

Not covered: Custodial care

All charges.

All charges.

Supportive and Palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient care and family counseling. These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

Nothing

Nothing

Not covered:

Independent nursing, homemaker services

All charges.

All charges.

Local professional ambulance service to the nearest hospital equipped to handle your medical condition when medically appropriate.

Air ambulance when medically appropriate

30% of our allowance

30% of our allowance

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

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

We have no calendar year deductible

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 manifests itself by symptoms of sufficient severity that would lead a prudent layperson to believe that immediate care is required. 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:

In a medical emergency, call the local emergency system (e.g., the local 911 telephone system), or go to the nearest emergency facility. Be sure to tell the paramedics, or emergency room personnel that you are a Coventry Health Care of Kansas, Inc. plan member so they can notify us. You or a family member must notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been timely notified.

Emergencies within our service area: If your symptoms are not life-threatening, contact your primary care physician, who is on call 24 hours a day, seven days a week. During after hours or weekends, your physician my use an answering service, therefore your physician or covering physician will generally return your call within 30 minutes. We also provide FirstHelp, which is available to our members 24 hours a day, seven days a week by calling 800-622-9528. With this service, registered nurses are available to help you to the appropriate level of care or provide medical advice.

If you need to be hospitalized and are admitted to a non-Plan facility, call Customer Service at 866-320-0697. You must notify us about your medical emergency within a reasonable time period as dictated by the circumstances. If you are hospitalized in a non-Plan hospital and a Plan physician believes your care can be provided in one of our Plan hospitals, we will transfer you when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan.

We also provide several Urgent Care centers which are open on evenings, weekends and holidays, and are designed to give our members fast, effective quality care for non-emergent conditions such as: sprains, influenza, sore throats, ear infections, minor lacerations, and upper respiratory infections.

Emergencies outside our service area:Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness. If you are hospitalized, the Plan must be notified within 48 hours on the first working day following your admission, unless it is not reasonably possible to notify the Plan within that time. If a Plan physician believes your care can be provided in one of our Plan hospitals, we will transfer you when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan.

Emergency care at a doctors� office

$15 per visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

Emergency care at an urgent care center

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

$50 per urgent care visit

$100 per visit; waived if admitted to hospital

$50 per urgent care visit

$125 per visit; waived if admitted to hospital

Not covered: Elective care or non-emergency care

All charges.

All charges.

Emergency care at a doctors� office

$15 per visit to your primary care physician

$30 per visit to a specialist

$20 per visit to your primary care physician

$35 per visit to a specialist

Emergency care at an urgent care center

$50 per urgent care visit

$50 per urgent care visit

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

$100 per visit; waived if admitted to hospital

$125 per visit; waived if admitted to hospital

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.

Local professional ambulance service to the nearest hospital equipped to handle your medical condition when medically appropriate.

Air ambulance when medically appropriate

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

30% of our allowance

30% of our allowance

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

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

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

We have no calendar year deductible.

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

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

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

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

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

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

Diagnostic and treatment of psychiatric conditions, mental illness and mental disorders. Services include:

Diagnostic evaluation

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

Crisis intervention for acute episodes

Medication management

30 per visit

$35 per visit

Psychological testing necessary to determine the appropriate treatment

30 per visit

$35 per visit

Diagnosis and treatment of alcoholism and drug abuse. Services include:

Detoxification (medical management of withdrawal from the substance)

Treatment and counseling (including individual and group therapy visits)

Rehabilitation

Note: Your mental health or substance abuse provider will develop a treatment plan to assist you in improving or maintaining your condition and functional level, or to prevent relapse.

Note: You may see an outpatient mental health or substance abuse provider without referral from your primary care physician. However, before you see a mental health provider you must obtain authorization for the visit from United Behavioral Health at 1-866-607-5970. They can be reached 24 hours a day, 7 days a week to answer questions and assist you in choosing appropriate services. Your mental health provider will obtain subsequent authorizations for treatment.

$30 per visit

$35 per visit

Inpatient psychiatric care

Services provided by a hospital or other facility

Inpatient substance abuse care

Inpatient detoxification

Residential treatment

$100 per day up to a $300 maximum per admission

$300 per day up to a $900 maximum per admission

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

$30 per visit

$35 per visit

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.

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

United Behavioral Health, is contracted by Coventry Health Care of Kansas, Inc., to provider a network of providers who offer a variety of therapeutic services on an inpatient and outpatient basis.

All inpatient and outpatient treatment must be authorized through United Behavioral Health, at 1-866-607-5970.

Limitation We may limit your benefits if you do not obtain a treatment plan.

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

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

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

We have no calendar year deductible.

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 licensed physician, referral physician or oral surgeon must write the prescription.

Where you can obtain them. You may fill the prescription at a participating pharmacy. You may obtain maintenance medication through Caremark, our mail order prescription drug program. Caremark�s Customer Service number is (800) 378-7040

We use a formulary. A formulary is a list of specific generic and brand name prescription drugs authorized by the Health Plan, and subject to periodic review and modification. Since there may be more than one brand name of a prescription drug, not all brands of the same prescription drug (e.g., different manufactures) may be included in the Formulary. If you would like information on whether a specific drug is included in our drug formulary, please call Customer Service at 1-866-320-0697.

If your pan physician specifically prescribes a non-formulary drug because it is medically necessary, you will receive the non-formulary drug at the Plan non-formulary copayment. If you request a non-formulary drug when your physician has prescribed a substitution, we will not provide the non-formulary drug. However, you may purchases the non-formulary drug from a Plan pharmacy at our allowance.

These are the dispensing limitations. Prescription Drugs will be dispensed in the quantity determined by the Prescribing Provider. The following also apply:

One (1) applicable copayment is due each time a prescription is filled or refilled at a retail pharmacy for up to a thirty-one (31) day supply.

Mail Order Drugs are obtained through Caremark, our mail order prescription drug program, and may be dispensed with three (3) applicable copayment(s), or $30 formulary generic and $90 brand name formulary, for a ninety-three (93) day supply. To order prescriptions or refills please contact Caremark�s Customer Service at (800) 378-7040 or visit the website www.rxrequest.com. Available 24 hours a day � 7 days a week.

Members called to active military duty in a time of national or other emergency who need to obtain a greater-than-normal supply of prescribed medications should call us at 1-866-320-0697.

If a brand name Prescription Drug is dispensed, and an equivalent generic Prescription Drug is available, you pay an Ancillary Charge in addition to the formulary brand name copayment. The Ancillary Charge will be due regardless of whether or not the Prescribing Provider indicates that the pharmacy is to �Dispense as Written.� The Ancillary Charge is the difference between the average wholesale price of the brand name and the maximum allowable cost price of the generic prescription. Copayments and Ancillary Charges do not apply to the Catastrophic Protection Out-of-Pocket Maximum.

Prescription drugs (continued)

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand-name product. Generics cost less than the equivalent brand-name product. The U.S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name drugs. Generic drugs are indicated on the formulary listing of prescription drugs.

When you do have to file a claim. When you receive drugs from a Plan pharmacy, you do not have to file a claim. For a covered out-of-area emergency, you will need to file a claim when you receive drugs from a non-Plan pharmacy.

Covered medications and supplies

High or Standard Option

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, except those listed as Not covered.

Insulin

Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedict�s solution, or equivalent, and acetone test tablets are each available for the $10 copay

Disposable needles and syringes for the administration of covered medications.

Drugs for sexual dysfunction

Contraceptive drugs (Contraceptive devices, see Section 5(a) )

Retail Pharmacy

$10 per generic formulary

$30 per brand name formulary

$55 per non-formulary

Mail Order (93 day supply)

$30 per generic formulary

$90 per brand name formulary

Noted: If there is no generic equivalent available, you will still have to pay the brand name copay.

If there is a generic equivalent and you choose the brand name drug, you will pay the brand name copay plus the difference in the average wholesale price between the generic and the brand name drug. This applies to both formulary and non-formulary drugs.

Not covered:

Drugs and supplies for cosmetic purposes

Medical supplies such as dressings and antiseptics

Drugs to aid in smoking cessation, include nicotine patches.

Drugs to enhance athletic performance

Fertility drugs

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

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

Drugs available without a prescription or for which there is a non-prescription equivalent

Appetite suppressants and other drugs to assist in weight control (except for the treatment of morbid obesity when the authorized by us and your primary care physician).

Nonprescription medicines; except those designated by the plan.

All charges.

Flexible benefits option

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

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

Alternative benefits are subject to our ongoing review.

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

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

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

24 hour nurse line

Call FirstHelp anytime you or a family member experience health symptoms that need attention. Nurses are available to you and your family 24 a day, 7 days a week and are trained to handle your questions. Any member who visits an emergency room or urgent care center as a result of advice from FirstHelp will automatically have associated claims approved. With FirstHelp authorization, you will know in advance if medical services will be covered. You may call 1-800-622-9528 or for the hearing impaired call 1-800-735-2966.

Services for deaf and hearing impaired

The Kansas TDD relay number is 1-800-766-3777.

The Missouri TDD relay number is 1-800-735-2966.

Transplant Network

In order to provide members requiring a transplant the opportunity for the best outcomes and experiences, we use our own Coventry Transplant Network.

We cover emergency restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

$30 per office visit

$35 per office visit

We have no other dental benefits.

Note: This benefit section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about HDHP benefits, contact us at 866-320-0697 or at our web site at www.chckansas.com .

Summary

Our high-deductible health plan option provides comprehensive coverage for high-cost medical events and a tax-advantaged way to help you build savings for future medical expenses.  The Plan gives you greater control over how you use your health care benefits, and you are not required to select a Primary Care Physician.

When you enroll in this HDHP option, we establish either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) for you.  Each month, we automatically pass through a portion of the total health Plan premium to your HSA or HRA based upon your eligibility as of the first day of the month.

With this Plan, preventive care is covered in full less your copayments.  As you receive other non-preventive medical care, you must meet the Plan�s deductible before we pay benefits according to the benefit chart on page 114.  You can choose to use funds available in your HSA to make payments toward the deductible or you can pay toward your deductible entirely out-of-pocket, allowing your savings to continue to grow.

This HDHP includes five key components: in-network preventive care; traditional in-network health care that is subject to the deductible; savings, catastrophic protection for out-of-pocket expenses, and, health education resources and account management tools.

In-network preventive care

The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), routine prenatal and well-child care, child and adult immunizations. These services are covered if you use a network provider and are fully described in Section 5.1(a).  You do not have to meet the deductible before using these services.

Traditional in-network medical care

After you have paid the Plan�s deductible, we pay benefits under traditional in-network coverage described in Section 5.1(b).

Covered services include:

Medical services and supplies provided by physicians and other health care professionals

Surgical and anesthesia services provided by physicians and other health care professionals

Hospital services; other facility or ambulance services

Emergency services/accidents

Mental health and substance abuse benefits

Prescription drug benefits

Dental benefits.

Savings

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see Section 5.1(c) for more details).

HSA

By law, HSAs are available to members who are not eligible for Medicare or do not have other health insurance coverage.  In 2005, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $41.67per month for a Self-Only enrollment or $83.33 per month for a Self and Family enrollment.   In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $1,050 for Self-Only and $2,100 for Self and Family - see maximum contribution information in Section 5.1(c). You can use funds in your HSA to help pay your health plan deductible.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don�t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

Your HSA is administered by Corporate Benefit Services of America, Inc.

Your contributions to the HSA are tax deductible

Your HSA earns tax-free interest

You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents. (See IRS publication 502 for a complete list of eligible expenses.)

Your unused HSA funds and interest accumulate from year to year

It�s portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire

When you need it, funds up to the actual HSA balance are available.

HRA

For members who aren�t eligible for an HSA, are eligible for Medicare or have another health plan, we will administer and provide an HRA.   

In 2005, we will give you an HRA credit of $41.67 per month for a Self-Only enrollment and $83.33 per month for a Self and Family enrollment.  You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don�t count toward the deductible. 

HRA features include:

For our HDHP option, the HRA is administered by Corporate Benefit Services of America, Inc.

Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP

Unused credits carryover from year to year

HRA credit does not earn interest

HRA credit is forfeited if you leave Federal employment or switch health insurance plans.

Catastrophic protection for out-of-pocket expenses

When you use network providers, your annual maximum for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $5,000 per person or $10,000 per family enrollment. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan�s allowable amount or benefit maximum). Refer to Section 4 Your catastrophic protection out-of-pocket maximum, Section 5.1(b) Traditional medical coverage subject to the deductible, and Section 5.1(c) Catastrophic protection for out-of-pocket expenses for more details.

Health education resources and account management tools

Section 5.1(d) describes the health education resources and account management tools available to you to help you manage your health care and your health care dollars.

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

The Plan pays 100% for the preventive care services listed in this Section after you pay $20 copayment primary care doctor visit or $35 per specialist office visit.

For all other covered expenses, please see Section 5.2 �Traditional Medical Coverage.

Some covered services that you receive during a preventive service office visit may not qualify as preventive services, and consequently, will be subject to applicable deductibles. In order to be exempt from applicable deductibles, preventive services must qualify as preventive services and listed in Section 223 of the Internal Revenue Code.

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.

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Professional services, such as:

Routine physicals

Routine screenings

Routine immunizations

$20 per visit to your primary care physician

$35 per visit to a specialist

Not covered:

Physical exams required for obtaining or continuing employment or insurance, attending schools, camp or travel.

Immunizations, boosters, and medications for travel.

All charges.

Professional services, such as:

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

Childhood immunizations recommended by the American Academy of Pediatrics

1 routine eye exam every 12 months

1 routine hearing exam every 24 months

$20 per visit to your primary care physician

$35 per visit to a specialist

No additional charge

$20 per visit to your primary care physician

$20 per visit to your primary care physician; $35 per visit to a specialist

Not covered:

Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.

Immunizations, boosters, and medications for travel.

All charges.

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

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

The deductible is $1,050 per person or $2,100 per family enrollment. The family deductible can be satisfied by one or more family members. The deductible applies to almost all benefits in Section 5.1. You must pay your deductible before your Traditional Medical Coverage may begin.

Under Traditional Medical Coverage, you are responsible for your coinsurance and copayments for covered expenses.

When you use network providers, you are protected by an annual catastrophic maximum on out-of-pocket expenses for covered services. After your coinsurance, copayments and deductibles total $5,000 per person or $10,000 per family enrollment in any calendar year, you do not have to pay any more for covered services from network providers. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan�s benefit maximum, and payments for dental care services).

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.

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The deductible applies to almost all benefits in this Section. In the You pay column, we say �No deductible� when it does not apply. When you receive covered services from network providers, you are responsible for paying the allowable charges until you meet the deductible.

100% of allowable charges until you meet the deductible of $1,050 for Self-Only or $2,100 for Self and Family.

After you meet the deductible, we pay the allowable charge (less your coinsurance or copayment) until you meet the annual catastrophic out-of-pocket maximum.

In-network: After you meet the deductible, you pay the indicated coinsurance or copayments for covered services. You may choose to pay the coinsurance and copayments from your HSA or HRA, or you can pay for them out-of-pocket.

Professional services of physicians

In physician�s office

In an urgent care center for routine services

During a hospital stay

In a skilled nursing facility

At home

$20 per visit to your primary care physician; $35 per visit to a specialist

20% of the Plan allowance

20% of the Plan allowance

20% of the Plan allowance

$20 per visit to your primary care physician; $35 per visit to a specialist

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

20% of our allowance

Complete maternity (obstetrical) care, such as:

Prenatal care (covered under Section 5.1 Preventive care)

Delivery

Postnatal care

Note: Here are some things to keep in mind:

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

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

We cover routine nursery care of the newborn child during the covered portion of the mother�s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. Surgical benefits, not maternity benefits, apply towards circumcision the newborn.

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

After deductible has been met

$20 for initial office visit to your primary care physician to confirm pregnancy

$35 for initial office visit to a specialist to confirm pregnancy

20% of our allowance for delivery

$20 for initial office visit to your primary care for postnatal care

$35 for initial office visit to a specialist for postnatal care

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

All charges.

A range of voluntary family planning services, limited to:

Voluntary sterilization (See Surgical procedures Section 5.1 (b)

Surgically implanted contraceptive

Injectable contraceptive drugs (such as Depo Provera)

Intrauterine devices (IUDs)

Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit

20% of our allowance

Not covered:

Reversal of voluntary sterilization

Genetic counseling

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

20% of our allowance

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

Cost of donor egg

Fertility drugs

All charges.

Testing

Treatment/Allergy injections

20% of the Plan allowance

$20 per visit to a primary care physician; $35 per visit to a specialist

Allergy serum

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 81.

$20 for office visit to your primary care physician

$35 for office visit to a specialist

20% of our allowance all other settings

Respiratory and inhalation therapy � limited to 60 visits per condition

$20 for office visit to your primary care physician

$35 for office visit to a specialist

20% of our allowance all other settings

Dialysis � hemodialysis and peritoneal dialysis

$20 for office visit to your primary care physician

$35 for office visit to a specialist

20% of our allowance all other settings

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

$20 for office visit to your primary care physician

$35 for office visit to a specialist

20% of our allowance all other settings

Growth hormone therapy (GHT)

Note: Growth Hormone Therapy is covered under the prescription drug benefit

Note: � We only cover GHT when we preauthorize the treatment. Call 1-866-320-0697for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

60 days per condition for the services of each of the following:

qualified physical therapists

occupational therapists

chiropractors (coverage limited to subluxation and manipulation)

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.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided for up to 60 sessions.

$35 per office visit

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

60 days per condition

$35 per office visit

First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 22 (see Preventive care, children)

$20 per visit to your primary care physician

$35 per visit to a specialist

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

Eye exam to determine the need for vision correction for children through age 22 (see Preventive care, children)

$20 per visit to your primary care physician

$35 per visit to a specialist

Annual eye refractions

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

$20 per office visit

Not covered:

Eyeglasses or contact lenses and after age22, examinations for them

Eye exercises and orthoptics

Radial keratotomy and other refractive surgery

All charges.

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

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

$20 per visit to your primary care physician

$35 per visit to a specialist

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.

We limit coverage to $1,000 per member per calendar year.

Orthopedic devices such as braces

Artificial limbs and eyes; stump hose

Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy. External prosthetic devices, except those associated with reconstructive surgery after a mastectomy, are limited to one per member per lifetime.

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

20% of our Plan allowance

Not covered:

Orthopedic and corrective shoes

Arch supports

Foot orthotics

Orthotics (regular or custom, including but not limited to ankle foot othotics or podiatric orthotics)

Heel pads and heel cups

Lumbosacral supports

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

Dental braces, devices, and appliances

Braces for aid in sports activities

Internally implanted devices, equipment, and prosthetics related to treatment of sexual dysfunction

Repair and replacement of orthopedic and prosthetic devices, unless necessitated by normal growth

Doc bands (Dynamic Orthotic Cranial Bands)

All charges.

We limit coverage to $1,000 per member per calendar year.

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;

Ostomy and urological supplies;

Prosthetic and orthotic supplies;

Blood glucose monitors;

Insulin pumps, and syringes for insulin pumps;

Apnea monitor;

Cane;

Replacement due to anatomical growth;

Repair and replacement of DME determined to be medically necessary.

Note: Call us at 866-320-0697as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

20% of our allowance

Not covered:

Motorized wheelchairs

Disposable supplies

Replacement of lost equipment

Repair, adjustment, or replacement necessitated by wear, tear, or misuse

All charges.

Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), physical therapist, speech therapist, occupational therapist.

Services include oxygen therapy, intravenous therapy and medications

20% of our allowance

Not covered:

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

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

Nursing care that could appropriately be rendered in a Plan medical office, affiliated hospital, or skilled nursing facility

Nursing care that can be performed safely and effectively by people whom, in order to provide the care do not require medical licenses or certificates, or the presence of a supervising licensed nurse

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

All charges.

See Physical and occupational therapies

No benefit

All charges.

Coverage is limited to:

Diabetes self- management educational classes, as referred by your Plan physician

$20 per office visit

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

A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

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

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

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

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

20% of our allowance

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care

All charges.

Surgery to correct a functional defect

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

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

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

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

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.

20% of our allowance

Not covered:

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

Surgeries related to sex transformation

All charges.

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

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

Removal of stones from salivary ducts;

Excision of leukoplakia or malignancies;

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

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

Treatment of TMJ.

20% of our allowance

Not covered:

Oral implants and transplants

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

TMJ related dental work

All charges.

Limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

Lung: Single � Double

Pancreas

Allogeneic (donor) bone marrow transplants

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

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

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 provided the recipient is a plan member. After referral to a transplant facility, the following will apply:

20% of our allowance

Not covered:

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

Implants of non-human or artificial organs

Transplants not listed as covered

All charges.

Professional services provided in �

Hospital (inpatient)

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

20% of our allowance

The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5.2(a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to the precertification information shown in Section 3.

Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets.

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

20% of our allowance

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Administration of blood and blood products

Blood or blood plasma, if not donated or replaced

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Take home items

Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

20% of our allowance

Inpatient hospital (continued)

After the deductible, you pay

Not covered:

Custodial care

Non-covered facilities, such as nursing homes, schools

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

Private nursing care

All charges.

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals

Blood and blood plasma, if not donated or replaced

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

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

20% of our allowance

Not covered: Blood and blood derivatives not replaces by the member

All charges.

A comprehensive range of benefits with no dollar or day limit when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are covered, including:

Bed, board, and general nursing care

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

20% of our allowance

Not covered: Custodial care

All charges.

Supportive and Palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient care and family counseling. These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

20% of our allowance

Not covered:

Independent nursing, homemaker services

All charges.

Local professional ambulance service to the nearest hospital equipped to handle your medical condition when medically appropriate.

Air ambulance when medically appropriate.

20% of our allowance

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that manifests itself by symptoms of sufficient severity that would lead a prudent layperson to believe that immediate care is required. 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:

In a life-threatening emergency, call the local emergency system (e.g., the local 911 telephone system), or go to the nearest emergency facility. Be sure to tell the paramedics, or emergency room personnel that you are a Coventry Health Care of Kansas, plan member so they can notify us. You or a family member must notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been timely notified.

Emergencies within our service area: If your symptoms are not life-threatening, contact your primary care physician, who is on call 24 hours a day, seven days a week. During after hours or weekends, your physician my use an answering service, therefore your physician or covering physician will generally return your call within 30 minutes. We also provide FirstHelp, which is available to our members 24 hours a day, seven days a week by calling 800-622-9528. With this service, registered nurses are available to help you to the appropriate level of care or provide medical advice.

If you need to be hospitalized and are admitted to a non-Plan facility, call Customer Service at 866-320-0697. You must notify us about your medical emergency within a reasonable time period as dictated by the circumstances. If you are hospitalized in a non-Plan hospital and a Plan physician believes your care can be provided in one of our Plan hospitals, we will transfer you when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan.

We also provide several Urgent Care centers which are open on evenings, weekends and holidays, and are designed to give our members fast, effective quality care for non-emergent conditions such as: sprains, influenza, sore throats, ear infections, minor lacerations, and upper respiratory infections.

Emergencies outside our service area:Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness. If you are hospitalized, the Plan must be notified within 48 hours on the first working day following your admission, unless it is not reasonably possible to notify the Plan within that time. If a Plan physician believes your care can be provided in one of our Plan hospitals, we will transfer you when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan.

Emergency care at a doctors� office

Emergency care at an urgent care center

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

$20 for office visit to your primary care physician

$35 for office visit to a specialist

20% of our allowance all other settings

Not covered: Elective or non-emergency care

All charges.

Emergency outside our service area

Emergency care at a doctors� office

Emergency care at an urgent care center

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

$20 for office visit to your primary care physician

$35 for office visit to a specialist

20% of our allowance all other settings

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.

Local professional ambulance service to the nearest hospital equipped to handle your medical condition when medically appropriate.

Air ambulance when medically appropriate.

20% of our allowance

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

We provide all diagnostic and treatment services recommended by a network provider and contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure.

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

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

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

Medication management

$35 per visit

Diagnostic tests

20% of the Plan�s allowance

Services provided by a hospital or other facility

20% of the Plan allowance

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

20% of the Plan allowance

Not covered: Services we have not approved.

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

All charges.

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

United Behavioral Health, is contracted by Coventry Health Care of Kansas, Inc., to provider a network of providers who offer a variety of therapeutic services on an inpatient and outpatient basis.

All inpatient and outpatient treatment must be authorized through United Behavioral Health, at 1-866-607-5970.

In-network limitation We may limit your benefits if you do not obtain an approved treatment plan.

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

Who can write your prescription. A licensed physician, referral physician or oral surgeon must write the prescription.

Where you can obtain them. You may fill the prescription at a participating pharmacy. You may obtain maintenance medication through Caremark, our mail order prescription drug program. Caremark�s Customer Service number is (800) 378-7040

We use a formulary. A formulary is a list of specific generic and brand name prescription drugs authorized by the Health Plan, and subject to periodic review and modification. Since there may be more than one brand name of a prescription drug, not all brands of the same prescription drug (e.g., different manufactures) may be included in the Formulary. If you would like information on whether a specific drug is included in our drug formulary, please call Customer Service at 1-866-320-0697.

If your pan physician specifically prescribes a non-formulary drug because it is medically necessary, you will receive the non-formulary drug at the Plan non-formulary copayment. If you request a non-formulary drug when your physician has prescribed a substitution, we will not provide the non-formulary drug. However, you may purchases the non-formulary drug from a Plan pharmacy at our allowance.

These are the dispensing limitations. Prescription Drugs will be dispensed in the quantity determined by the Prescribing Provider. The following also apply:

One (1) applicable copayment is due each time a prescription is filled or refilled at a retail pharmacy for up to a thirty-one (31) day supply.

Mail Order Drugs are obtained through Caremark, our mail order prescription drug program, and may be dispensed with three(3) applicable copayment(s), or $45 formulary generic and $75 brand name generic, for a ninety-three (93) day supply. To order prescriptions or refills please contact Caremark�s Customer Service at (800) 378-7040 or visit the website www.rxrequest.com. Available 24 hours a day � 7 days a week.

Members called to active military duty in a time of national or other emergency who need to obtain a greater-than-normal supply of prescribed medications should call us at 1-866-320-0697.

If a brand name Prescription Drug is dispensed, and an equivalent generic Prescription Drug is available, you pay an Ancillary Charge in addition to the formulary brand name copayment. The Ancillary Charge will be due regardless of whether or not the Prescribing Provider indicates that the pharmacy is to �Dispense as Written.� The Ancillary Charge is the difference between the average wholesale price of the brand name and the maximum allowable cost price of the generic prescription. Copayments and Ancillary Charges do not apply to the Catastrophic Protection Out-of-Pocket Maximum

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand-name product. Generics cost less than the equivalent brand-name product. The U.S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name drugs. Generic drugs are indicated on the formulary listing of prescription drugs.

When you do have to file a claim. When you receive drugs from a Plan pharmacy, you do not have to file a claim. For a covered out-of-area emergency, you will need to file a claim when you receive drugs from a non-Plan pharmacy.

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, except those listed as Not covered.

Glucose test strips

Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction (see Prior authorization below)

Contraceptive drugs and devices

Injectable contraceptive drugs (such as Depo Provera)

Growth hormones and other self-administered injectables

Insulin � Under retail pharmacy benefit, you can obtain up to a 3 month supply of insulin

Oral Contraceptive drugs � Under retail pharmacy benefit, you can obtain up to a 3 month supply of oral contraceptive drugs

Retail Pharmacy

$15 per generic formulary

$25 per brand name formulary

$50 per non-formulary

Mail Order (93 day supply)

$45 per generic formulary

$75 per brand name formulary

Noted: If there is no generic equivalent available, you will still have to pay the brand name copay

Not covered:

Drugs and supplies for cosmetic purposes

Medical supplies such as dressings and antiseptics

Smoking cessation drugs, and devices including nicotine gum

Drugs to enhance athletic performance

Fertility drugs

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

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

Drugs available without a prescription or for which there is a non-prescription equivalent

Nonprescription medicines; except those designated by the plan.

Appetite suppressants and other drugs to assist in weight control (except for the treatment of morbid obesity when the authorized by us and your primary care physcian).

All charges.

Flexible benefits option

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

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

Alternative benefits are subject to our ongoing review.

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

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

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

24 hour nurse line

Call FirstHelp anytime you or a family member experience health symptoms that need attention. Nurses are available to you and your family 24 a day, 7 days a week and are trained to handle your questions. Any member who visits an emergency room or urgent care center as a result of advice from FirstHelp will automatically have associated claims approved. With FirstHelp authorization, you will know in advance if medical services will be covered. You may call 1-800-622-9528 or for the hearing impaired call 1-800-735-2966.

Services for deaf and hearing impaired

The Kansas TDD relay number is 1-800-766-3777.

The Missouri TDD relay number is 1-800-735-2966.

Transplant Network

In order to provide members requiring a transplant the opportunity for the best outcomes and experiences, we use our own Coventry Transplant Network.

Administrator